ph4330 exam 2

Prospective Reimbursement

Service Benefit Plan Used primarily by managed care organizations -Employer has a contract with a benefit plan & pays a premium for each of its employees -Employees usually also pay a portion of the premium

Medsup Plans

-Cover copays, deductibles, & coinsurance, can be very expensive -Medicare has 10 medsup plans that vary by state -Medicare Part C enrollees are not eligible

Preferred Provider Organizations (PPOs)

-Do not have a gatekeeper like the HMO so a member does not need a referral to see a specialist -Do not have a copay but a deductible -Developed by providers & hospitals to ensure that non members could still be served while providing a discount to MCOs for their members

Managed care plans

-Establish relationships with organizations & providers to provide a designated set of services to their members -Establish criteria for their members to utilize the MCO -Establish measures to estimate cost control -Provide incentives to encourage health service resources -Provide & encourage utilization of programs to improve the health status of their enrollees

Children's Health Insurance Program (CHIP)

-Initiated in response to the number of children who are uninsured in the U.S. -CHIP gave states $40 billion over a decade to provide healthcare for these children -Offers additional funds to states to expand Medicaid benefits to children younger than 19 who may otherwise not qualify because their family income exceeds medicaid levels

Medicaid services

-Inpatient & outpatient hospital services -Physician care -Nursing facility services -Home health services for children under 21 -Midwife services -Pediatric & family nurse practitioner services States responsible for at least 40% of the cost for provider services & must equally share administrative costs of the medicaid programs eligibility varies by state

Medicaid

-Provides health insurance to the indigent -It's a welfare program administered at the state level -Provides coverage to 1 in 5 people in the U.S. -Not a federally mandated program -Individuals who meet requirements can be dually enrolled in both medicaid & medicare Eligible people include 1. Families with children receiving support under the Temporary Assistance for Needy Families (TANF) Program 2. People receiving supplemental Security Income (SSI) 3. Children & pregnant women with income at or below 133% FPL 4. Children whose parents have income too high for medicaid but too low for private insurance

"Donut Hole"

-Medicare Part D coverage gap, that ACA should remedy -Starts after the beneficiary & the drug plan together have spent a designated amount for the covered drugs -Individuals must pay 45% of the plan's costs for covered brand drugs & 58% of the plan's covered generic drugs, beneficiary pays these percentages until they reach the coverage gap & then a copayment for each covered drug is paid until the end of the year

Medicare part D: Prescription Drug Benefits (The medicare prescription drug improvement & modernization act of 2003)

-Tax revenues of the federal government support majority of the costs -Provides seniors relief from high prescription costs -Voluntary program, enrollees pay a premium for coverage -Benefits rolled into Part C -Affordable prescription drug plans were made available for medicare advantage plan enrollees & traditional medicare health plans -For seniors who are considered indigent, the MMA established a low-income subsidy for the costs of Part D

Center for Medicare & Medicaid Innovation

-To support the development & testing of innovative healthcare payment & service delivery models -Seven different categories

medical part b

-covers physician services -24% from enrollee premium and 76% from federal treasury funds covers two types of services: 1) medically necessary services-services or supplies needed to diagnose or treat -aca mandates no cost sharing for preventive services covers things like: -clinical research -ambulance services -durable medical equipment -mental health treatment -inpatient/outpatient care

60% of national health expenditures :

-hospital care -physician and clinical services -prescription drugs

medical part c aka medicare advantage

-managed care model -covers all services in par a and b -designed to move medicare patients into more cost effective health insurance programs such as hmo's or ppo's -medicare pays a fixed amount for your care every month to companies -each medicare advantage plan can charge different out of pocket cost and have different rules for how you get services

where is health care in the u.s derived from?

-out of pocket or cost sharing -health insurance plans, such as indemnity plans -public or government funding (Medicaid / medicare) -health savings account (HSA)

3 parties involved in providing health care

-provider -patient -fiscal intermediary (health insurance or gov)

the increase in healthcare spending can be attributed to three causes:

-when prices increase in an economy overall the cost of medical care will increase -as life expectancy increase in the united states more individuals will require more medical care for chronic diseases -as healthcare technology and research provide more sophisticated and more expensive procedures

Approximately 65% of U.S. physicians are

specialists, which includes surgeons, cardiologists, and psychiatrists.

licensed practical nurse or licensed vocational nurse

700,000 licensed practical nurse (LPNs) in the United States. They are the largest group of nurses and provide basic nursing care. • Education is offered by community colleges or technical schools. • Training takes approximately 12-14 months and includes both education and supervised clinical practice. • LPNs have a high school diploma and a licensing exam. The 2014 median salary is approximately $40,380.

