Test 1 HSM 250

Medicare Part D—Medicare Prescription Drug Coverage

A beneficiary is eligible to receive this benefit after joining a Medicare drug plan; such plans are usually run by insurance companies approved by Medicare. Plans vary in cost, based on options and drugs covered

Coordination of Benefits (COB)

A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.

Medicaid

A federal and state assistance program that pays for health care services for people who cannot afford them.

Medicare

A federal program of health insurance for persons 65 years of age and older or disabled or with end-stage renal disease

Workers' Compensation

A form of insurance paid by the employer providing cash benefits to workers injured or disabled in the course of employment.

Physician-Hospital Organization (PHO)

A health care plan in which physicians join with hospitals to provide a medical care delivery system and then contract for insurance with a commercial carrier or an HMO

Stop Loss

A provision under which an insured pays a certain amount, after which the insurance company pays 100 percent of the remaining covered expenses.

Days per Thousand

A standard unit of measurement of utilization. Refers to an annualized use of the hospital or other institutional care. It is the number of hospital days that are used in a year for each thousand covered lives.

Managed Care Organization (MCO)

A type of medical plan that pays for and manages the medical care a patient receives.

Health Maintenance Organization (HMO)

Alternative means of health care in which people or their employers are charged a set amount and the HMO provides health care and covers hospital costs.

Deductible

Amount you must pay before you begin receiving any benefits from your insurance company

Staff Model

An HMO arrangement in which the HMO employs salaried physicians.

Group Model

An HMO model in which the HMO contracts with a multispecialty group practice and separately with one or more hospitals to provide comprehensive services to its members.

Beyond-the-walls

Case management implemented in settings other than acute such as outpatient, community, payor based, and long-term care.

Within-the-walls

Case management models that are implemented in the acute care/ hospital setting & focus primarily on managing the care of patients during an acute episode of illness

Differentiate between governmental and private (commercial) insurance

Commercial insurance is known as private insurance and includes liability, no fault auto, no fault workman's comp. Governmental are public programs, funded by the government. and include medicare, medicaid, and Military and is given to those who meet the qualifying criteria.

Spend Down

Depleting private or family finances to the point where the individual or family becomes eligible for Medicaid assistance.

Consolidated Omnibus Reconciliation Act (COBRA)

Federal legislation that requires employers to extend health insurance coverage at group rates, usually for up to 18 months, to any employee who is laid off, quits, or is fired, except under certain circumstances.

Medicare Part C—Medicare Advantage Plans

Health coverage option includes part A & part b & operated by private insurance companies that are approved by & under contract w medicare

Fee-for-Service

Health plan that repays the policyholder for covered medical expenses

Premiums

Items offered free or at a minimal cost as a bonus for purchasing a product

Differentiate between Medicare and Medicaid benefit programs

Medicare: financed by social security, benefits those 65 and older or who have a disability, or end stage renal disease Medicaid: financed by state and federal taxes, benefits those considered indigent, with income at or below poverty levels or are uninsured

Outliers

Numbers that are much greater or much less than the other numbers in the set

Methods of reimbursement for healthcare services

Prospective payment system, diagnosis related groups, length of stay, per Diem reimbursement, capitation, fee-for-service, discounted fee-for-service, pay-for-performance, bundling and unbundling

Managed Care Contract (MCC)

Such arrangements assist the MCO in reducing the costs of healthcare services and the provider in securing new or maintaining old business. Issues that are negotiated in an MCC are numerous

Medigap Plans

Supplemental insurance policies provided through private companies to cover costs not reimbursed by Medicare.

Diagnosis-Related Groups (DRGs)

System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

Third-Party Liability (TPL)

The legal obligation of third parties to pay all or part of the expenditures for medical assistance furnished under a state plan.

Prospective Payment System (PPS)

The nationwide payment schedule that determines the Medicare payment for each inpatient stay of a Medicare beneficiary based on DRGs

Medicare Benefits Period

The period that Medicare benefits are open for enrollment

Primary Care Physician (PCP)

The physician responsible for directing all of a patient's medical care and determining whether the patient should be referred for specialty care.

