What Act shaped how commercial insurance carriers approached the concepts of paying for medical care? - ANSWER-HMO Act of 1973
ACA - ANSWER-Affordable
... [Show More] Care Act
HMO (Health Maintenance Organization) - ANSWER-The organization is both the insurer and provider of a set of defined services. Patients within this network must use an in-network provider for their services to be covered.
Capitation Payment - ANSWER-part of prospective payment in which healthcare providers receive fixed monthly payments for services rendered regardless of whether or not services are used
PPO (Preferred Provider Organization) - ANSWER-A network of healthcare providers, such as hospitals and physicians. They have entered into a contract with a third-party entitled to deliver healthcare services to individuals covered under the plan.
POS - ANSWER-Combines the features of both an HMO and PPO, with costs for covered persons falling somewhere between the two. Required to have a PCP, but can self refer to other in-network specialists.
EPO - ANSWER-Services are covered only if patients use doctors, specialists or hospitals in the plan's network. There are no out of network benefits.
ACO - ANSWER-Accountable Care Organization
What employer-based insurance was first? - ANSWER-Blue Cross
ERISA (Employee Retirement Income Security Act) - ANSWER-Federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans.
Government health Coverage Examples - ANSWER-Medicare and Medicaid
Medicare Managed Care Plans - ANSWER-These plans charge a monthly premium and a small copayment for each office visit, but not a deductible. Like private payer managed care plans, these plans often require patients to use a specific network of physicians, hospitals, and facilities. Some plans offer the option of receiving services from providers outside the network for a higher fee. Participants are generally required to select a primary care provider (PCP) from within the network.
Medicaid Managed Care - ANSWER-Plans that operate under the terms of waivers filed by the state Medicaid agencies requesting that a program be established that varies from the traditional Medicaid program.
Medicare Parts - ANSWER-- part a (inpatient hospital care)
- part b (MD and outpatient care)
- part c (managed care option)
- part d (prescription drugs)
Which of the following is an anticipated change in the relationship between consumers and providers? - ANSWER-Providers will face many new service demands and consumers will have virtually unfettered access to those services
Medicare provides health insurance benefits to the following individuals. - ANSWER-All persons age 65, individuals with permanent renal (kidney) failure, disabilities
QMBs - ANSWER-Medicare beneficiaries who qualify for certain Medicaid benefits if they have incomes below the FPL and resources at or below twice the standard allowed under the SSI program.
Centers for Medicare and Medicaid Services (CMS) - ANSWER-Administers all federally supported healthcare financing programs
Federal Trade Commission (FTC) - ANSWER-Examines mergers of hospitals and other healthcare institutions
Section 501(c)3 - ANSWER-Grants tax-exempt status and monitors compliance with legislation.
Office of the Inspector General (OIG) - ANSWER-Investigates organizations for violations of the Medicare and Medicaid anti-kickback statute.
Department of Justice (DOJ) - ANSWER-Prosecutes healthcare fraud under various federal criminal statutes.
US Public Health Service - ANSWER-Promotes the protection and advancement of the nation's physical and mental health.
Securities and Exchange Commission (SEC) - ANSWER-Enforces the newly passed securities laws and promotes stability in the markets
Balanced Budget Act of 1997 Objectives - ANSWER-Decrease Medicare reimbursement levels, Mandate an end to the most areas of cost-based reimbursement and Medicare Part C plans
Inpatient Prospective Payment System (IPPS) - ANSWER-system in which Medicare reimburses hospitals for inpatient hospital services according to a predetermined rate for each discharge.
Outpatient Prospective Payment System (OPPS) - ANSWER-The Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications
Medicare Payments to Physicians - ANSWER-Part B
Purpose of Medicare Value Based purchasing (VBP) programs - ANSWER-Provides differential payments to physicians based on the quality of care provided
MSPQ - ANSWER-Questions to be asked to patients in order to help determine if Medicare is primary or secondary for the patient's service that is about to be provided.
Advanced Beneficiary Notice (ABN) - ANSWER-document given to medicare beneficiaries indicating the services medicare is unlikely to pay for
Medicare Outpatient Observation Notice (MOON) - ANSWER-A form given to Medicare beneficiaries to inform them of their outpatient observation status and to explain to them what that may mean financially.
Consumer Bill of Rights - ANSWER-codified the ethics of exchange between buyers and sellers, including rights to safety, to be informed, to choose, and to be heard.
Financial disclosure - ANSWER-Physicians are required to disclose to Medicare any financial arrangements that create incentive for limiting care
Participation in treatment decisions - ANSWER-Addresses communication about Treatment options and Advance directives; Physicians' financial disclosure' and Prohibition against gag rules
Confidentiality of health information - ANSWER-Requires MA plans to safeguard the privacy of any information that identifies a particular enrolee.
Overall function of Medicaid - ANSWER-Pay for medical assistance for certain individuals and low-income families
Medical Loss Ratio (MLR) - ANSWER-The difference of healthcare costs to revenue received. Calculated as total medical expense divided by total revenue.
Provider-sponsored organization (PSO) - ANSWER-Type of point-of-service plan in which the physicians that practice in a regional or community hospital organize the plan
Cost Sharing - ANSWER-Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; a cost-control mechanism.
Gatekeeper - ANSWER-a primary care provider who refers patients to other providers for services he or she cannot perform
Deductible - ANSWER-Flat dollar amounts paid by an enrollee before benefits apply
High Deductible Health Plan (HDHP) - ANSWER-A plan that requires individuals to pay a higher deductible to cover medical expenses before insurance plan payments begin; chosen to save money on premiums.
Co-insurance - ANSWER-A provision in the member's coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80%
Copayment - ANSWER-A provision under which the insured pays a flat dollar amount each time a covered medical service is received
Stop Loss - ANSWER-A provision under which an insured pays a certain amount, after which the insurance company pays 100 percent of the remaining covered expenses.
coordination of benefits - ANSWER-A provision that helps determine the primary payer in situations where an insured is covered by more than one policy, thus avoiding claims overpayments.
Out of Pocket maximum - ANSWER-The dollar limit set on the total amount of covered charges that will be paid by the enrolee.
Percent of Pay - ANSWER-A rarely used share of cost structure in which employees out of pocket costs are fixed as percentages of a respective employee's salary.
tiered provider networks - ANSWER-health insurance products that group providers into tiers based on the cost or efficiency of care they deliver and then steer pts to choose these providers through lower premiums or cost sharing
Capitation - ANSWER-A fixed payment amount based upon the number of members assigned to a provider.
percent of charges - ANSWER-A payment methodology where a claim is paid at a predetermined percentage discount rate.
Per diem payment - ANSWER-Type of prospective payment method in which the third-party payer reimburses the provider a fixed rate for each day a covered member is hospitalized. [Show Less]