Women represent nearly

80% of the healthcare workforce.

Chief financial officer (CFO)

Supervises the comptroller who is shared with accounting & reporting functions

Prospective payment system

A mandate to hospitals to establish reimbursement rates for certain conditions

Community First Choice

A optional Medicaid benefit -Focuses on community health services to medicaid enrollees with disabilities -Enables consumers to receive care at home or at community health centers rather than going to a hospital or other facility -Provides 6% increase in federal matching payments to states for expenditures related to this option -Enables lower-income consumers & children to have access to healthcare at an affordable cost

Pioneer ACO Model

A program designed for early adopters of coordinated care Any monetary savings are shared with medicare

Medicare shared Savings Program

A program that helps medicare fee-for-service program providers becomes an ACO

Cost-plus reimbursement

A type of retrospective reimbursement Reimbursement rates for institutions are based on the total costs incurred in operating the institution that are used to calculate the per diem rate It allows a portion of the capital costs to determine the rate

Claims Processing

After services are delivered, the agency has to verify & pay the claims received from the providers

The Medicare Prescription & Drug Improvement & Modernization Act (MMA) renamed the program Medicare Advantage (MA)

Allowed the option of PPOs as an option -It also allowed enrollees to participate in private fee for service (PFFS) plans as part of the MA

Discounted Fees

Are a type of fee for service but are discounted based on a fee schedule -The provider provides the service & then can bill the MCO based on the fee schedule

Concurrent utilization reviews

Are decisions that are made during the actual course of service such as length of inpatient stay or additional surgery

Accountable Care Organizations (ACOs)

Are groups of providers & hospitals who volunteer to give coordinated care to medicare patients -The goal of ACOs is to ensure that patients, especially ones with chronic conditions, receive timely care while avoiding duplication of services & preventing medical errors

Carve-outs

Are services that Medicaid is not obligated to pay for under a MCO contract -Carve-outs have occurred because the MCO cannot provide the service or it is too expensive -Unfortunately, mental health services & substance abuse treatment services are often categorized as carve-out services

Salaries

Are the third method of payment -In this instance, the provider is actually an employer of the MCO

Physician network rentals or silent PPOs

Are unauthorized third parties outside the contract between the MCO & the physician that gain access to the MCO discount rates -Examples of these network rentals are automobile insurers or workmen's compensations insurers -They obtain the physician's rates from a database

Program of All-Inclusive Care for the Elderly (PACE)

Authorized by the balanced budget act of 1997 -Funded by Medicare & Medicaid -Provides community-based care & services to people who otherwise need nursing home levels of care -Provide care & services in the home, community and the PACE center -Implemented at the state level -Can be offered as a medicaid option -Participants must be medicare eligible or 55 years or older with a disability, live in a PACE area, & be certified for nursing home care -Operational in 32 states

States used regulatory efforts such as

Certificate of need (CON) to control expenditures by requiring an assessment to certify that a hospital is needed for a designated area

Bundled Payments Initiative

Composed of 4 broadly defined models of care which link payments that multiple service beneficiaries receive during an episode of care Model 1- Retrospective Acute Care Hospital Stay Model 2- Retrospective Acute Care Hospital Stay Plus Post-Acute Care Model 3- Retrospective Post-Acute Care Only Model 4- Acute Care Hospital Stay Only

Physicians who contract with several MCOs are

Concerned with providing quality care to their patients because the MCO's focus is on cost -As a result of their focus on cost, the physician's ability to practice without close monitoring of their healthcare choices can be limited -Surveys indicate that the more managed care networks the physician contracts, the less satisfied they are with managed care

The managed care model for health care delivery was developed for the primary purpose of

Containing health care costs -By administering both the healthcare services & the reimbursement of these services & therefore eliminating a third party health insurer -The industry felt that this model would be very cost effective

Independent Practice Associations(IPA)

Contracts with a group of physicians who are in private practice to see MCO members at a prepaid rate per visit -The physicians may sign contracts with many HMOs

Retrospective Reimbursement

Determines the amount of reimbursement after the delivery of services & provides little financial risk to providers This method contributed to the increase in healthcare costs

No-Fault Liability

Developed to avoid costly legal fees because there is no process to assess blame the employee doesn't have to demonstrate that the employer was in the wrong & the employer is protected from lawsuits

TRICARE

Developed to respond to the growing needs of retired military members, as a major component of of the military health system -It combines the healthcare resources of the uniformed services with networks of civilian healthcare professionals, institutions, pharmacies & suppliers to provide access to high quality healthcare services -It's regionally managed, HMO type operation -Fee-for-service program

