INTRO TO HEALTH-CH.6 FINANCIAL MANAGEMENT QUESTIONS AND ANSWERS

LEADERSHIP: CHAPTER 4: FINANCIAL MANAGEMENT IN HEALTH CA
cf cf cf cf cf cf cf



RE:
INTRO TO HEALTH-CH.6 FINANCIAL
MANAGEMENT QUESTIONS AND ANSWERS

PayingcfforcfHealthcfCarecf-cfanswer--•Payercf-cfthecfpartycffromcfwhomcfthecfprovidercfiscfexpectingcfpayment

•Insurancecfcompany
•Governmentcfagency
cf•E.g.,cfMedicare/Medicaid



•Self-paycf-cfout-of-pocket
•Third-partycfpayercf-cfentitycfthatcfpayscfforcfsomecforcfallcfofcfthecfhealthcfcarecfservicescfoncfbehalfcfofcfthecfpt
cf•Negotiates cfwithcfprovidercftocfdeterminecfpayment

cf•Considerscfquality



•Ptscfmaycfhavecfacfprimarycfpayercfandcfacfsecondarycfpayer
cf•E.g.,cfMedicarecfsupplementalcfplans



PayingcfforcfHealthcfCare(Slidecf2cfofcf2)cf-cfanswer--•Reimbursementcf-
cfpaymentcftocfhealthcfcarecfprovidercfincfexchangecfforcfservicescfrendered

cf•Providercfrenderscfservices,cfthencfrequestscfpaymentcffromcfthecfpayercfviacfclaim

cf•Lesscfoften:

cf•Patientcfpays,cfthencfrequestscfreimbursementcffromcfinsurancecfcompany

cf•Insurancecfplanscftodaycfdocfnotcfusuallycfmakecfptcfpaycfhospitalcfthencfsubmitcfacfclaimcfthemselves



Insurance(Slidecf1cfofcf2)cf-cfanswer--•Insurercfcoverscfthecfcostscfofcfsomecforcfallcfhealthcfservices
cf•Collectscfmonthlycfpremium



•Cost-sharing,cfvariescfbycfinsurancecfplan
cf•Copaycf-cffixedcfamountcfptcfpayscfatcftimecfofcfservice

cf•Co-insurancecf-cfpercentagecfofcfchargescfthecfptcfpays

cf•E.g.,cfpayercf80%,cfptcfpayscf20%



•Deductiblecf-cffixedcfamountcfthecfptcfmustcfreachcfbeforecfthird-partycfpayercfiscfresponsiblecf
cf•Ifcfdeductiblecfiscf$500,cfthecffirstcf$500cfmustcfbecfpaidcfbycfptcfbeforecfinsurancecfwillcfbegincftocfreimburse



•Whencfcost-sharingcffeaturescfarecfhigher,cfthecfpremiumcfiscflower,cfandcfvicecfversa

Insurance(Slidecf2cfofcf2)cf-cfanswer--•Guarantorcf-
cfparentcforcflegalcfguardiancfultimatelycfresponsiblecfforcfacfminor'scfmedicalcfbills



•"Employer-sponsored"cfhealthcfcare
cf•ArosecffromcfeffortscftocfattractcfqualitycfemployeescfaftercfWorldcfWarcfII

cf•Premiumscfwerecfrelativelycfinexpensivecfatcfthecftime

cf•Payerscfenjoyedcfincreasedcfclientcfbase

cf•Ascfhealthcfcarecfcostscfrose,cfsocfdidcfthecfcostcfofcfpremiums

cf•Today,cfemployerscfusuallycfonlycfpartcfacfportioncfofcfpremiumscfoncfbehalfcfofcfemployees

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, LEADERSHIP: CHAPTER 4: FINANCIAL MANAGEMENT IN HEALTH CA
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RE:
AssumptioncfofcfRiskcf-cfanswer--•Riskcf-cfthecfdangercfofcfancfundesiredcfoutcome

cf•Patient
cf•Riskcfofcfneedingcfservicescfthatcfarecftoocfcostlycftocfafford



•Payer
cf•Costcftocftreatcfpatientcfmaycfcostcfmorecfthancfpremiumscfcollected



•Providercf
cf•Riskcfofcfnotcfbeingcfcompensated

cf•Riskcfofcfincorrectcfdiagnosiscforcftreatment



•Insurancecfbalancescfriskcfbycfinsuringcfacflargecfnumbercfofcfpatientscf(riskcfpool)cfandcfpromisingcftocfpaycfthecfprovider

AssumptioncfofcfRisk(Slidecf2cfofcf2)cf-cfanswer--•Groupcfplans
cf•Throughcfemployer

cf•Consistcfofcfpoolscfofcfpotentialcfpts

cf•Riskcfofcfpayingcfforcfancfunhealthycfindividualcfcancfbecfaveragedcfbycfthecfthird-partycfpayer

cf•Employer/subscribercfcancfpaycflowercfpremiumscfbycflimitingcfcoveredcfservices

cf•Pressurecfoncfinsurercftocflimitcfincreasescforcfriskcflosingcfentirecfgroupcfplan



•AffordablecfCarecfActcf(2010)cf-cfExchangescforcfMarketplace
cf•Individualscfwithoutcfemployer-sponsoredcfcoveragecfbuycfintocfgroupcfplans



TypescfofcfHealthcfInsurancecf-cfanswer--•Governmentcf-cfe.g.,cfMedicare,cfMedicaid

•Commercial
cf•Indemnitycfinsurancecf-Cashcftocfthecfptcfwhocfreceivedcfcarecfforcfcertaincfsicknessescfandcfaccidents

cf•Uncommoncftoday

cf•Partcfofcfancfoverallcfincreasecfofcfmoneycfspentcfoncfhealthcfcare

cf•Out-of-pocketcfexpensecfwascflow

cf•Physicianscfhadcfnocfincentivecftocfbecfconservativecfwithcftestingcforcftreatment



•Managedcfcare
cf•Preferredcfprovidercforganizationscf(PPOs)cf

cf•Healthcfmaintenancecforganizationscf(HMOs)



ManagedcfCarecf-cfanswer--•Managedcfcarecf-cfpayercfcontrolscfreimbursementcfprocesscfandcfthecfpt'scfchoicescfforcfcar

•Responsecftocfrisingcfhealthcfcarecfcosts,cfpremiumcfincreases

•Insurercfandcfprovidercfhavecfcontract
cf•Agreecfoncfreimbursementcfamountscfforcfservices



•Providerscfapplycftocfbecfincludedcfincfinsurer'scfnetwork

•Ptscfselectcfin-networkcfprimarycfcarecfprovidercf(PCP)
cf•Treatscfptscfaccordingcftocfplancfguidelines

cf•Actscfascfgatekeeper:cfcontrolscfptcfaccesscftocfdiagnosticscfandcfspecialistscfthroughcfreferrals



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