Healthcare Reimbursement Exam 1
Questions and Answers
payer - ANS-insuror
physician providing services - ANS-provider
indemnity insurance, self funded plans, managed care plans - ANS-commercial
insurance
"to promise to compensate for a loss" - ANS-indemnify
pure- insurance company reimburses the healthcare provider "full charges" and the
patient owes zero when receiving healthcare services
modified- the insurance company requires that patient share the costs of healthcare
services when rendered - ANS-indemnity insurance: pure indemnity vs. modified
indemnity
paid to the insurance company as the cost of buying the insurance (by individual or
employer who purchases the insurance) - ANS-premium
each member of the insurance plan - ANS-enrollee or covered life
the person who has the policy - ANS-subscriber
when the subscriber has coverage for other family members such as kids, spouses -
ANS-dependent
"self"= the employer
-when employer takes the financial risk
-ERISA - ANS-self funded plan
Medicare partC
name changed in 2003 medicare prescription drug act
-private plans are paid a capitated risk adjusted rate by CMS to cover members heath
expenses
-may chose from 20 plans - ANS-medicare advantage
health plans or low income/asset individuals "means tested"
-federally administered separately by each state
, -wide difference in programs from state to state
-most medical spending is not medical
-for poor, blind, disabled - ANS-medicaid
comprehensive care for low income/resource families with children (CHIP)
-based on income
-3 commercial companies: Anthem, CareSource MDwise, MHS - ANS-hoosier health
wise
2006- plan for adults and pregnant women who earn up to 200%of federal poverty level
-for those who do not qualify for medicaid
-funded by state of Indianas cigarette tax
-provides traditional commercial benefits and preventative care - ANS-HIP healthy
Indiana plan
no out of network benefits similar to HMOs
-implemented as cost savings measure
-increased discounts - ANS-Exclusive provider organization EPO
market response to HMO restrictions
-financial incentives for patients to stay in network - ANS-PPO preferred provider
organization
less-more managed
traditional indemnity-self funded-ppo-pos-hmo - ANS-managed care
gov would set initial medicare DRG payment rates at a generous level
-control the rate of increase each year
-hospitals reacted quickly and effectively began reducing operating costs
-effective in slowing rate of cost increase in hospitals - ANS-DRG diagnostic related
groups
increased incentives for crops to self insure their employees rather than purchase
insurance from an insurance company - ANS-ERISA employee retirement income
security act
Nixon signed.
to pass financial risk to providers
-fixed prepaid premium
-limited delivery system: primary care "gatekeeper"
-full coverage for designated health services
-introduced dual choice: employers w 25 or more employees to offer HMO option to
their employees in addition to traditional insurance - ANS-HMO Act of 1973
1930s during great depression
formed to help area citizens to afford hospital care and first prepaid hospital in US
Questions and Answers
payer - ANS-insuror
physician providing services - ANS-provider
indemnity insurance, self funded plans, managed care plans - ANS-commercial
insurance
"to promise to compensate for a loss" - ANS-indemnify
pure- insurance company reimburses the healthcare provider "full charges" and the
patient owes zero when receiving healthcare services
modified- the insurance company requires that patient share the costs of healthcare
services when rendered - ANS-indemnity insurance: pure indemnity vs. modified
indemnity
paid to the insurance company as the cost of buying the insurance (by individual or
employer who purchases the insurance) - ANS-premium
each member of the insurance plan - ANS-enrollee or covered life
the person who has the policy - ANS-subscriber
when the subscriber has coverage for other family members such as kids, spouses -
ANS-dependent
"self"= the employer
-when employer takes the financial risk
-ERISA - ANS-self funded plan
Medicare partC
name changed in 2003 medicare prescription drug act
-private plans are paid a capitated risk adjusted rate by CMS to cover members heath
expenses
-may chose from 20 plans - ANS-medicare advantage
health plans or low income/asset individuals "means tested"
-federally administered separately by each state
, -wide difference in programs from state to state
-most medical spending is not medical
-for poor, blind, disabled - ANS-medicaid
comprehensive care for low income/resource families with children (CHIP)
-based on income
-3 commercial companies: Anthem, CareSource MDwise, MHS - ANS-hoosier health
wise
2006- plan for adults and pregnant women who earn up to 200%of federal poverty level
-for those who do not qualify for medicaid
-funded by state of Indianas cigarette tax
-provides traditional commercial benefits and preventative care - ANS-HIP healthy
Indiana plan
no out of network benefits similar to HMOs
-implemented as cost savings measure
-increased discounts - ANS-Exclusive provider organization EPO
market response to HMO restrictions
-financial incentives for patients to stay in network - ANS-PPO preferred provider
organization
less-more managed
traditional indemnity-self funded-ppo-pos-hmo - ANS-managed care
gov would set initial medicare DRG payment rates at a generous level
-control the rate of increase each year
-hospitals reacted quickly and effectively began reducing operating costs
-effective in slowing rate of cost increase in hospitals - ANS-DRG diagnostic related
groups
increased incentives for crops to self insure their employees rather than purchase
insurance from an insurance company - ANS-ERISA employee retirement income
security act
Nixon signed.
to pass financial risk to providers
-fixed prepaid premium
-limited delivery system: primary care "gatekeeper"
-full coverage for designated health services
-introduced dual choice: employers w 25 or more employees to offer HMO option to
their employees in addition to traditional insurance - ANS-HMO Act of 1973
1930s during great depression
formed to help area citizens to afford hospital care and first prepaid hospital in US