The federal government has sought to control healthcare expenditures through programs such as

Diagnosis-related groups (DRGs) Ambulatory patient groups (APGs) Ambulatory payment categories (APCs) Home health resource groups (HHRGs) Resource utilization groups (RUGs) Resource-based relative value scales (RBRVSs)

(MD)

Doctor of Medicine

(DO)

Doctor of Osteopathic Medicine

Worker's Compensation

Employer is financially liable for employees who become injured or fall ill as a result of working conditions -State administered program -Employees receive cash for lost wages, payment for medical treatment, survivors death benefits, & indemnification for loss of skills -Protects both the employer & employee Employees are eligible for the program for the these issues 1. medical 2. death 3. disability 4. rehabilitation services

The Purpose of Medicare+Choice Was To

Encourage Medicare enrollees to use managed care services -Medicare offered risk plans & cost plans for their enrollees

The Health Plan Employer Data and Information Set (HEDIS)

Established by the NCQA in 1989 -It is used by nearly 100% of all health plans to measure service & quality of care -The reported data is available to MCOs & physicians

The National Committee on Quality Assurance (NCQA)

Established in 1990 to monitor health plans & improve healthcare quality -The NCQA accredits MCO although a voluntary review process it includes surveys by managed care experts & physicians

Utilization Review

Evaluates the appropriateness of the types of services provided -There are three types of utilization reviews: 1. prospective 2. concurrent 3. retrospective

Third-party payers

Government, Insurance companies & Managed care organizations

Cost shifting

Healthcare organizations have to find other ways to be reimbursed or they won't be profitable so they cost shift by raising the prices to privately insured patients to offset the small reimbursement charges of medicaid & medicare

Staff Model

Hires providers to work at a physical location

PartA:

Hospitalization insurance

Experience rating

How often they have used the workmen's compensation program for employees who have been injured on the job

Gate keeping

In some MCOs, the primary care provider is the gatekeeper of all of the care for the patient member -Any secondary or tertiary care would be coordinated by the gatekeeper

Retrospective bundled payment

Includes models 2 & 3 -Arrangement in which actual expenditures are reconciled against a target price for an episode of care

Usual, Customary & Reasonable (UCR) services

Insurance companies developed in response to government standardizing reimbursement for healthcare services - If there is a difference in the reimbursement rates the provider asked the patient to pay the difference

Retrospective utilization review

Is an evaluation of services once the services have been provided -This may occur to assess treatment patterns of certain diseases

Prospective utilization review

Is implemented before the service is actually performed by having the procedure authorized by the MCO based on clinical guidelines

Part C:

Medicare Advantage: It covers all services in Parts A and B. It is voluntary and available when an individual enrolls in Parts A and B. This program was designed to move Medicare patients into more cost-effective health insurance programs such as HMOs or PPOs.

Tax Equity & Fiscal Responsibility Act (TEFRA) Social Security Amendments of 1983

Manage medicare cost controls

• Part B:

Medicare Part B is a supplemental health plan to cover physician services. It is financed 24% from enrollee premiums and 76% from federal treasury funds.

Medigap or Medicare Supplemental Plan:

Medsup plans cover copays, deductibles, and coinsurance, which can be very expensive. Medicare has created 10 medsup plans that vary by state.

Restriction on Provider choice

Members of an MCO often have restrictions on their choice for a provider

Group Model

Negotiates with a group of physicians exclusively to perform services -This was the first type of HMO model introduced by Kaiser Permanente

Nurses constitute the largest group of health care professionals. •

Nurses provide the majority of care to patients. • They are the patient advocate. • There are several different types of nurses that provide patient care. • There are several different levels of nursing care based on education and training.

Risk plans

Pay a premium per member which is based on a county of resident basis -Members could use both in network & out of network providers -The risk plans covered all Medicare services & vision & prescription care

Per Diem Rates

Per patient per day rates -Defined dollar amount per day for care provided

Part D:

Prescription Drug Plan: Affordable drugs

Indian Health Service (IHS)

Principal federal healthcare provider & health advocate for Indian people & to raise their health status to highest possible level -Provides a comprehensive health service delivery system for American Indians & Alaskan Natives

Captitated Rate

Receive a set rate for serving enrolled patients regardless of how much care the provider gives Used by medicaid & medicare for their managed care programs

Medicare cost plans

Reimburse the MCOS on a preset monthly basis per enrollee based on a forecasted budget -The cost plans allowed members to pursue care outside the network

Internal auditor

Reports to the CFO, ensures that accounting procedures are performed in accordance with appropriate regulations

