Course Content 1/2024
Outpatient pre-treatment authorization plan (OPAP)
- Requires pre-authorization of outpatient physical, occupational, and speech therapy services - Requires periodic treatment /progress plans to be filed
Tricare Options
- TriCare Prime: military treatment facilities - TriCare Extra : preferred provider organization -TriCare standard: (formally CHAMPUS) fee for service
Federal employee program (FEP)
- employer sponsored health benefits program established by an active Congress in 1959 - Under written and administered by participating insurance plans, i.e. Blue Cross Blue Shield that are called local plans
Preferred Provider Organization (PPO)
- offers discounted healthcare services to subscribers, who use designated healthcare providers - provides coverage for services rendered by healthcare providers who are not part of the PPO network - subscriber a.k.a. member is responsible for remaining within the network and must also adhere to the manage care requirements of the PPO policy
Breach of confidentiality under HIPAA
-Healthcare providers are required to notify patients when PHI has been breached notification must occur within 60 days after discovery of the breach -media notification must occur when more than 500 individuals that reside in one state or jurisdiction, are impacted by the breach
Common forms of Medicare fraud
-billing for services that were not performed -Misrepresenting diagnosis to justify payment -Kickbacks -Unbundling codes
Release of info under HIPAA
-covered entity must have a signed authorization to release information -Mandated 60 day time limit allowed for processing
Preferred provider network (PPN)
1 adhere to manage care provisions 2 except the PPN allowed rate, which is generally 10% lower than the PAR allowed rate 3 abide by all cost, containment, utilization, and quality assurance provisions of the program
Types of Health Insurance
1 commercial 2 Blue Cross Blue Shield - (PAR) participating provider: submit insurance claims for all BCBS subscribers and provide access to the PROVIDER RELATIONS DEPARTMENT which assist in resolving claims or payment problems 3 Medicare 4 Medicaid 5 TRICARE - healthcare program for active military and their families 6 Worker's Compensation
HIPAA (Health Insurance Portability and Accountability Act)
1. Restricts use of pre-existing conditions and health insurance coverage determinations 2. Set standards for medical records privacy and establishes tax favor treatment of long-term care insurance.
CONT...Federal employee program (FEP)
101- individual high option plan 102- family high option plan 104- individual standard low option plan 105- family standard low option plan
Medicaid
1965 Congress Pass, title 19 of the Social Security act, establishing a federally mandated State administered medical assistance program for individuals with income below the federal poverty level - helps provide medical and health related services to families with limited resources or low income
Medicare
A federal program of health insurance for persons 65 years of age and older - The largest medical program in the United States ; this federal program is authorized by Congress and administered by the centers for Medicare and Medicaid
COBRA (Consolidated Omnibus Budget Reconciliation Act)
A landmark federal law passed by Congress in 1986 - contains specific regulations that allow employees who lose their jobs to continue with their health plan for 18 months
Managed Care
A system of medical team members organized into groups to provide quality and cost-effective care that encompasses both the delivery of healthcare and the payment of services
Disability insurance
A type of insurance paid to an individual if he/she is injured and is unable to work - reimbursement for income loss as a result of temporary or permanent illness injury
Medicare prescription drug part D
Add prescription drug coverage to the original Medicare plan some Medicare cost plans, some Medicare private fee for service plans and Medicare medical savings account plans
Point of Service Plan (POS)
Allow subscribers to choose at the time medical services are needed whether they will go to a provider within the plans network or outside the network —— outside the network, usually out-of-pocket expenses and copayments increase
Health insurance
Contract between policyholder and a third-party payer or government program to reimburse the policyholder for all or a portion of the cost of medically necessary, treatment or preventive care, provided by healthcare professionals
Medicare hospital insurance part a
Covers inpatient hospital, critical care access, skilled nursing facility, hospice care, and some home healthcare
Electronic, healthcare transaction
Establishes a uniform language for electronic data exchange (EDI) HIPAA requires payers to implement these transactions
Commercial group health plan coverage
Fringe benefit program to retain high-quality employees and ensure productivity by providing preventive medical care to create a healthy workforce
HITECH Act
Health information technology for economic and clinical health act was signed into law in 2009 (part of the American Recovery and Reinvestment Act) to motivate the implementation of electronic health records (EHR)and supporting technology in the US
Medicare advantage part C a.k.a. formally Medicare + Choice
Includes manage, healthcare and private fee for service plans that provide contracted care to Medicare patients - It's an alternative to the original Medicare plan reimburse under Medicare part a
Office of the National Coordinator for Health Information Technology (ONC)
It's work on health IT is authorized by (HITECH) — they have the authority to establish programs to improve healthcare quality, safety, and efficiency, including electronic health records and private and secure, electronic health information exchange
Medicare medical insurance part B
Pays for doctor services, outpatient hospital, care, durable medical equipment, and some medical service that are not covered by part a
Health Maintenance Organization (HMO)
Plan that assumes or shares the financial and healthcare delivery risks associated with providing comprehensive medical services to subscribers in a return for a fixed prepaid fee
Federal anti-kickback law
Protect patients from fraud and neglect by curtailing the corrupt influence of money on healthcare choices
Healh care
Provided by health professionals in allied health fields - maintenance or improvement of health via the prevention, diagnosis and treatment of disease, illness injury, and other physical and mental impairments in human beings
Medical care
Provided by licensed healthcare providers- identification of disease and treatment of those who are sick, injured, or concerned about their health
Medigap
Provides reimbursement for out-of-pocket cost, not covered by Medicare. In addition to those that are the beneficiary share of healthcare costs
Medicare Part A
Reimburses institutional providers for inpatient hospice and some home health services
Medicare Part B
Reimburses institutional providers for outpatient services and physicians for inpatient and office services
Personal health record (PHR)
Similar to EHR Except the individual controls what kind of information goes into it. This can be used to keep track of information from Dr. visits and outside doctors office, such as health, priorities, tracking what you eat, exercise, and blood pressure. Sometimes PHR can link with doctors EHR
Primary Care Manager (PCM)
The healthcare provider assigned to a TRICARE enrollee and is responsible for providing all routine, nonemergency and urgent healthcare
Electronic prescribing (e-prescribing)
a technology that enables a physician/doctor to transmit a prescription electronically to a patient's pharmacy
Personal Injury Protection (PIP)
coverage for medical, hospital, and funeral costs of the insured and passengers in the event of an auto accident -regardless of fault also pays for loss, earnings, rehabilitation and replacement of services, such as childcare if a parent is disabled
Military health services system (MHSS)
entire health care system of the U.S. uniformed services and includes military treatment facilities (MTFs) as well as various programs in the civilian health care market, such as TRICARE.
Second Surgical Opinion (SSO)
second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery (e.g., outpatient clinic or doctor's office versus inpatient hospitalization). - if a second surgical opinion is not obtained prior to surgery patient out-of-pocket expenses may be greatly increased
Electronic Health Records (EHR)
the electronic form of personal and health data - this is accessible when you have a problem even if the office is closed and makes it easier for doctors to share information with specialists so that those who need your information have it available —————- digital version of a patient's medical history such as demographic condition, diagnosis, prescription, and overall health information
