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Terms in this set (31)
The former are all federally mandated
What is the difference between Medicare/Medicaid/Tricare and commercial insurance plans?
designed to absorb risk, serving those who may have costly/complex medical needs as well as the relatively healthy. We work and pay into this throughout working lives to receive benefits at retirement or in the case of serious disability. All Americans fund the program and are covered by it when eligible.
required to protect businesses by providing risk management to those least likely to use medical care (gainfully employed, relatively healthy and young); previously elected and protected individuals with the fewest needs. (why Medicare was first enacted in 1965).
Employers' benefit packages
How do most commercial insurance participants access healthcare?
80-90% of employers are
40% (20-29 y/o)
What percent (and age range) are uninsured?
Health insurance is a way to share this risk
Risk of illness and injury is a part of life, and risk of financial loss due to healthcare costs is also a part of life. So what is health insurance?
They pick groups to insure which are statistically healthy. They set limitations on coverage. They negotiate with healthcare providers to discount their charges. They charge the consumer premiums, deductibles, and co-pays.
How can insurance companies pay costs?
Blues, United, Cigna, Aetna, Humana (these are the big commercial payors, and usually, the smaller commercial payors will go through one of these bigger payors)
What are the BUCAHs?
how much $$$ you pay before insurance kicks in
set $$ you pay per office visit
Out of pocket expense
what you pay that insurance doesn't cover
someone who provides services; insurance company
In general, the higher the deductible, the lower the premium (inverse relationship)
How are the costs of deductibles and premiums related?
the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy; exists because "providers need to be vetted"
exists to "link providers to payers, where contracts are already established"
Health plans obligations, provider obligations, term and termination, financial terms, fee schedules
All commercial insurance agreements are unique. All contracts are negotiated. What do contracts specify?
Provider/insurance, provider/employer, provider/patient (self-pay)
Types of contracts/agreements in insurance include:
The Patient Protection and Affordable Care Act (ACA)
Nicknamed Obamacare, was signed into law in 2010. Required all citizens to have insurance. Created state-based insurance exchanges with regulations. Required plans to offer no-cost preventative benefits. Provided premium subsidies to individuals who could not afford coverage. Mandated employers to offer certain coverage if >100 and employees must work >30 hours per week to receive benefits. Dependent age raised to 26. Large tax consequences to employers and insurance companies, all leading to increased premiums for commercially compliant policies. Partially repealed by Trump in 2018, effective 2019.
Cost, lack of perceived progress, lack of patient education, scheduling/work
What are barriers to patient compliance in physical therapy?
unit is 15 minutes (8 minute rule); an hour has 4 units; units can be service-based (untimed), attended, and unattended; based on CPT code description
Regulations for commercial payers are different from federal payers, but the following are the same:
units per patient/encounter, patients per day, FOTO (Focus on Therapy Outcomes)
Dr. Warf: Both
Dr. Colson: Are companies credentialed or are individuals credentialed?
Dr. Warf: Absolutely not. Your charges are based on your contract.
Dr. Colson: Each patient is covered different. Can you charge them differently?
Dr. Warf: You still bill the same. Charges are the same, but bills can be adjusted.
Student: What about self-pay? Can you charge them differently?
Dr. Warf: ... at MS Sports Med includes surgery and 90 days post op (PT, HH, follow up visits, etc). We get paid so much up front and don't get paid until all 5 criteria are met (patient satisfaction, pain, outcomes, etc.).
Dr. Colson: Can you talk to them about bundling?
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