Treasurer

Responsible for cash management, banking, accounts payable, etc

Exclusive Provider Organizations (EOP)

Similar to PPOs but they restrict members to the list of preferred or exclusive providers members can use

Network model

Similar to the Group model but these providers may see other patients who are not members of the HMO

Health Maintenance Organizations (HMOs)

The HMOs are the oldest type of managed care -Members must see their primary care provider first in order to see a specialist

Silent PPOs

The main insurer who has the contract with the physician does not provide the information to the physician & the third parties continue to benefit from the discounted rates -There are several states that prohibit these silent PPOs

Capitation Policy or Per Member Per Month Policy

The provider is paid a fixed monthly amount per employee which is often called a PMPM payment

Physician hospital Organizations (PHO)

These organizations include physician hospitals, surgical centers, & other medical providers that contract with a managed care plan to provide health services

Dentists prevent, diagnose, and treat teeth, gum and mouth diseases.

They are required to complete four years of dental school from an accredited dental school once a bachelor's degree is completed. • They are awarded a Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DDM) • 2014 salary was $154,650

Podiatrists provide medical and surgical care for people suffering from foot, ankle, and lower leg problems.

They diagnose illnesses, treat injuries, and perform surgery. • Podiatrists must have a Doctor of Podiatric Medicine (DPM) degree, which is a 4-year degree after earning a bachelor's degree. • 2014 salary was $121,000

Doctors of Optometry or ODs, are the main providers of vision care.

They examine people's eyes to diagnose vision problems. • Optometrists may prescribe eyeglasses or contact lenses. • Optometrists need a Doctor of Optometry (O.D.) degree. 2014 salary was $101,500

Medigap or Medicare Supplement Plan or Medsup

To cover out-of-pocket expenses Medicare enrollees can receive additional coverage from 1. Medicaid if the medicare enrollee is eligible 2. Enrollment in Medicare Advantage, which can provide supplemental coverage 3. Employer-sponsored retiree insurance 4. Supplemental insurance policies from private insurance companies, which are called medigap or medsup policies

It is important to identify allied health professionals because they provide

a range of essential healthcare services that complement direct provider care

Advance Payment ACO Model

a supplementary incentive program for smaller practices & physician based & rural providers in the shared savings program They receive monthly payments to use for coordinated care

Quaternary care is

an extension of tertiary care and is considered cutting-edge specialty medicine.

NPPs play a major role in:

areas that are underserved by physicians such as rural and underserved urban areas; in community health centers; and the managed care environment. • NPPs can be used with repetitive technical tasks such as screening tools for diseases. • They may also take care of non-life-threatening cases in emergency departments, perform physicals, drug testing, and other routine activities. • Their salaries are nearly 50% less than physician salaries so they are a cost-effective caregiver for patients

catastrophic health insurance

covering expensive illness

fee for service

developed by BCBS, is based on the concept of a person purchasing coverage for certain benefits

medical part a

financed by hospital insurance , money is collected though employer/employee 1.45% self employed pay 2.5% you pay no premium if you and spouse paid medicare taxes for at least 10 years if no one paid then your 2016 premium will be $411 part a covers hospital care, skilled nursing, facility care, nursing home care, hospice, and home health services

Secondary care

focuses on short-term interventions that may require a specialist's intervention. Examples of secondary care would include hospitalizations

allied health professionals

four main categories: laboratory technologists and technicians, therapeutic science practitioners, behavioral scientists, and support services. • They provide support to physicians and nurses. •The Commission on Accreditation of Allied Health Education Programs (CAAHEP) accredits 2,000 U.S. programs that offer allied health specialties.

Differences in salaries are a reason for shortages of

generalists and specialty maldistribution.

Family care practitioners are also called

generalists as are general internal medicine physicians and general pediatrics. Their focus is preventive services such as immunizations and health examinations. • They often serve as gatekeepers for patients, which means they coordinate patient care if patients need to see a specialist.

4 types of private health insurance:

group insurance: anticipates large group of people will buy insurance from employer individual private health insurance: risk is determined by individuals health managed care plans: are a type of health program that combines administrative costs for cost control

Tertiary care

is a complex level of medical care and is typically performed by surgeons who are physicians that perform operations to treat disease, physical problems, and injuries. • This type of care is usually based on a referral from a primary care provider.

quaternary care

is an extension of tertiary care and refers to highly specialized, cutting performed in research facilities and highly specialized facilities. • An example of this type of care is proton beam therapy, which is cutting-edge technology.

voluntary health insurance

social insurance and public welfare insurance provided by government federal , local, state

Primary care

is the essential component of the U.S. healthcare system because it is the point of entry into the system. • Primary care focuses on continuous and routine care of an individual.

