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83 Cards in this Set

  • Front
  • Back
* Conversion Factor
* national dollar amount that is applied to all services paid on the Medicare Fee Schedule (MFS) basis
* congress provided a CF to be used to convert RVUs to dollars

updated annually on the basis of the data sources, the CF indicates
* percent changes to the medicare economic index (MEI)
* percent changes in physician expenditures
* relationship of expenditures to volume performance standards
* change in access and quality

* the CF varies according to the type of service provided (ie. medical, surgical, nonsurgical)
* Centers for Medicare and Medicaid Services
* formerly HCFA, Health Care Financing Administration
* Social Security taxes go to CMS along with an equal match from the government. The CMS then sends the money to the Medicare Administrative Contractors (MACs)
* handles the daily operation of the Medicare program through the use of Medicare Administrative Contractors (MACs) - overseen by the Secretary of the Department of Health and Human Services

CMSs mission - to ensure effective, up-to-date health care coverage and to promote quality care for beneficiaries.
CMSs Vision - to achieve a transformed and modernized health care system.
* CMS will accomplish our mission by continuing to transform and modernize America's health care system.
* Department of Health and Human Services
* the secretary of the DHHS is responsible for the administration of the Medicare program
* The operation of the programs is delegated to Medicare Administrative Contractors (MACs) (formerly Fiscal Intermediaries [FIs])
* Exclusive Provider Organization
* similar to a Health Maintenance Organization except that the providers of the services are not prepaid, but rather are paid on a fee-for-service basis
* Health Care Financing Administration
* now known as Centers for Medicare and Medicaid Services (CMS)
* Health Maintenance Organization
* a health care delivery system in which an enrollee is assigned a primary care physician who manages all the health care needs of the enrollee
* is a total package of health care.
* The out-of-pocket expenses are minimal as long as the patient receives services within the organization.
* An assigned physician acts as the gatekeeper to refer patients both inside and outside the organization.
* services (like lab work) are prepaid by the HMO
* Individual Practice Association
* an organization of physicians who provide services for a set fee. Health Maintenance Organizations often contract with the IPA for services to their enrollees.
* Maximum Actual Allowable Charge
* limitation on the total amount that can be charged by physicians who are not participants in Medicare (non-QIO)
* Medicare Administrative Contractors
* are usually insurance companies, such as Travelers or Blue Cross/Blue Shield that bid for a contract with CMS to handle the Medicare program in a specific area.
* MACs handle the paperwork and pay the claims for Medicare
* Managed Care Organization
* a group that is responsible for the health care services offered to an enrolled group of persons
* the organization coordinates or manages the care of the enrollee
* providers must have prior approval from the MCO before services are rendered.
* the PCP may recommend a specialist outside the network if one isn't available in network.
* Medicare Economic Index
* government-mandated index that ties increases in the Medicare prevailing charges to economic indicators
* Medicare Fee Schedule
* schedule that listed the allowable charges for Medicare services; was replaced by the Medicare reasonable charge payment system.
* A national fee schedule replaced the RBRVS. This schedule is known as the Medicare Fee Schedule (MFS)
* Payment to a provider is 80 percent of the fee on the MFS. Payment is only made after the patient has paid the deductible for the year.
* The MFS is used for both physicians and other suppliers in an outpatient setting.
* Medical Volume Performance Standards
* government's estimate of how much growth is appropriate for nationwide physician expenditures paid by the Part B Medicare program
* purpose is to guide Congress in its consideration of the appropriate annual payment update
* recommendations must be made by April 15th to Congress, and by May 15th to the (PPRC) - Physician Payment Review Commission for the fiscal year.
* Congress has until October 15th to either accept or modify the two proposed MVPs recommendations
* if congress does not react by October 15th, they use a default mechanism that is published in the Federal Register that provides the formula for deriving the MVPD
* Omnibus Budget Reconciliation Act of 1989
* act that established new rules for Medicare reimbursement

added section 1848, Payment for Physician Services
1. establishment of standard rates of increase of expenditures for physicians' services
2. Replacement of the reasonable charge payment mechanism by a fee schedule for physicians' services
3. Replacement of the maximum actual allowable charge (MAAC) which limits the total amount non-QIO physicians could charge.

