Intro to Healthcare Reimbursement-
Chapter 1 Exam-Graded A
Social insurance, national health service, private health insurance - ANSWER-The three
nations models for for delivering healthcare services:
Also called the Bismarck model. Introduced in 1883 by German Chancellor Otto von
Bismarck, this model is the oldest in the world. The foundation for this model is
universal healthcare coverage for a set of benefits defined by the national government.
In this model, every worker and employer must contribute to sickness funds, agencies
that collect and redistribute money per government regulations; they are a form of social
security. With a varying modifications, France, Japan, the Netherlands, and many other
countries have adopted this German model. - ANSWER-Social insurance model
Also called the Beveridge model. In the UK, the government owns the clinics and
hospitals and pays the doctors and health personnel who work in these public facilities.
This government run model is a single-payer health system the UK government is the
only payer. The healthcare system is financed by the country's general revenues. The
general revenues come from taxes that increase in proportion to income. Spain and the
Scandinavian countries have adopted this model - ANSWER-National health service
model
In this model, many private health insurance companies exist. The private health
insurance companies collect premiums to create a pool of money. This pool of money is
used to pay health claims. Unlike the Bismarck system, the insurance company
determines the contribution, and this contribution is not based on the employees
incomes. The United States and Switzerland use the private healthcare insurance
model. - ANSWER-Private health insurance model
The size of this economic sector, its complexity, intricate payment methods and rules,
and broad program scopes - ANSWER-Four characteristics are key to understanding
the US healthcare sector:
Healthcare insurance benefits that cover only one individual, the member (enrollee,
subscriber, certificate holder). - ANSWER-Individual (single) coverage
Health insurance coverage extended to the spouse and unmarried children of the
primary insured member. Certain age restrictions on the coverage of children may
apply. - ANSWER-Dependent coverage
, A landmark federal law passed by Congress in 1986 that provides continuing coverage
of group health benefits to employees and their families upon the occurrence of certain
qualifying events where such coverage would otherwise be terminated. - ANSWER-
COBRA (Consolidated Omnibus Budget Reconciliation Act)
The healthcare term referring to the compensation or repayment for healthcare
services. - ANSWER-Reimbursement
Health insurance companies, workers compensation, and Medicare - ANSWER-Third-
party payer
Unit of payment, the time orientation, and the degree of financial risk for the parties. -
ANSWER-Three characteristics describe various methods of health care
reimbursement:
The payer learns of the costs of the health services after the patient has already
received the services - ANSWER-Retrospective payment systems
The payments are preset before care is delivered. - ANSWER-Prospective payment
method
A healthcare payment method in which providers receive payment for each service
rendered. Is a common method of calculating health care reimbursement. Examples of
fee-for-service reimbursement are self-pay, traditional retrospective payment, and
managed care. - ANSWER-Fee for service reimbursement
A predetermined list of fees that the third-party payer allows for payment for all
healthcare services. - ANSWER-Fee schedule
Represents the average or maximum amount the third-party payer will reimburse
providers for the service. - ANSWER-Allowable charge
Defined as usual in the providers practice, customary in the community, and reasonable
for the situation - ANSWER-usual, customary, and reasonable (UCR)
Defined as customary in the providers practice, prevailing in the community, and
reasonable as the providers lowest actual charge - ANSWER-Customary, prevailing,
and reasonable (CPR)
A discounted fee schedule that Medicare uses to reimburse physicians. A payment
method that classifies health services based on the cost of providing physician services
in terms of effort, practice expenses, and malpractice insurance - ANSWER-Resource-
Based Relative Value Scale (RBRVS)
Third-party payers manage both the cost of healthcare and the outcomes of care. By
managing care, these methods begin to address the criticism of fee-for-service
Chapter 1 Exam-Graded A
Social insurance, national health service, private health insurance - ANSWER-The three
nations models for for delivering healthcare services:
Also called the Bismarck model. Introduced in 1883 by German Chancellor Otto von
Bismarck, this model is the oldest in the world. The foundation for this model is
universal healthcare coverage for a set of benefits defined by the national government.
In this model, every worker and employer must contribute to sickness funds, agencies
that collect and redistribute money per government regulations; they are a form of social
security. With a varying modifications, France, Japan, the Netherlands, and many other
countries have adopted this German model. - ANSWER-Social insurance model
Also called the Beveridge model. In the UK, the government owns the clinics and
hospitals and pays the doctors and health personnel who work in these public facilities.
This government run model is a single-payer health system the UK government is the
only payer. The healthcare system is financed by the country's general revenues. The
general revenues come from taxes that increase in proportion to income. Spain and the
Scandinavian countries have adopted this model - ANSWER-National health service
model
In this model, many private health insurance companies exist. The private health
insurance companies collect premiums to create a pool of money. This pool of money is
used to pay health claims. Unlike the Bismarck system, the insurance company
determines the contribution, and this contribution is not based on the employees
incomes. The United States and Switzerland use the private healthcare insurance
model. - ANSWER-Private health insurance model
The size of this economic sector, its complexity, intricate payment methods and rules,
and broad program scopes - ANSWER-Four characteristics are key to understanding
the US healthcare sector:
Healthcare insurance benefits that cover only one individual, the member (enrollee,
subscriber, certificate holder). - ANSWER-Individual (single) coverage
Health insurance coverage extended to the spouse and unmarried children of the
primary insured member. Certain age restrictions on the coverage of children may
apply. - ANSWER-Dependent coverage
, A landmark federal law passed by Congress in 1986 that provides continuing coverage
of group health benefits to employees and their families upon the occurrence of certain
qualifying events where such coverage would otherwise be terminated. - ANSWER-
COBRA (Consolidated Omnibus Budget Reconciliation Act)
The healthcare term referring to the compensation or repayment for healthcare
services. - ANSWER-Reimbursement
Health insurance companies, workers compensation, and Medicare - ANSWER-Third-
party payer
Unit of payment, the time orientation, and the degree of financial risk for the parties. -
ANSWER-Three characteristics describe various methods of health care
reimbursement:
The payer learns of the costs of the health services after the patient has already
received the services - ANSWER-Retrospective payment systems
The payments are preset before care is delivered. - ANSWER-Prospective payment
method
A healthcare payment method in which providers receive payment for each service
rendered. Is a common method of calculating health care reimbursement. Examples of
fee-for-service reimbursement are self-pay, traditional retrospective payment, and
managed care. - ANSWER-Fee for service reimbursement
A predetermined list of fees that the third-party payer allows for payment for all
healthcare services. - ANSWER-Fee schedule
Represents the average or maximum amount the third-party payer will reimburse
providers for the service. - ANSWER-Allowable charge
Defined as usual in the providers practice, customary in the community, and reasonable
for the situation - ANSWER-usual, customary, and reasonable (UCR)
Defined as customary in the providers practice, prevailing in the community, and
reasonable as the providers lowest actual charge - ANSWER-Customary, prevailing,
and reasonable (CPR)
A discounted fee schedule that Medicare uses to reimburse physicians. A payment
method that classifies health services based on the cost of providing physician services
in terms of effort, practice expenses, and malpractice insurance - ANSWER-Resource-
Based Relative Value Scale (RBRVS)
Third-party payers manage both the cost of healthcare and the outcomes of care. By
managing care, these methods begin to address the criticism of fee-for-service
