Fill in 4

docx

School

Valencia College, Osceola *

*We aren’t endorsed by this school

Course

3210

Subject

Electrical Engineering

Date

Apr 3, 2024

Type

docx

Pages

Uploaded by EarlEnergyHummingbird5

https://lti.cognella.com/h5p/embed.php?url=https%3A%2F%2Flti.cognella.com%2Fpluginfile.php %2F115877%2Fmod_h5pactivity%2Fpackage%2F0%2Fch04- 1291372247173940308.h5p&preventredirect=1&component=mod_h5pactivity Basics of Health Insurance and Managed Care Lecture Study Notes Chapter 4: Provider Payments To help you prepare for quizzes and exams, you may complete these “fill in the blank” Lecture Study Notes as you review each lecture.  You have 2 options on how you may use these notes: Export the notes before beginning the lecture by clicking "Export your study notes" on the final slide. This allows you to print out the file with blanks so you can fill in the answers as you go through the lecture; or Open a second screen tab to fill in the lecture notes electronically while you listen to the lecture and then export it after you have completed the lecture. In this case the file prints with your answers. Note: If you exit this webpage, your work will not be saved. If you would like to save your work, click "Export your study notes" on the final slide. Enter your name and date below: General Approaches to Provider Payment 1. Do insurers and providers use one single approach to payments (yes or no)? 2. Who are payers? Key Payment Methods 3. Fill in the blanks.  What is fee-for-service?  Providers are paid for ____________ service.  Payments are based on the _______________ of services, not the _________________ of members. 4. Fill in the blanks.  What is capitation? Providers are paid a _______________ amount based on the insurance membership, instead of the number of services received.  Payments are based on the ______________ of members, not __________.  This is also referred to as a per member/per _________________ (PM/PM) amount. Key Payment Methods, cont. 5. Under capitation, does the provider get paid if the provider never sees the patient in a given month (yes or no)? 6. Under capitation, who is at financial risk if the cost of services exceeds the monthly rate? Fee-for-Service 7. Is fee-for-service more, or less, expensive for the overall healthcare system than capitation?

8. In general, how can providers make more money under fee-for-service? 9. What is one disadvantage of fee-for-service?  Capitation 10. Is capitation more, or less, expensive than fee-for-service for the overall healthcare system? 11. In general, how can providers make more money under capitation? 12. What is one disadvantage of capitation? 13. Fill in the blank. What are two advantages of capitation?  Capitation has a predictable __________ flow and is _____________ costly to administer. 14. How can capitation payments be adjusted? Capitation, cont. 15. Can capitation payments be used for all types of providers (yes or no)? 16. What is the “panel of members”? 17. Who has a higher financial risk under capitation if the panel of members is sicker than expected? 19. What are services that are not covered under capitation, but billed separately, called? 18. As it relates to capitation, what information is described in the provider’s contract?

Payment Timing 20. What are retrospective payments? 21. What are prospective payments? 22. Which type of payment (retrospective or prospective) includes a provider contract? Retrospective Payments 23. What type of payments are always used for out-of-network providers (prospective or retrospective)? 24. Historically, what type of payment has been used (prospective or retrospective)? 25. Can capitation payments be made retrospectively (yes or no)? Prospective Payments 26. Is a prospective payment negotiated (yes or no)?  27. Are prospective payments ever used for out-of-network services (yes or no)?  28. Prospective payments may be used in three different circumstances.  What are they? 29. What type of payment (retrospective or prospective) is more likely to be used by health plans for innovation?  31. Is an allowable fee prospective or retrospective?  32. What are other names for an allowable fee? 

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

33. How are services listed in the fee schedule (by what two types of codes)? In-Network Allowable Fee 30. What is the allowable fee? Fee Schedule 34. Fill in the blank. What is the fee schedule?  List of ___________________ allowable fees an insurer will pay. Actual Charges 35. Fill in the blank. What document describes the difference between actual charges and allowed amounts for health plan members?  Explanation of ____________________ (EOB) 36. Is the doctor responsible for creating and sending the EOB to the patient? (Or is it the insurance company’s responsibility?) Explanation of Benefits 37. When do health plan members receive an EOB statement? 38. Fill in the blanks.  What information is provided in an EOB statement?  Describes ______________ that are covered by an insurance company; clarifies cost of care _______________, money ___________ by using in-network providers, and ______________ costs. Balance Billing 39. Fill in the blanks.  What is balance billing?  It is when the in-network providers charge the patient the difference between the provider’s ________________ charge and the _________________ amount. Hospital Chargemaster 40. Fill in the blank.  What is the chargemaster?  List of _______________ charges for a hospital 41. What types of services are included in the chargemaster?

