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Principles of Healthcare Reimbursement Chapters 5-8 Review
Terms in this set (44)
System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan.
eliminating a certain specialty of health services from coverage under the healthcare policy.
Model of care; the case manager advises nursing staff on specific nursing care issues, coordinates the referral of clients to services provided by other disciplines, ensures that client education has been implemented, and monitors the client's progress through discharge.
A process used by private insurers that only tries to cover the healthiest people, lowering the risk of health services.
Episode of Care
Health care services given during a certain period of time, usually during a hospital stay.
A list of a health plan's selected drugs and their proper dosages; often a plan pays only for the drugs it lists.
Individual, usually a primary-care physician, who is given control of patient access to specialists and services in a managed care organization
A form of reimbursement used for radiological and other procedures that combines the professional and technical components of the procedures and disperses payment as lump sums to be distributed between the physician and the healthcare facility
Health Maintenance Organizations
HMOs; provide a broad range of health care services to members for a set monthly, prepaid fee. These are not insurers, but providers. These do not put limits on how much health care is used and will have a gate-keeper or primary care physician. You must receive preapproval for hospital admittance. There is usually a small copayment and no deductible. If you use a doctor not on the plan's list, you will the full freight of the costs.
Managed Care Organizations
MCOs, A generic term applied to a managed care plan. May apply to EPO, HMO, PPO integrated delivery system or other different managed care arrangement. MCOs are usually prepaid group plans, physicians are typically paid by the capitation method
A health maintenance organization that has multiple provider arrangements, including staff, group, or individual practice association structures
Performed to review for medical necessity of inpatient care prior to the patient's admission
Preferred Provider Organizations
Health care organizations that allow members to choose their own physicians for a fee
A multispecialty group practice where all healthcare services are provided within the building(s) owned by the HMO is called a:
Arrangement under which a capitated provider prepays an ancillary provider for specified medical services for plan members
A process of reviewing the medical necessity for services and providers use of medical care resources
Distribution of patients into categories reflecting severity of illness or resource uses.
Case Mix Index
The average relative weight of all cases treated at a given acility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the groups in the classification system; calculated by dicviding the sum of the weights of diagnosis-related groups for patients icharged during a given period divided by the total number of patients discharged.
A claim that does not need to be investigated by the payer. A clean claim passes all internal billing edits and payer specific edits and is paid without need for additional intervention.
the presence of two or more unrelated disease conditions at the same time in the same person
DRGs; groups of inpatient services with fixed reimbursement amounts with adjustments based on severity, regional costs, and teaching cost, regardless of length of stay or use of service
Contractor that manages health care claims.
Major Diagnostic Categories
MDC, the division of all principal diagnoses into 25 mutually exclusive principal diagnosis areas within the DRG system
Medicare Administrative Contractor
New entities assigned by CMS to replace the Part A fiscal intermidiaries and Part B carriers; also known as A/B within specific multistate jurisdictions. DME MAC's handle claims for durable medical equipment, supplies, and drugs billed by physicians.
A data value that is much higher or lower than the other data values in the set
Numeric weight assigned to each DRG, which is used in calculating reimbursement
Ambulatory Payment Classifications
APCs, A system of outpatient hospital reimbursement based on procedures rather than diagnoses.
Supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests.
Factor by which a quantity that is expressed in one set of units must be multiplied in order to convert it into another set of units
Representative collection of goods & services
A physician or other health care provider who chooses not to join particular government or other program or plan.
Outpatient Code Editor
The computer program used by Medicare to review claims for hospital-based outpatient services.
Payment Status Indicator
Are assigned to every HCPCS/CPT code under the Medicare hospital OPPS, to identify how the service or procedure described by the code would be paid.
Physician Fee Schedule
also called the resource-based relative value scale RBRVS limits the amount for nonparticipating providers;
reimbursement under the fee schedule is based on relative units RVUs that consider resources used in providing a service.
Physician Quality Reporting Initiative
Physician Quality Reporting Initiative (PQRI) A voluntary reporting system implemented by the Centers for Medicare and Medicaid Services that offers participating professionals the opportunity to earn a bonus payment for prospectively entering codes related to specific quality performance measures.
Relative Value Scale
A system of assigning unit values to medical services based on an analysis of the skill and time required of the physician to perform them.
Relative Value Units
System created to determine practice expense RVU's for all Medicare physician fee schedule services
Resource-based Relative Value Scale
A payment method utilized by medicare and other government programs to provide reimbursement for physician and some outpatient services. The RBRVS system consists of a fee schedule of approved amounts calculated based on relative values assigned to each procedure.
Activities of Daily Living
ADLs; behaviors related to personal care that typically include bathing, dressing, eating, toileting, getting in or out of a bed or a chair, and walking.
Case Mix Group
The ninety-seven function-related groups into which inpatien rehabilitation facility discharges are classified on the basis of the patient's level of impairment, age, comorbidities and functional ability and other factors.
Facility submits one consolidated bill to Medicare Administrative Contractor that covers the services, such as laboratory, x-ray, and pharmacy, that the patient, client, or resident receives during his or her admission to the facility, including services from outside vendors.
Home Health Resource Groups
Fixed, pre-determined rate for each 60-day episode of care, regardless of services given. OASIS used to rate a patient's functional status and clinical severity which translate into HHRG points
Minimum Data Set
MDS; A report that focuses on the degree of of assistance or skilled care that each resident of a long-term care facility needs
The belief that people with disabilities should be physically and socially integrated into the mainstream of society regardless of the degree or type of disability