* OBRA 1990 - required that before January 1 of each year, beginning with 1992 the Secretary establish, by regulation, fee schedules that determine payment amounts for tall physicians' services furnished in all fee schedule areas for the year.
* this is updated each April 15 and is composed of 3 basic elements:
1. the relative value units (RVUs) for each service
2. A geographic adjustment factor to adjust for regional variations in the cost of operating a health care facility
3. A national conversion factor
* Preferred Provider Organization
* a group of providers who form a network and who have agreed to provide services to enrollees at a discounted rate
* is composed of providers who form a network to offer health care services as a group.
* Enrollees who seek health care outside the PPO pay more of the costs out-of-pocket.
* enrollees are usually responsible for paying a portion of the costs (costs sharing)
* no gatekeeper, but they have strict guidelines that denote approved expenses and how much the enrollee will pay.
* Quality Improvement Organization
* The MACs usually do not pay what the provider submits as charges. Often there is a significant decrease
* currently more than half of all physicians in the nation are participating providers
* previously called PROs

* QIO provider receives 5 percent more than non-QIOs
* if the provider accepts assignment, the MACs send the payment directly to the provider, not to the beneficiary
* The claims for QIO are processed faster, and the providers' names are listed in the QIO directory that is sent to all beneficiaries

** a bonus is offered for each recruited and enrolled QIO provider
* Resource-Based Relative Value Scale (Outpatient)
* A national fee schedule replaced the RBRVS. This schedule is known as the Medicare Fee Schedule (MFS)
* scale designed to decrease Medicare expenditures, redistribute physician payments more equitably, and ensure quality health care at reasonable rates
* a physician outpatient payment reform implemented in 1992. This reform allowed for physicians to be paid the lowest of the following: physician charge for the service, physician's customary charge, or the prevailing charge in the locality.
* Relative Value Unit
* normally unit values are assigned for each service
* unit values have been assigned to each CPT code determined on the basis of the resources necessary for the physician to perform a service
* are determined on the basis of the resources necessary to the physician's performance of the service. By analyzing a service, a Harvard team was able to identify its separate parts and assign each part an RVU value.

Parts of a component:
1. work component - the amount of time, the intensity of effort, and the technical expertise required for the physician to provide the service
2. overhead component or practice expense - the allocation of costs associated with the physician's practice (rent, staffing, supplies) that must be expended in order to provide a service
3. malpractice component - the cost of the medical malpractice insurance coverage/risk associated with providing the service

* the sum of the three components is the RVU of a service
* a relative value was established for a midlevel, established-patient office visit (99213) and all other services are valued at, above, or below this service relative to the work, overhead, and malpractice expenses associated with the service.
* an agreement with the Medicare Administrative Contractors (MACs) in which the provider agrees to accept what the MACs pay as payment in full
Federal Register
* official publication of all "presidential Documents," "Rules and Regulations," Proposed Rules," and "notices"; government-instituted national changes are published in the Federal Register
* The fall edition of the Federal Register is implemented the following calendar year
* The important issues of the Federal Register are the October edition, which contains hospital facility changes, and the November and December editions, which contain outpatient facility changes.
* The CMS notifies the hospitals of the official policies and rule changes in the Federal Register
Group Practice Model (GPM)
* an organization of physicians who contract with a Health Maintenance Organization (HMO) to provide services to the enrollees of the HMO
* a payment is negotiated, the HMO pays the group, and then the group pays the individual physicians.
Medicare Part A
* the hospital insurance portion
* Hospitals submit bills for Part A services by using ICD-10-CM/ICD-9-CM codes and the MS-DRG (MS-DRG assignment reports Part A)
* Hospitals submit their charges on the UB-04 when submitting paper claims
* The ICD-10-CM/ICD-9-CM codes are the basis for payment under Part A of the Medicare program for hospital charges.
* Part A pays for a semiprivate room, meals and special diets while in the hospital, and all medically necessary hospital services.
* Personal convenience items, such as slippers, are not paid for under the program
* Other expenses that may be paid under Part A are rehabilitation services, skilled nursing services, some personal convenience items for long-term illness or disability, home health visits, and hospice care for the terminally ill. These expenses are not automatically covered and certain criteria must be met to be eligible for coverage.
Medicare Part B
* supplemental portion (other than hospital)
* Part B is not automatically provided to beneficiaries when they become eligible for Medicare
* Beneficiaries must purchase the supplemental coverage and pay a monthly premium
* Medicare Part B pays for some services and supplies not covered under Part A, such as physicians' services, outpatient hospital services, home health care, and medically necessary supplies and equipment.
* beneficiaries must sign up for part B when they become eligible otherwise they pay an additional 10% annual premium for each year they didn't have coverage, unless qualified under a special case
Medicare Part C
* Medicare Advantage portion
* provides beneficiaries with the option of selecting the type of health coverage and health care provider they want.
* For example, choices include (HMO) health maintenance organizations, point of service plans, fraternal types of coverage, etc.
* also offers the beneficiary the option to purchase additional coverage such as vision, hearing, dental, and wellness programs.

