KINN's Chapter 16/17

What is a Capitation plan?

A healthcare plan that allows payment of a flat fee for each patient it covers. Capitation is a payment in advance to provide by HMO for contracted group of patient's

When a hospital hires a doctor and pays their salary, what kind of model is that?

A staff model.

What does the utilization review committee do?

A utilization review committee reviews individual cases to make certain that medical care services are medically necessary (not medical fees)

Which two health plans are required to become participating providers (PARs)

All government-sponsored health plans and most privately sponsored health plans

Which managed care plans requires preauthorization's?

All managed care plans, including HMOs, PPOs, and EPOs require authorization for medical services such surgery, expensive medical tests and medication therapy.

What is the allowable amount (charge)

Allowable charge is the maximum that third-party payer will pay for a procedure or service

Define third party payer

An institution or company that provides reimbursement to health care providers for rendered to a third-party

Know what BLOCKS 1,2,4,7,13,14,11d,24d,25,31,33a- on the CMS 1500 form are used for?

Blk 1: Type of insurance carrier Blk 2: Patient's Name Blk 4: Insured's Name Blk 7: Insured's Address Blk 11d: Is there another health benefit plan? Blk 13: Insured's or Authorized person's signature Blk 14: Date of current illness, injury or pregnancy (LMP) Blk 24d: Procedure , Service or Supplies for CPT/HCPCS and Modifier Blk 25: Federal Tax I.D # can be listed as a SSI or EIN Blk 31: Signature of Physician or Supplier Blk 33a: Billing Provider info & PH # also add the Rendering Provider ID #

Define and explain what a group policy is for

Businesses have offered their eligible full-time employees health insurance as a group policy, a privately sponsored health insurance plan purchased by an employer for a group of employees.

TRICARE is a healthcare program for who? Explain in 3 parts.

Covers family members of active duty personnel, military retirees and their eligible family members under the age of 65, and the survivors of all uniformed services.

CHAMPVA is a healthcare program for who?

For the spouses and dependent children of veterans suffering spouses total, permanent, service-connected disabilities and for surviving spouses and dependent children of veteran who died as a result of service-related disabilities.

Which MCO has the lowest monthly premiums, and low financial responsibility?

HMO plans typically have the lowest monthly premiums, with lower patient financial responsibility.

What is staff model HMO?

One or more providers hired by an HMO

Which Medicare plan for primary care services and specialists' services is a patient required to pay monthly premium?

Part B Medicare Health Plan

Define Medicare A,B,C,D- Part A: is a hospital insurance for qualified Medicare participates & is financed with special contributions deducted from employed individuals' salaries, w/ matching contributions from their employers.

Part B: is medical insurance for ambulatory care, including primary care & specialists for which patients are required to pay a monthly premium; also functions similar to a PPO in that patients can visit any specialist w/out referral. Part C: is an option for Medicare-qualified patients to turn their Part A & Part B benefits into a privately sponsored plan that can offer some additional benefits. Part D: is a prescription drug program offered to Medicare-qualified individuals that requires an additional monthly premium.

Medigap is used to cover the difference between Medicare's reimbursement and the ?

Patient financial responsibilities

Define a Premium, deductible and co-pay

Premium- is an amount paid periodically to the insurer by the insured for covering his/her risk. Deductible- a specified amount of money that the insured must pay before an insurance company will pay a claim. Copay- a patient financial responsibility, which is due at the time of the office visit

Which referral can be approved online?

STAT referral

What are the three sections on the CMS 1500 forms?

Section 1: Carrier Section 2: Patient and Insured Information * Section 3: Physician or Supplier Information

Medicaid is funded by whom, and who is eligible

The federal government provides funding to the state for medicaid programs & the state individually decide whether to provide funds for extension of benefits. Eligibility for benefits: - Individuals who are medically needy -Recipients of Aid to Families with dependent children (AFDC) -Individuals who receive SSI -Individuals who receive certain types of Federal & state aid -Individuals who are Qualified Medicare beneficiaries (QMBs) -Individuals in instiutions or receiving long-term care in nursing facilities and intermediate-care facilities