CHFP Exam Flash Cards (Answered) 100%
Correct. Perfect Exam Prep for Your
Exams 2024/2025.
Facility Providers
Hospitals
Skilled Nursing Facilities
Assisted Living Facilities
Home Health Agencies
Ambulatory Surgery Center
Professional Providers
Physicians
Pharmacists
Nurses
Allied Professional Providers (APPs) - PT, clinical social work, & others
Primary Care Physicians - Usually trained in:
Family Practice
General Practice
General Internal Medicine
Pediatrics
Primary Care Physicians role is viewed as:
Coordinator of a patients care
Assessing a patient's condition
Referring a patient to a specialist physician
Specialists
Focus on in-depth training in special diseases, body systems, or types of healthcare services.
Since the majority of their work is done within a hospital facility, specialties of radiology,
anesthesiology, and pathology - along with emergency room physicians and hospitalits are referred
to as?
Hospital-based Physicians
Types of out-of-pocket payments by patients that can be required as part of a health insurance plan
are:
Deductibles
Co-payments
Coinsurance
Deductible
,a predetermined amount that insured must pay each year before the insurance company will pay
Coinsurance
a percentage of the insurance payment amount that is paid by the patient, along with the amount
paid by the insurer.
Copayment
A flat amount that the patient pays at each time of service.
Benefit Payment
Amount paid by the insurer to the provider after the claim is determined as appropriate.
Covered benefit
The services for which the insurer will pay.
Medicare
A federal program of health insurance for persons 65 years of age and older, persons with
disabilities, and persons with End Stage Renal Disease (ESRD).
Medicare Part A (aka Hospital Insurance or HI)
Provides hospital insurance automatically @ age 65 (if FICA qualified) @ no fee but may have
deductible & co-pay.
Categorical eligibility
Persons who have paid Medicare wage taxes for at least 40 calendar quarters. Part of only Medicare
Part A.
Medicare Part A Covers
Inpatient hospital services, certain organ transplants, ESRD treatment , inpatient skilled nursing
facility care, home health care and hospice care.
Lifetime Reserve
Medicare Part A after 180 days per spell of illness, the patient has a one-time bank of days to cover
long stays.
Medicare Part A Coverage for Hospital Stays
o Cost of days 2 - 60 of a spell of illness or hospitalization
o Days 61-180 - the patient pays a coinsurance amount per day
o After 180 days, Medicare Part A stops & lifetime reserve may kick in
Medicare Part B
Voluntary program where a patient that meets the age or medical condition requirements for
Medicare Part A (but not the requirement to pay taxes for 40 calendar quarters) may participate in
the insurance benefit.
Funded by a combination of premiums paid by the beneficiary and general tax revenues from the
federal government.
,Part B Only
Patients who are covered by Medicare Part B but not Medicare Part A.
Medicare Part C (Medicare Advantage)
•Replaces and covers expenses found in Part A and B
•Medicare private fee-for-service plans (PFFS)
•Medicare managed care plans (HMOs and PPOs)
•Medicare specialty plans
Medicare Part D Prescription Drug Coverage
a United States federal-government program to subsidize the costs of prescription drugs and
prescription drug insurance premiums for Medicare beneficiaries.
***Prescription drug coverage for Medicare enrollees, which offsets some of the out-of-pocket costs
for medications.
Medicaid
A federal and state assistance program that pays for health care services for people who cannot
afford them. ***Joint program between federal government and states.
Spend-down program
Program that allows patients to pay a portion of their medical expenses each month with Medicaid
available to assist with the remaining medical expenses. This program is for persons who are at or
below the state income level. Medicaid eligibility is then determined month to month.
hospital acquired conditions (HAC)
reasonably preventable conditions for which hospitals do not receive additional payment when one
of the conditions was not present on admission
individual mandate (ACA)
The Affordable Care Act requires nearly everyone to have health insurance that meets minimum
standards. With some exceptions, people who do not maintain health insurance coverage will have
to pay a tax penalty
Employer Mandate (ACA)
Requires employers with more than 50 employees to provide health insurance benefits to
employees.
