Reimbursement Test 1 part 1

rad2329's version from 2016-09-22 19:52

Section 1

Question Answer
Fee for serviceA method of reimbursement through which providers retrospectively receive payment based on either billed charges for services provided or on annually updated fee schedules; also called fee-for-service reimbursement
With fee for service the patient is expected to pay who?The healthcare provider after a service was rendered.
Name types of service that might be paid as fee for service?Cosmetic surgery, substance abuse treatment, testing and correction of vision and hearing.
Name two types of Commercial insurances?Private Insurance and Employer-based Self-Insurance.
How is Private Health Insurance financed?Premiums that are a preset amount and paid monthly.
What were people expected to do before insurance was so wide-spread and available?Individuals were guaranteed access to healthcare only when they were able to pay for it.
What is a premium?The amount of money that a policyholder or certificate holder must periodically pay an insurer in return for healthcare coverage.
Premiums are set aside in ?a special fund.
Claims submitted are paid out of ?the fund's reserves.
Explain the Insurance payment process for private health insurance.Claim is submitted and reviewed for services, diagnosis codes are reviewed for medical necessity, payment is made to either the policyholder or the provider.

Section 2

Question Answer
What four types of information are found on most insurance policies?What medical services the company will cover, When the company will pay for medical services, How much and for how long the company will pay for covered services, Which process is to be followed to ensure that covered medical expenses are paid.
Pre-Medicare/Medicaid Campaigns for National Health Insurance. American Association of Labor Legislation (AALL) 1915Proposed coverage for services physicians, nurses, and hospitals; sick pay; maternity benefits; and a death benefit of $50 to pay for funeral expenses. Plan supported by AMA, never passed into law.
What is the Hill-Burton Act?In return for federal funds for facility construction, healthcare facilities agreed to provide medical services for free or at reduced rates to patients who were unable to pay for their own care.
What was the Hill-Burton Act formally called?The Hospital Survey and Construction Act.
What did President Lyndon Johnson do in 1965?Created federal programs for the elderly and poor as part of his Great Society legislation.
What is Title XVIII of the SSA (Social Security Act) better known as?Medicare (Health Insurance for the Aged and Disabled).
What was Medicare designed to complement?The retirement, survivors, and disablity insurance benefits enacted under Title II of the SSA. Covered most Americans over the age of 65 when it was first implemented in 1966
In 1973, what additional groups became eleigible for Medicare Benefits?Those entitled to SS or Railroad Retirement disability cash benefits for at least 24 months, most persons with end stage renal disease, and certain individuals over 65 who were not eligible for paid coverage but elected to pay for Medicare benefits.
What agency today administers Medicare and Medicaid Services.The Centers for Medicare and Medicaid Services (CMS), and administrative agency within The Department of Health and Human Services (HHS).

Section 3

Question Answer
The Medicaid program became effective ?In 1966 under Title XIX of the SSA. (Social Security Act).
Medicaid is a cost sharing program between?Federal and State
Medicaid pays for the healthcare services provided to ?Public assistance programs for low-income groups, families with dependent children, the aged, and the disabled.
Medicaid eligibility is based on ?Meeting criteria other than income, today the program covers only about 40 percent of the population living in poverty.
Who previously administered or had oversite over Medicare and Medicaid?Department of Health, Education, and Welfare, predecessor to the Department of Health and Human Services (HHS).
What is PPS and when was it started?Prospective payment systems in 1983.
Define PPS.A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided.
What is PPS based on?Predetermined payment rates or periods and linked to the anticipated intensity of services delivered as well as the beneficiary’s condition.
Why was PPS started?In response to skyrocketing costs of healthcare which was depleting the national budget and draining the SSA.
The PPS for inpatient acute care was the first to be implemented, followed by ?Numerous others ranging from home health services to outpatient facility services. The most recently implemented system is for inpatient psychiatric facilities.

Section 4

Question Answer
What has managed care virtually eliminated ?Traditional fee-for-service reimbursement in just two decades.
Cost management - cost containment has lead to ?Many programs being implemented such as managed care delivery and reimbursement system.
In the development of prepaid Health Plans what was the First Commerial Insurance Company?Franklin Health Assurance Company of Massachusetts, 1860.
What did the Franklin Health Assuarance Company provide private healthcare coverage for?Injuries that did not result in death.
By 1900 who were offering prepaid health plans?Accident insurance companies and life insurance companies.
When was modern health insurance born?In 1929 when Baylor University Hospital in Dallas Texas, agreed to provide healthcare services to Dallas schoolteachers.
What was the first modern health insurance called and what did it cover?Blue Cross, and provided room, board, and certain ancillary services to the teachers for a set monthly fee of 50 cents. Payment was made directly to the hospital, not to the patient.
How was Blue Cross different than standard indemnity plans? Indemnity plans offered by private insurance plans.The patient is reimbursed or (indemnified) for covered services up to a specified dollar limit. It was then the responsibility of the hospital to collect the money from the patient.
Who eventually developed the Blue Shield plans?Blue Shield plans were developed by physicians.