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Flashcards in Quiz 1 Deck (65)
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1

For profit

- Any profit generated from the enterprise can be paid to shareholders (owners)
Example: insurance companies (united, humana, etc)

2

Not for profit

- Any profit generated from the enterprise is put back into the business; NO shareholders/owners

3

Deductible

the amount the patient must pay annually before the insurer will pay anything

4

Copay

- the amount patient pays at time of service ALL YEAR (even after deductible is met)

5

Coinsurance

- percentage of the total cost that the patient must pay

6

Private insurance

- non-government
Example: BCBS, United

7

Public insurance

- government insurance
Example: Medicare, Medicaid, tri-care

8

Fee for service (FFS)

AKA “indemnity” provider bills the insurer, so cost responsibility is that of the insurers

9

Preferred provider organization (PPO)

providers sign contracts governing payment and the number of physicians in the network is restricted

10

Health Maintenance Organization (HMO)

- cost responsibility lies with PCP’s through capitation = so this reduced health care costs

11

Consumer Directed Health Plan (CDHP)

cost responsibility of the patient

12

Claim

what the provider submits to insurance

13

Explanation of benefits

defines the allowable

14

Allowable

total amount the provider is paid per the contract with the insurer

15

Medicare

federal insurance for all elderly ages 65+

16

Medicare Advantage Plan

elderly patients can opt out of Medicare’s plan for another commercial insurer, but Medicare pays the patient’s premium to the commercial insurer

17

Medicaid

insurance plan for the poor

18

What is “risk”?

- Another party assuming financial risk for the customer; protects customer from financial ruin in case of expensive unforeseen incidents

19

Demand risk

- how many people seek out the service

20

Volume (utilization) risk

types of services performed, quantity of services, and length of time of service

21

FFS incentives

no incentives for quality or cost containment

22

FFS risk

insurer at financial risk

23

What is discounted fee for service (DFFS)?

attempt by insurers to decrease cost by establishing that a certain % of the charge is subtracted off the top

24

DFFS incentives

no incentive for quality or cost containment

25

DFFS risk

insurer at risk

26

What is fee schedule?

each billing code has a fixed payment tied to it

27

Fee schedule incentives

incentive to do more of the codes that pay well, less of the low-paying codes; no incentive for quality, some incentive for cost containment

28

Fee scheduling risk

insurer bears all demand and risk volume; provider bears some volume

29

Per Diem payment methods (outpatient)

pay per visit

30

Per Diem outpatient incentives

decrease overall clinic costs, decrease time span of visits, no incentive for quality