42. When is the chargemaster used to determine retrospective payments? 43. When is the chargemaster used to determine prospective payments? Hospital Pricing Transparency 44. As of Jan. 1, 2019, what does CMS require of hospitals, related to chargemasters? Surprise Bills 45. Fill in the blanks. What is a surprise bill?  ________________ charges incurred when a patient ______________________ receives care from an out-of-network provider 46. Fill in the blanks.  What does the ACA require (related to surprise bills)?  Health plans must cover out-of-network __________ services and apply in-network cost-sharing.  But, providers can still ________________ bill patients. Out-of-Network Payments 47. Fill in the blanks.  What is the Usual, Customary, and Reasonable (UCR) fee schedule? The amount a health insurer pays a provider based on what is typically charged for the _____________, or similar service, in a given ___________________________area. 48. Besides UCR, what is another fee schedule that insurance companies may use when there is no provider contract in place? Resource-Based Relative Value Scale 49. Fill in the blanks.  What is a relative value scale?  Set of numeric ________________ used to adjust provider payments to reflect their proportional ___________________ by ensuring that _______________, otherwise important procedures have a ________________ scale than simpler ones. 50. Fill in the blank.  What is the resource-based relative value scale (RBRVS)?  ________ fee schedule for physicians 51. What 1989 law created the RBRVS?

53. Do private payers and Medicaid ever use the RBRVS fee schedule (yes or no)? Resource-Based Relative Value Scale, cont. 52. What are the three components of the RBRVS? Medicare Prospective Payments 54. What government insurance program is often the first to use innovative payment methods? 55. Did the first payment reform initiatives start with inpatient or outpatient services? 56. Fill in the blanks.  How are providers paid under the Inpatient Prospective Payment System (IPPS)?  Medicare pays hospitals per _________________ and/or ___________________ group, regardless of the length of stay. Medicare Prospective Payments, cont. 57. Fill in the blanks.  Besides IPPS, what are four other types of Medicare prospective payment systems? ______________________________________ Prospective Payment System ______________________________________ Prospective Payment System ______________________________________ Prospective Payment System ______________________________________ Prospective Payment System Conclusion 58. Do most insurers use a single method of provider payment in practice (yes or no)? Key Terms Allowed Amount = the maximum amount an in-network provider can charge members for a given service. This is the negotiated rate that an insurance company has agreed upon with in-network providers. Balance Billing = prohibits in-network providers from charging health plan enrollees the difference between provider actual charges and the allowable rate negotiated with the insurance company. Capitation = a payment arrangement under which providers are paid a fixed amount based on the insurance membership instead of services received. This per-member, per-month amount is paid to the provider regardless of whether the insured member receives a service during the month. In this way, the provider receives a capped payment and assumes financial risk if the cost of the service exceeds the monthly rate. Chargemaster = a list of a hospital’s charges for medical services. Typically, these charges are higher than what an insurance company actually pays. Diagnosis-Related Groups (DRGs) = a bundled payment arrangement for inpatient services that is used by Medicare. Each group of services is weighted to reflect the average cost of resources used in providing services. Because this payment is established prior to the service being rendered, it is considered a prospective payment, and places the provider at some financial risk. Also see bundled payment. Explanation of Benefits (EOB) = statement from an insurance company that provides information on provider service charges, the amount the

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

insurance company paid, and the amount for which the member is responsible. Fee-for-Service = method of service delivery and financing where providers are paid for each service performed, and patients have the freedom to choose the providers they see. “Fee for service” plans are also known as “indemnity” plans. Fee Schedule = list of maximum allowable fees that an insurance company will pay for services. Price Transparency = pricing information that is available to consumers and payers to help define the value of healthcare services when comparing providers or facilities. Prospective Payment = fixed provider payment rate that has been negotiated under contract prior to a service being rendered and costs incurred. Relative Value Scale (RVS) = an approach to paying providers in which insurance companies and Medicare add a weight adjustment to payments (e.g., adjusting the payment to account for a surgeon’s analysis time in addition to the actual procedure). By adjusting payments, this approach pays more for more complex services (e.g., diagnostic colonoscopy as compared to an office visit). Resource-Based Relative Value Scale (RBRVS) = basically, the Medicare fee schedule. In Medicare, payments for services are determined by including the resource costs in providing the service. The resource cost includes: physician work, practice expense, and malpractice insurance. Retrospective Payment = payment rate that varies based upon actual, incurred charges. These payments are made after the insurance company receives a claim, and the service has already been rendered and costs incurred. Surprise Bill = unexpected charges incurred when a patient unknowingly receives care from an out- of-network provider. Usual, Customary and Reasonable (UCR) = the amount a health insurance company pays a provider based on what is typically charged for the same or similar service in a given geographic area. This may be used when there is no negotiated rate (e.g. out-of-network providers)