has various managed care options:
* Preferred Provider Organization (PPO)
* Medicare Health Maintenance Organization (HMO)
* Private Fee-For-Service (PFFS)
* Medicare Special Needs Plans (SNP)
* Medicare Medical Savings Account (MSA)
Medicare Part D
* Prescription Drug Insurance portion
* is the part of Medicare that provides outpatient prescription drug coverage
* Part D is provided only through private insurance companies that have contracts with the government
** it is never provided directly by the government (like original Medicare is)
* is optional for most people; whether the beneficiary should enroll depends on his/her current drug coverage and needs
* beneficiaries who receive the benefit pay a monthly premium, and pay a deductible and a copayment
Participating Provider Program
* are those health care providers that have signed an agreement with the Medicare Administrative Contractors (MACs) in which the provider agrees to accept what the MACs pay as payment in full
* This arrangement is termed "Accepting Assignment."
* If the provider accepts assignment, Block 27 on the paper CMS-1500 is checked as shown here.
* probable outcome of an illness
Staff Model
* a Health Maintenance Organization that directly employs the physicians who provide services to enrollees
Physician extenders
* such as nurse practitioners, physician assistants, and nurse anesthetists, etc.,
* provide medical services typically performed by a physician
third-party reimbursement
* Reimbursement, HIPAA, and Compliance play a critical role
* the largest third-party payer is the government through the medicare program
* maximizing
* upcoding services to a higher level to receive increased reimbursement is never appropriate.
population is changing
* The elderly are the fastest growing segment of the United States population
* By 2050, the elderly will represent 20% of the population
* is primarily a third-party payer for the elderly
* established in 1965
* is funded by the payroll taxes in the form of Social Security tax that is paid by employers and employees
* Social Security Administration administers funds for medicare
* Medicare covers 80% percent of covered medical services. Beneficiaries pay 20% percent of the cost of covered medical services and an ever-increasing annual deductible
* beneficiary pays deductibles, premiums, and coinsurance payments (20%), 100% of non-covered services
* 2012 deductible for Part A is $1156 per hospital stay of 1-60 days and for Part B, $140

two parts to medicare:
1. Part A - the hospital insurance portion
2. Part B - supplemental portion (other than hospital)

* Persons covered under the Medicare program are beneficiaries.
* Due to the increasing elderly population, Medicare has a rapidly expanding influence on health care
* By 2018, national health spending is expected to reach $4.4 trillion and comprise 20.3% of the Gross Domestic Product
* specific regulations for Medicare are contained in the Internet Only Manual.
The Medicare Prescription Drug Improvement and Modernization Act (MMA)
* allowed Centers for Medicare and Medicaid Services (CMS) to reduce the 48 Medicare fiscal intermediaries (FIs) to 10 (or 19 in book) Medicare Administrative Contractors (MACs)
* established a prescription drug benefit under Medicare Part D. On January 1, 2006, Medicare beneficiaries could enroll in the Medicare Part D prescription drug plan and choose from several plans that offer drug coverage.
non-QIO provider
* Non Quality Improvement Organization
* The payment for non-QIO provider claims goes directly to the patient
* Further, the non-QIO has a 5 percent lower fee schedule
* claims processing is much slower than the processing for the QIO provider
* The notice of payment is also sent to the patient that indicates the increased out-of-pocket expenses the patient must pay when they use a non-QIO-physician.
physician center
* located on the Centers for Medicare and Medicaid Services website
* where providers obtain the current reimbursement schedules
* a patient who receives services in an ambulatory health care facility and is currently not an inpatient
Coding for Medicare Part B Services
here are three coding systems used to report services under Medicare Part B:
1. CPT
3. ICD-10-CM/ICD-9-CM

* The payments for services are published in the weekly Federal Register.
* Coding supervisors need to keep current on all changes made in the Medicare reimbursement policies
* Medicare fiscal intermediaries (FIs)
* are private insurance companies that serve as the federal government's agents in the administration of the Medicare program, including the payment of claims.

