Reimbursement and Research Flashcards

1
Q

First Party

A

Patient

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2
Q

Second Party

A

Health Care Professional delivering services

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3
Q

Third Party

A

Insurer

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4
Q

Payer

A

the insurer who makes the payment for services under the insurance coverage policy

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5
Q

Capitation

A

a reimbursement method that pays the provider a set fee each month, based on the number of patients enrolled in the insurance plan.

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6
Q

Capitated payment

A

a form of reimbursement for health care services in which a health provider is paid a predetermined (fixed) amount for each patient enrolled in his or her care.

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7
Q

Fee-for-service

A

a payment for specific health care services that were provided to a patient

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8
Q

Medicare is a health insurance provider for…

A

People age 65 or older,
under age 65 with certain disabilities,
any age with end stage renal disease (perm. Kidney failure needing dialysis or kidney transplant)

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9
Q

People age 65 or older can apply for?

A

medicare

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10
Q

any age with end stage renal disease (perm. Kidney failure needing dialysis or kidney transplant) can apply for?

A

medicare

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11
Q

under age 65 with certain disabilities can apply for?

A

medicare

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12
Q

Largest provider of health care services in the US?

A

medicare

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13
Q

established in 1965 as part of the social security act

A

medicare

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14
Q

Medicare Part A

A

covers inpatient care (but not long term care), hospice and some home health care

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15
Q

Medicare Part B

A

covers doctors services and outpatient care, some home health care, DME (durable medical equipment)

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16
Q

Medicare Part C (medicare Advantage)

A

Monthly premiums
provided by private companties approved by medicare
covers same as parts A and B plus additional services amd Rx

17
Q

Medicare D

A

Monthly premiums
prescription drugs
available to those with parts A and B

18
Q

Current cap for Medicare?

A

$1900

patient can receive 1900 in PT and SLP services in a calendar year (jan1-dec31)

19
Q

KX modifier?

A

the requirement to billing indicating services are reasonable and necessary to extent the cap for medicare.
extended to 3700

20
Q

When do exceptions to KX modifier expire?

A

Dec31

21
Q

G-codes

A

Functional limitations reporting at eval, and no more than every 10th visit, and at discarge (PT resposibility)

22
Q

Medicaid

A
state and federally funded
state run 
provides medical and health-related services
enacted in 1965 part of social security
small copay usually required
23
Q

What people are covered under medicaid?

A

kids
disables, blind or pregnant
financial resources
US citizen or lawfully admitted immigrant

24
Q

HMO

A

health maintenance organizations

25
Q

HMO function

A

a type of managed care organization (MCO) that is provided by a limited number of professionals for a fixed fee
monitors and limits excessive expeditures
Must see PCP before specialists, only see providers within the network
initially created to decrease cost by providing preventative services

26
Q

PPO

A

a variation (in regards to HMO) in which patients can visit physicians outside of the network for increased costs and can visit specialists without referral

27
Q

Managed care

A

a system in which the provision of benefits and services are controlled;administrative incentives and constraints

28
Q

Current procedural terminology (CPT)

A

condes assigned to health care service and billing and reimbursement