reimbursement.txt

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Author:
jpowell22
ID:
109734
Filename:
reimbursement.txt
Updated:
2011-10-17 20:18:22
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10 17 11
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Description:
lecture 9
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  1. What refers to the variety of policies that can be purchased to cover certain help-related services and goods?
    health insurance
  2. What does it mean to be insured?
    covered by a policy
  3. Who is the individual who purchases a policy?
    subscriber
  4. Who is the insurer?
    health insurance company
  5. What are benefits?
    covered services (services that are reimbursed by the insurance company)
  6. Who finances health care?
    • employers
    • individuals directly
    • government
  7. What is medicare?
    • federally funded
    • for elderly population (65+)
    • ppl with end stage renal disease
    • disabled ppl who are entitled to social security
  8. What is medicaid?
    • for indigent population
    • funded by state and federal govt
    • states determine eligibility, reimbursments, and specific benefit level
  9. What methodology requires payment after services have been rendered, called "fee-for-services", ind. or health insurer is at risk,and providers have little incentive to limit services?
    retrospective
  10. What methodology establishes payments in advance, and the providers are paid these amounts reguardless of the costs incurred, the provider takes the risk, and contains DRGs?
    prospective
  11. What 2 things does managed care contain?
    • predetermined payment schedule,
    • provider network
  12. What is the most restrictive health policy?
    HMO (health maintenance organization)
  13. What insurance provides a gatekeeper who determines everything for the patient to restrict costs?
    HMO
  14. What insurance is an open managed care model where employer negotiates lower fees in return for providing a high volume of pts?
    PPO (prefered provider organization)
  15. What insurance offers in and out of network benefits (more coverage in network), theres an annual deductible, co-payments, and insured pays difference for out of network care?
    POS (point-of-service)
  16. What is the evaluation of the medically necessary, appropriate, and efficient use of health care services, procedures, and facilities?
    utilization review (UR)
  17. What is a case management?
    provides monitoring and coordination of txs rendered to patients to control costs and utilization
  18. What is a consumer-driven health care plan?
    combines employer contributions with increased employee choice and responsibility and increased health plan and provider accountability

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