Certified nurse-midwives (CNM) are RNs who have graduated from a

nurse midwifery education program that has been accredited by the American College of Nurse-Midwives' Division of Accreditation. • Nurse-midwives have been practicing in the United States for nearly 90 years. • 2014 salary was $96,970.

Generalists are also called

primary care physicians.

comprehensive health insurance policies

provide benefits that include outpatient and inpatient services. surgery, etcetera

Managed care refers to

the cost management of health care services utilization by controlling who the consumer sees & how much the service cost. -Managed care organizations were introduced 40 years ago, but became more entrenched in the healthcare system when the Health Maintenance Organization Act of 1973 was signed into law

family and medical leave act (fmla)

was passed to protect employee in the event of a family illness

non physician practitioners (NPPS)

which includes non physician clinicians (NPCs) and midlevel practitioners (MLPs). • They are often called physician extenders because they often are used as a substitute for physicians. • They are not involved in total care of a patient so they collaborate closely with physicians. • Categories of NPPs include physician assistants (PAs), nurse practitioners (NPs), and certified nurse practitioners (CNMs).

MDs use an allopathic approach

which means MDs actively intervene in attacking and eradicating disease and focus their efforts on the disease.

DOs tend to stress preventive treatments and use a holistic approach to treating a patient,

which means they do not focus only on the disease but on the entire person. Most DOs are generalists.

Chiropractors have a holistic approach to treating their patients,

which means they focus on the entire body with emphasis on the spine. • Becoming a chiropractor requires earning a Doctor of Chiropractic (D.C.) degree and getting a state license. • 2014 salary was $67,000

major medical policies

which reimburse hospital services

Psychologists study the human mind and human behavior. Some psychologists work independently, doing research or working only with patients.

• Others work as part of a healthcare team, collaborating with physicians, social workers, and others to treat illness and promote overall wellness. • Psychologists can complete a Ph.D. in psychology or a Doctor of Psychology (PsyD) degree • 2014 salary was $71,000.

NursePractitioners(NPs)arethelargest categories of advanced practice nurses.

• They are required to obtain an RN and a master's degree or doctoral degree. They may receive a certificate program and complete direct patient care clinical training. • NPs emphasize health education and promotion as well as disease treatment—referred to as care and cure. • 2014 median salary was $95,320.

A registered nurse (RN) is a trained nurse who has been licensed by a state board after passing the national nursing examination.

• They can be registered in more than one state. • There are different levels of registered nursing based on education. • An associate degree or a four-year degree as a registered nurse. • Average salary is $66,640.

dental assistants.

• They clean patients' teeth and educate patients on proper dental care. • Dental assistants work directly with dentists in the preparation and treatment of patients. • 2014 salary is $35,390

Dental hygienists clean teeth, examine patients for oral diseases, and provide other preventative dental care.

• They educate patients on ways to improve and maintain oral health. • Dental hygienists typically need an associate's degree in dental hygiene. • 2014 salary is $71,520

Advanced practical nurse (APN) or midlevel practitioners are nurses who have experience and education beyond the requirements of an RN.

• They operate between the RN and MD, which is why they are called midlevel practitioners. • They normally obtain a Master of Science in Nursing (MSN) with a specialty in the field of practice. $102,670

Physician assistants (PAs), a category of NPPs, provide a range of diagnostic and therapeutic services to patients.

• They take medical histories, conduct patient examinations, analyze tests, make diagnoses, and perform basic medical procedures. • They are able to prescribe medicines in all but three states. • They must be associated and supervised by a physician but the supervision does not need to be direct

Specialists are required to be certified in their area of specialization.

• This may require additional years of training, as discussed in the previous paragraph and require a board certifying or credentialing examination. • The most common specialties are dermatology, cardiology, pediatrics, pathology, psychiatry, obstetrics, anesthesiology, specialized internal medicine, gynecology, ophthalmology, radiology, and surgery.

Pharmacists are responsible for dispensing medication that has been prescribed by physicians.

• advise patients and healthcare providers on potential side effects of medications. • Pharmacy programs require applicants to have taken postsecondary courses such as chemistry, biology, and anatomy. • 2-3 years of undergraduate study; for some programs, applicants must have a bachelor's degree. • 2014 salary is $120,950

Certified nursing assistants (CNAs) are unlicensed patient attendants who work under the supervision of physicians and nurses.

• answer patient call bells that need their service; assist patients with personal hygiene, changing beds, ordering their meals; and assist patients with their ADLs. • Most CNAs are employed by nursing care facilities. • Their pay is very low—2014 salary is $25,000.