There are two primary functions for the FI:
1. reimbursement review
2. medical coverage review.
* Administration on Aging
* physicians, hospitals, and other suppliers that furnish care or supplies to Medicare patients
* must be licensed by local and state health agencies to be eligible to provide services or supplies to Medicare patients
* must also meet various additional Medicare requirements before being eligible for payments
* the 20% that Medicare does not pay
* often beneficiaries have additional insurance to cover out-of-pocket expenses or non-covered services
Health Insurance Portability and Accountability Act (HIPAA) of 1996
includes provisions for governing:

* Health coverage portability
* Health information privacy
* Administrative simplification
* Medical savings accounts
* Long-term care insurance

The most major change to the health industry is the Administrative Simplification which includes: Electronic transactions and code sets standards requirements, privacy and security requirements, and national identifier requirements.
* are activities involving the transfer of health care information
* the movement of electronic data between two entities and the technology that supports the transfer.
* ie. using Electronic Data Interchange (EDI)
* Electronic Data Interchange
* providers must complete an EDI enrollment form before submitting electronic media claims (EMC) or other EDI transactions
* the software that supports the electronic transmissions must be compatible with HIPAA transaction standard Version 5010 and the Natinoal Council for Prescription Drug Programs (NCPDP) version D.0

10 standard HIPAA transactions for EDI transmission:
1. claims and encounter information
2. payment and remittance advice
3. claims status inquiry and response
4. eligibility inquiry and response
5. referral certification and authorization inquiry and response
6. enrollment and disenrollment in a health plan
7. health plan premium payments
8. coordination of benefits
9. claims attachments
10. first report of injury
* Electronic Media Claims (EMC)
* Natinoal Council for Prescription Drug Programs (NCPDP)
Health Insurance Portability and Accountability Act (HIPAA)
* was created to govern health care portability, privacy of information, simplification of reporting by standardizing code sets, billing forms, and rules.
* today, more than 99% of Part A and 96% of Part B claims are filed electronically.
* HIPAA assigns a number to all providers called a National Provider Identification number
code sets
* composed of numbers and/or letters that identify specific diagnosis and clinical procedures on claims and encounter forms.

examples of code sets for procedure and diagnosis coding:
* ICD-10-CM
* ICD-10-PCS
* ICD-9-CM
* patient protected health information
* HIPAA requirement that governs disclosure of PHI for privacy
* includes conversations with nurses and other staff about a patients health care or treatment.
* all PHI is included in the privacy requirements
* electronic medical record
* a computerized health record limited to one practice
* electronic health record
* the entire health record compiled from multiple resources
HIPAA security requirements
* addresses the administrative, technical, and physical safeguards requred to prevent unauthorized access to protected health care information
* Medicare Economic Index (MEI)
* first published in the Federal Register on June 16, 1975
* the MEI attempts to present an equitable measure for changes in the costs of physicians' time and operating expenses.
* it is recalculated annually
* congress mandated the MEI as part of the 1972
amendment to the Social Security Act
* geographic practice cost index
* the urban institute developed scales that measure cost differences in various areas.; GPCIs have been established for each of the prevailing charge localities.
* an entire state can be considered a locality for purposes of physician payment reform
* GPCIs reflect the relative costs of practice in a given locality compared with the national average
* a separate GPCI has been established and is applied to each component of a service
Beneficiary protection
several provisions in the physician payment reform were designed to protect medicare beneficiaries.
1. as of September 1, 1990 all providers must file claims for their Medicare patients (free of charge). all claims must be submitted within 12 months of the service date, after 12 months the claims are denied.
2. the OBRA of 1989 requires participating physicians to accept the amount paid for eligible Medicaid services (mandatory assignment) as payment in full. This was a major change in Medicare.
3. effective January 1, 1991 the MAAC limitations that applied to nonparticipating physician charges were replaced by new limits called limiting charges. the new provisions sate that nonparticipating physicians and suppliers cannot charge more than the stated limiting charge.
limiting charge
* since 1993 the limiting charge for a service has been the same for all physicians within a locality, regardless of specialty.
* the limiting charge is a percentage over the allowable (115% times the allowable amount) - this is the maximum amount a Medicare patient can be billed for a service
* applies to every service listed in the Medicare Physicians' fee schedule that is performed by a nonparticipating physician including global, professional, and technical services performed by a physician.
* when a nonphysician provider (ie. portable x-ray supplier, lab technician) performs the technical component of a service that is on the fee schedule, the limiting charge does not apply
* CPT codes are assigned many different prices, the amount is determined by multiplying the RVU wight by the geographic index and the conversion factor for the fee schedule amount.
balanced billed
* billing the medicare patient for the difference between what Medicare pays and the limiting charge.