Tricare

U.S. government health insurance plan for all military personnel

Utilization Manager

Using utilization tools, such as ISSI, reveals the patient's changing condition and the necessary level of care and setting. For acute care case management, this provides a cue to the case manager to speed up a discharge plan if the patient is doing exceptionally well or change a discharge plan if the patient is deteriorating or remains debilitated

Care coordination

Working directly with clients and families over time to assist in arranging and managing resources the client requires to maintain health and independent functioning; seeks to achieve the maximum cost-effective use of scarce resources

Centers for Medicare & Medicaid Services (CMS)

a federal agency within the U.S. Department of Health and Human Services that is responsible for Medicare and Medicaid, among many other responsibilities.

Preferred Provider Arrangements (PPA)

a fee-for-service alternative to traditional health insurance under which those covered are given financial incentives to choose from a panel of preferred providers with whom the payer has contracted.

Direct Contract Model

a health maintenance organization (HMO) similar to the individual practice association except that the HMO contracts directly with the individual physician. The HMO recruits a variety of community healthcare providers -primary care and specialist

Network Model

a model of memory that views it as an organized system of linked information

Third Party

a party that challenges the two major parties

Specialist Care Provider (SCP)

a physician specializing in a particular area of health care such as cardiology, digestive diseases, or neurology. Health plan members may not be able to access this without a referral from the PCP

Copayment

a small fixed fee paid by the patient at the time of an office visit

Care Management

a system of care for patients with particular conditions where services are delivered across the continuum of care; ensures seamless transition between providers.

Management Information System (MIS) •

a system used to provide management with needed information on a regular basis

Entrepreneurial Case Management

also known as case management consultants, independent case managers may be contracted by patients, family members, physicians, or insurance companies; need good business skills, & the ability to work autonomously; independent case managers.

Medicare Risk Contracts

are actually commercial, private, or managed care plans that contract with the CMS to provide services to Medicare beneficiaries for a fixed monthly payment paid by Medicare on behalf of the beneficiaries who opt to enroll in a MAP.

Advocacy

being patient/family centered and focused in one's approach to care; important role for a case manager and one of their greatest challenges; essence is caring for another human being

Determine the role of case managers in managed care contracting

can be defined as an organization that provides and/or finances medical care using provider payment mechanisms that encourage cost containment, involves selective contracting with networks of care providers (individuals and organizations), and imposes controls on the utilization of healthcare services.

Long-Term Care (LTC)

care for persons who require 24 hour care and assistance

Social Worker Case Manager

case manager who has the specific set of skills needed to assist someone in a certain social model; foster children as the target population reflect a predominantly social model; in behavioral health programs, they're successful

Home Health Case Management

case managers service the needs of the chronically ill in the home setting; coordination of several therapeutic modalities may be necessary in the individual case including wound care, infusion therapy services, physical therapy and more.

Roles and responsibilities of case managers

clinical care management includes patient selection and identification, assessment and problem identification, plan of care/ case management plan development including the transitional plan, implementation and reassessment of the plan, patient and family education, assessment of the patient and family's social support network and coping skills, assessment of the patient's health insurance status; management and leadership includes coordination, facilitation, and expedition of care activities, scheduling of and following up on test, procedures, and treatments, brokering of family resources, negotiation of care options, evaluation of quality of care, facilitation of communication among healthcare team members, teaching and mentoring of others, advocating for patients and families, participation on committees; financial and resource management include addressing under and over utilization of resources and services, management of length of stay, utilization review and management, management of variances/delays in care, management of denials, appeal of denials, engagement in cost reduction activities and projects; information management includes data collection, analysis, management, and reporting, communication and dissemination of information, documentation, sharing of information about patient's care and progress

Current Procedural Terminology, 4th edition (CPT-4)

codes list procedures and services and differentiate them with a five-digit number. These codes function as a record of physician utilization practices by HMOs (and other insurance companies/benefit programs) and are useful for billing purposes

Hospice Case Management

coordinate the care and comfort of the dying patients and their families; special focus on care of patients suffering from a terminal illness and who have a limited life expectancy; care at the end-of-life; complex consequences of illness as the patient's death nears as well as post death during the family's bereavement stage.

Medicare Part A—Hospital Insurance

covers Medicare inpatient care, including care received while in a hospital, a skilled nursing facility, and, in limited circumstances, at home.

