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
cf cf cf cf cf cf cf
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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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
1cf/
cf13
, LEADERSHIP: CHAPTER 4: FINANCIAL MANAGEMENT IN HEALTH CA
cf cf cf cf cf cf cf
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
2cf/
cf13
