Reimbursement

What is PPS?

Prospective payment system which means reimbursement has a system that has already established reimbursement for any given patient

What is a fee for service system?

A fee for service system reimburses for each procedure completed and billed.

What is an HMO?

A health maintenance organization that provides practitioners and services in their own system. Preventative services are emphasized.

Dexscribe commerical insurance (also known as major medical plans)

Major Medical plans are generally considered insurance for catastrophic care. Choice of physicians is preserved. Preventative care is limited.

What is a fee schedule?

A fee schedule is a list of the amount of reimbursement agreed upon for various treatments, usually based on CPT codes.

What is an insurance deductible?

A deductible is the amount of money the beneficiary must pay before insurance benefits begin.

What type of healthcare system has the managment theory of keeping all expenses "in house"?

HMO

What is a PPO.

A preferred provider organization. PPOs provide incentives to practitioners and patients to use their network providers.

What is an insurance co-payment?

A co-payment is the amount of money the beneficiary must pay for each visit to a practitioner.

What is a case manager?

A case manager is an individual responsible for following and managing cases, attending to details and approving/denying requested treatments.

What is Capitation?

Capitation is a fixed and usually flat rate of reimbursement is provided for all services provided.

What is seamless integration?

Seamless integration is a continuum of care through the same organization removing any duplication of services.

What type of healthcare system retains the advantage of choice but also provides incentive to use its network's list of providers?

A PPO.

What is a case rate as a means for determining reimbursement?

Case rate reimbursement provides a set amount based on diagnosis/level of symptoms, regardless of services provided.

What does a policy's out of pocket maximum refer to?

The out of pocket maximum refers to the total amount of money a beneficiary must spend before insurance covers the full amount up to the policy limit.

What is a Resource Based Relative Value System?

Reimbursement based on the amount of resources consumed by providing care.

What is Worker's Compensation?

Worker's Compensation is an insurance program providing wage replacement and medical benefits to employees injured on the job.

What is per diem as a means to determine reimbursement?

A per diem reimbursement payment includes a set amount per session regardless of treatment provided.

Describe the Medicare B Therapy Cap.

The therapy cap was set at $1500 in the BBA of 1997. While it does benefit from a cost of living raise, it continues to limit PT services available to beneficiaries.

What other changes occurred with the Balanced Budget Act of 1997?

SNFs, Acute Rehab and Home Care became reimbursed under PPS rather than fee-for-service

What is a third party payer?

An individual or corporation that makes a payment on an obligation or debt, but is not party to the contract that created the obligation/debt.

What are three primary differences between Medicare and Medicaid?

1. Populations covered; 2. Funding source; 3. Inconsistency of covered services between states