Other provisions of the Affordable Care Act include:
Medicaid Eligibility
Accountable Care Organizations (ACOs)
Value-Based Purchasing
Bundled Payments
Medicaid eligibility
, - Expanded under ACA by increasing the income limits of persons to qualify for this program.
- Decision to expand Medicaid lies with each state.
- Intent of increasing the number of persons eligible for Medicaid is to reduce the number of persons
seeking care for healthcare emergencies who have no ability to pay.
- With more of the population covered by Medicaid, providers no longer have to shift the costs of
care for the uninsured to other patients and other insurance plans.
Accountable Care Organization (ACO)
An organization of healthcare providers accountable for the quality, cost, and overall care of
Medicare beneficiaries who are assigned and enrolled in the traditional fee-for-service program.
Triple Aim of:
1. Improving the individual experience of care
2. Improving the health of populations (population health)
3. Reducing the per capita cost of care of populations
Triple Aim Reform:
1. Quality Outcomes
2. Reduced Cost
3. Increased Patient Safety and Satisfaction with Treatment
Triple Aim 3rd Definition:
1. Healthy Population
2. Extraordinary patient care
3. Reasonable costs
Bundled Payments (ACA)***Fundamental of Affordable Care Act
New payment mechanism introduced by the Affordable Care Act that pays a single amount for an
episode of care.
Value Based Purchasing (VBP)***Fundamental of Affordable Care Act
Places a portion of the payments to the provider at risk of loss if specified quality objectives are not
met or exceeded.
The amount of risk has been increasing year-to-year since implementation of the ACA and is applied
to hospital and physician provider entities.
Healthcare Technology
Exerts significant upward pressure on the operating expenses in this industry. While technological
innovation in some areas such as computers or consumer electronics usually yields reductions in
price to the buyer, such is not the case in health care.
Technology Priorities
As pressures by care purchasers limit payment growth, healthcare providers must make new kinds of
technology investments to help manage outcomes, quality, safety and cost.
New Technology Priorities include
Correct. Perfect Exam Prep for Your
Exams 2024/2025.
Facility Providers
Hospitals
Skilled Nursing Facilities
Assisted Living Facilities
Home Health Agencies
Ambulatory Surgery Center
Professional Providers
Physicians
Pharmacists
Nurses
Allied Professional Providers (APPs) - PT, clinical social work, & others
Primary Care Physicians - Usually trained in:
Family Practice
General Practice
General Internal Medicine
Pediatrics
Primary Care Physicians role is viewed as:
Coordinator of a patients care
Assessing a patient's condition
Referring a patient to a specialist physician
Specialists
Focus on in-depth training in special diseases, body systems, or types of healthcare services.
Since the majority of their work is done within a hospital facility, specialties of radiology,
anesthesiology, and pathology - along with emergency room physicians and hospitalits are referred
to as?
Hospital-based Physicians
Types of out-of-pocket payments by patients that can be required as part of a health insurance plan
are:
Deductibles
Co-payments
Coinsurance
Deductible
,a predetermined amount that insured must pay each year before the insurance company will pay
Coinsurance
a percentage of the insurance payment amount that is paid by the patient, along with the amount
paid by the insurer.
Copayment
A flat amount that the patient pays at each time of service.
Benefit Payment
Amount paid by the insurer to the provider after the claim is determined as appropriate.
Covered benefit
The services for which the insurer will pay.
Medicare
A federal program of health insurance for persons 65 years of age and older, persons with
disabilities, and persons with End Stage Renal Disease (ESRD).
Medicare Part A (aka Hospital Insurance or HI)
Provides hospital insurance automatically @ age 65 (if FICA qualified) @ no fee but may have
deductible & co-pay.
Categorical eligibility
Persons who have paid Medicare wage taxes for at least 40 calendar quarters. Part of only Medicare
Part A.
Medicare Part A Covers
Inpatient hospital services, certain organ transplants, ESRD treatment , inpatient skilled nursing
facility care, home health care and hospice care.