Limiting charge = $115 (maximum charge)
Allowable = $100
Medicare pays = $80 (80% of allowable)
patient is billed = $35 (20% of allowable - $20, plus limiting charge minus allowable charge ($115 - $100) - $15 = $35
uniformity provision
* a payment system with uniform policies and procedures that ensures physicians across the country be paid the same for the same services rendered
ie. preoperative and postoperative periods
* whenever an adjustment of the full fee schedule amount is made to a service, the limiting charge for that service must also be adjusted.
* adjustments to the limiting charge must be manually calculated before submitting claims for all services in which a fee schedule limitation applies
* payments to nonparticipating physicians do not exceed 95% of the physician fee schedule for a service
site-of-service limitations
* services that are performed primarily in office settings are subject to a payment discount if they are performed in an outpatient hospital department.
* this is because the hospital will be billing Medicare for the room and supplies so in these instances the RVU for practice expense is reduced by 50%
ie. if a physician performs an arthrocentesis in a hospital outpatient setting instead of in his office where it is normally done.
Medicare Fraud and Abuse
* is a program established by the CMS with the intent of decreasing fraud and abuse of the CMS health care programs
* Fraud is the intentional deception to benefit
* Abuse generally involves impropriety or lack of medical necessity for services billed
* Reports of fraud can also be made to the Office of the Inspector General (OIG)
* Beneficiary signatures are kept on file in the provider's office, charges are submitted without the need for the patient's signature on the claim form

The following are parties who can be involved in fraud and abuse:
* Physicians
* Hospitals
* Laboratories
* Billing services
* Anyone who submits claims for Medicare services
* You must only submit charges substantiated in the medical record to ensure you are not in violation of the Fraud and Abuse guidelines
* Fraud can be not only billing for services not provided, but also misrepresenting the diagnosis, kickbacks, unbundling of services, falsifying medical necessity, or consistently waving the co-payment that the patient is responsible to pay
* assigning multiple CPT codes when one CPT code would fully describe the service or procedure
* against providers can be submitted either orally or in writing to the Medicare Administrative Contractors (MACs).
* Allegations can be made by anyone.
* Allegations are followed up by the MAC
* Review takes place after claims have been submitted, and the MAC may go back and perform a historical review of previous claims submitted
* a bribe or rebate for referring patients for any service covered by Medicare
* Any personal gain is a kickback and a felony with a fine of more than $25,000 and 5 years in jail or both
Office of the Inspector General (OIG)
* Each year the OIG develops a work plan
* The plan outlines the monitoring of the Medicare program
* MACs then monitor those areas specified in the plan
Managed Health Care
* is a network of health care providers that offer health care services under one organization
* It could be a group of hospitals, physicians, or other providers
* Ninety percent of people with health care have some type of health care organizational coverage, such as an HMO
* A managed care organization is a group that is responsible for health care services to enrolled persons or groups.
* They coordinate various health care services, and if the organization does not hire providers directly, they negotiate with the providers for a set amount to provide services
* Managed care has come under criticism for denying patients access to services
* There are incentives for the organization to keep the patient within the organization.
* Services provided both outside the organization and inside the organization are controlled to manage costs
Surgical Modifier Circumstances
1. Multiple Surgeries
2. Providers Furnishing Part of the Global Fee Package
3. Physicians Who Assist in Surgery
4. Two Surgeons and Surgical Team
5. Purchased Diagnostic Services
6. Reoperations
* a Surgical Modifier Circumstance for multiple surgeries
* General - if a surgeon performs more than one procedure on the same patient on the same day,discounts are made on all subsequent procedures, excluding add-on codes
* Medicare will pay 100% of the fee for the highest value procedure , 50% for the second most expensive procedure, and 50% for the third, fourth, and fifth procedures. Each procedure after the fifth requires documentation and special review to determine the payment amount.
* discounting is why the order of the codes and the use of modifiers are so important
* these discount amounts are subject to review every year by the CMS
* Third-party payers often follow different discount limits rules from those of Medicare.
Endoscopic Procedures
* a Surgical Modifier Circumstance for multiple surgeries
* with multiple endoscopic procedures; in the same indented category of the CPT, Medicare allows the full value of the highest valued endoscopy, plus the difference between the next highest endoscopy and the highest valued endoscopy.
* some non-Medicare carriers follow this pricing method, and some follow their own multiple-procedure discounting policies
Dermatologic Surgery
* a Surgical Modifier Circumstance for multiple surgeries
* for certain dermatology services, there are CPT codes that indicate that multiple surgical procedures have been performed.
* when the CPT code description states "additional", the general multiple-procedure rules do not apply. ie. mole removal + additional mole removals
Multiple Surgeries
A Surgical Modifier Circumstance