Medicare Part B—Medical Insurance

covers certain doctors' services, outpatient care, medical supplies, and preventive services

Negotiator

essentially a communication exchange for the purpose of reaching an agreement

Cost-Benefit Analysis

family members need comparative financial information or insurance companies may request prices; many case workers required to do this for the case, and required to make a formal documentation of savings per case for accounting purposes

Capitation

fixed monthly payment to a provider, paid in advance of services and regardless of whether services were needed and provided; a full range of medical services may be expected for each member

Social Security Income (SSI)

for people who have not worked enough to receive disability benefits

Preferred Provider Organization (PPO)

group of healthcare providers that provide services to a specific group, often at a reduced rate

Medicare Advantage Plan (MAP or MA)

health plan options (like HMOs and PPOs), approved by Medicare and run by private companies. MAPs are not supplemental insurance and must follow rules set by Medicare

Case Manager

helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner

Categorically Eligible

individuals must fit into a category that makes them eligible according to Title XIX (Medicaid) of the Social Security Act;

Point-of-Service (POS)

insurance plan in which a patient may choose an HMO or a non-HMO provider but must pay a deductible for using a non-HMO provider

Five reimbursement-related responsibilities of case managers

knowing the types of reimbursements, the benefits, which plan will work best for the patient

Fiscal Responsibility

making good decisions about money

CAP

maximum dollar amount allowed in an insurance policy

International Classification of Diseases, 10th revision (ICD-10)

most widely used classifications of diseases in the world. These alphanumeric codes are used by hospitals and other providers when reporting diagnostic and treatment information about members of federally funded programs such as Medicare, Medicaid, and Maternal and Child Health. All third-party payors are required to submit ICD codes for billing purposes

Insurance Case Management

must balance quality of care and patient advocacy with the responsibility for carefully shepherding that health's plan dollars. If there is a conflict between the expectations of the insurance company and the facility to which the member is currently admitted for care the case manager must depend on communication and negotiation skills in resolving such conflict.

Social Security Disability (SSD)

pays benefits to you and certain members of your family if you are "insured," meaning that you worked long enough and paid Social Security taxes. Supplemental Security Income pays benefits based on financial need

Case management

people-oriented; negotiates the managed care system in a way that ideally benefits everyone, particularly the patient; assists people to navigate through the healthcare and community systems to find solutions that work.

Pay-for-Performance (P4P)

performance-oriented incentives for hospitals and physicians to improve the quality of patient healthcare

Coverage Gap

point where a patient and the medicare drug plan have spent a predetermined amount of money for covered drugs and the patient is responsible for the entire cost of the drugs.

Nurse Case Manager

registered nurses who coordinate all aspects of the care of individual patients; ensure proper utilization of services and resources as well.

Carve-Out

replaces a portion of the insurance coverage provided to beneficiaries (health plan members); usually explicitly excluded from a provider managed care contract and tend to include expensive procedures or catastrophic conditions such as organ or bone marrow transplantation or AIDS care coverage

Discharge Planner

requires an assessment of the total medical, psycho-social, and financial elements of each patient's situation; discharges from a hospital to a skilled nursing facility or home, and from a sub acute facility to a home and the planning that goes into this.

Managed care

systems-oriented; focuses on health insurance plans and the management of member benefits; a set of techniques used by or on behalf of purchasers of healthcare benefits to manage healthcare costs by influencing patient care decision making

Confidentiality

the act of holding information in confidence, not to be released to unauthorized individuals;

Collaboration

the action of working with someone to produce or create something

Factors that impact models of case management

the context of the care setting (ambulatory, community-based, ect.), patient population served and its needs (acute episode of illness, specific disease, ect.), reimbursement method applied (managed care, capitation, ect.), the care provider needed for care provision (generalist, specialist, ect.)

Transitional Planner

the plan for a patient being transferred from a care setting to another or home

Privacy

the right of people not to reveal information about themselves

Coinsurance

the sharing of expenses by the policyholder and the insurance company

Acute Care Case Management

time limited, episodic nursing case management at the hospital level; integrates clinical care management, utilization management, and transitional planning functions.

Open Enrollment Period

time when a policyholder selects from offered benefits

Integrator

to align goals and strategies in a case management setting

Medicare SELECT

type of Medigap policy available in some states where beneficiaries choose from a standardized Medigap plan.