Lifetime Reserve
Medicare Part A after 180 days per spell of illness, the patient has a one-time bank of days to cover
long stays.
Medicare Part A Coverage for Hospital Stays
o Cost of days 2 - 60 of a spell of illness or hospitalization
o Days 61-180 - the patient pays a coinsurance amount per day
o After 180 days, Medicare Part A stops & lifetime reserve may kick in
Medicare Part B
Voluntary program where a patient that meets the age or medical condition requirements for
Medicare Part A (but not the requirement to pay taxes for 40 calendar quarters) may participate in
the insurance benefit.
Funded by a combination of premiums paid by the beneficiary and general tax revenues from the
federal government.
,Part B Only
Patients who are covered by Medicare Part B but not Medicare Part A.
Medicare Part C (Medicare Advantage)
•Replaces and covers expenses found in Part A and B
•Medicare private fee-for-service plans (PFFS)
•Medicare managed care plans (HMOs and PPOs)
•Medicare specialty plans
Medicare Part D Prescription Drug Coverage
a United States federal-government program to subsidize the costs of prescription drugs and
prescription drug insurance premiums for Medicare beneficiaries.
***Prescription drug coverage for Medicare enrollees, which offsets some of the out-of-pocket costs
for medications.
Medicaid
A federal and state assistance program that pays for health care services for people who cannot
afford them. ***Joint program between federal government and states.
Spend-down program
Program that allows patients to pay a portion of their medical expenses each month with Medicaid
available to assist with the remaining medical expenses. This program is for persons who are at or
below the state income level. Medicaid eligibility is then determined month to month.
hospital acquired conditions (HAC)
reasonably preventable conditions for which hospitals do not receive additional payment when one
of the conditions was not present on admission
individual mandate (ACA)
The Affordable Care Act requires nearly everyone to have health insurance that meets minimum
standards. With some exceptions, people who do not maintain health insurance coverage will have
to pay a tax penalty
Employer Mandate (ACA)
Requires employers with more than 50 employees to provide health insurance benefits to
employees.
Other provisions of the Affordable Care Act include:
Medicaid Eligibility
Accountable Care Organizations (ACOs)
Value-Based Purchasing
Bundled Payments
Medicaid eligibility
, - Expanded under ACA by increasing the income limits of persons to qualify for this program.
- Decision to expand Medicaid lies with each state.
- Intent of increasing the number of persons eligible for Medicaid is to reduce the number of persons
seeking care for healthcare emergencies who have no ability to pay.
- With more of the population covered by Medicaid, providers no longer have to shift the costs of
care for the uninsured to other patients and other insurance plans.
Accountable Care Organization (ACO)
An organization of healthcare providers accountable for the quality, cost, and overall care of
Medicare beneficiaries who are assigned and enrolled in the traditional fee-for-service program.
Triple Aim of:
1. Improving the individual experience of care
2. Improving the health of populations (population health)
3. Reducing the per capita cost of care of populations
Triple Aim Reform:
1. Quality Outcomes
2. Reduced Cost
3. Increased Patient Safety and Satisfaction with Treatment
Triple Aim 3rd Definition:
1. Healthy Population
2. Extraordinary patient care
3. Reasonable costs
Bundled Payments (ACA)***Fundamental of Affordable Care Act
New payment mechanism introduced by the Affordable Care Act that pays a single amount for an
episode of care.
Value Based Purchasing (VBP)***Fundamental of Affordable Care Act
Places a portion of the payments to the provider at risk of loss if specified quality objectives are not
met or exceeded.
The amount of risk has been increasing year-to-year since implementation of the ACA and is applied
to hospital and physician provider entities.
Healthcare Technology
Exerts significant upward pressure on the operating expenses in this industry. While technological
innovation in some areas such as computers or consumer electronics usually yields reductions in
price to the buyer, such is not the case in health care.
Technology Priorities
As pressures by care purchasers limit payment growth, healthcare providers must make new kinds of
technology investments to help manage outcomes, quality, safety and cost.
New Technology Priorities include