Three types:
1. General
2. Endoscopic Procedures
3. Dermatologic Surgery
Providers Furnishing Part of the Global Fee Package
* A Surgical Modifier Circumstance
* under the fee schedule, Medicare pays the same amount for surgical services furnished by several physicians as it pays if only one physician furnished all of the services in the global package.
* medicare pays each physician for his or her part of the global surgical services.
* the policy is written with the assumption that the surgeon always furnishes the usual and necessary preoperative and intraoperative services and also, with a few exceptions, in-hospital postoperative services.
* In most cases, the surgeon also furnishes the postoperative office services necessary to ensure normal recovery from the surgery, but sometimes that care is given to another physician.
Medicare payment % for postoperative care furnished by someone other than the surgeon. These are based on the weighted percentages based on the percentage of total global surgical work.
* Preoperative care 15%
* Intraoperative service 70%
* Postoperative care 15%

** Some individual third-party payer policies may not split their global payments in this manner.
Physicians Who Assist in Surgery
* A Surgical Modifier Circumstance
* physicians assisting the primary physician in a procedure receive a set percentage of the total fee for the service.
a. Medicare sets the payment level for assistants-at-surgery at 16% of the fee schedule amount for the global surgical service.
b. Non-Medicare payers may set this percentage at 20% or more
c. CPT modifiers -80 (Assistant Surgeon), -81 (Minimum Assistant Surgeon), and -82 (Assistant Surgeon, when qualified resident surgeon not available)
d. HCPCS modifier -AS (Assistant at Surgery) would be appended to the code to indicate the type of assistnant
Two Surgeons and Surgical Team
* A Surgical Modifier Circumstance
* When two primary surgeons (usually of different specialties) perform a procedure, each is paid an equal percentage of the global fee.
* For co-surgeons, Medicare pays 125% of the global fee, dividing the payment equally between the two surgeons (each will receive the lesser of the actual charge or 62.5% of the global fee)
* No payment is made for an assistant-at-surgery when co-surgeons) or -66 (Surgical Team) would be appended to the procedure code
Purchased Diagnostic Services
* A Surgical Modifier Circumstance
* for physicians who bill for a diagnostic test performed by an outside supplier, the fee schedule amount is limited to the lower of the billing physician's fee schedule amount or the price paid for the service.
* A Surgical Modifier Circumstance
* the amount paid by medicare for a return to the operating room for treatment of a complication is limited to the intraoperative portion of the code that best describes the treatment of the complications.
* when an unlisted procedure is reported because no other code exists to describe the treatment, payment is usually based on a maximum of 50% of the value of the intraoperative services originally performed
* Modifiers -78 (Return to Operating/Procedure Room for a Related Procedure During the Postoperative Period) or -79 ( Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period) would be appended to the code to more specifically identify that the service was a reoperation.
* Third-party payers have their own guidelines. Many do not apply discounts for these subsequent surgical procedures.
Point-of-Service (POS)
* aka. open-ended HMO or self-referral option
* benefits that allow enrollees to receive services outside of the HMO health care network, but at increased cost in copayments, in coinsurance, or in a deductible
* POS benefits may be offered by the HMO but it is not required to offer, and the CMS doesn't provide any additional funding for this benefit
* POS is attractive to enrollees because they can see a wider range of physicians at a lower cost.
Program for All-Inclusive Care for the Elderly (PACE)
* program developed to address the needs of long-term care clients, providers, and payers
* the program provides a comprehensive package of services that permits the clients to continue to live in their homes while receiving services rather than being placed in an institution.
Affordable Care Act
* signed by the President in March 2010
* its goal is to put in place a comprehensive health insurance reform with the hope that insurance companies would be more accountable, lower health care costs, guarantee more health care choices, and enhance the quality of health care.
* the physician responsible for controlling and managing the health care of an HMO enrollee
Medicare Eligibility
originally designed for:
1. people aged 65 and older

two groups added after medicare was established:
1. persons eligible for disability benefits from Social Security
2. persons with permanent kidney failure