Module 1 - ambulatory care, managed care, reimbursement

community health center

The setting where care for an urban, underserved population would most likely be provided

dental hygienist

those who are: nurse practitioner, physician assistant, and certified nurse midwife

Which of the following is not considered to be a mid-level provider/advanced practice clinician? What are 3 examples of those who are?

licensed

Health care facilities and providers are required to be ______ to provide health care services.

certified

In order for health care facilities to participate in the Medicare program, the facility must be ______ by CMS.

voluntary

Accreditation is a(n) ______ process of review of a provider of health care facility.

dialysis center

those they do: ambulatory surgery centers, office-based surgery centers, and sleep centers

The Joint Commission accredits all of the following health care facilities except ______. What are some they do accredit? (3)

Medicare programs

The Office of Inspector General (OIG) is responsible for protecting the integrity of which of the following? 

History and physical

The reason for the patient visit typically is recorded in what part of the health record? 

problem list

A ______ is a list of the patient's diagnoses and problems that is compiled over time. 

growth chart

Which form typically would be included in a pediatric health record and may not be found in other patient records?

patient oriented

those that are: source oriented, problem oriented, and integrated

All of the following are examples of typical organization formats for ambulatory records except? Those that are include (3):

resource-based relative-value scale

Physician reimbursement is based on ______. 

demographic data

Which information is most likely to be included in the appointment system? 

True

Many risk management issues that arise in freestanding ambulatory care relate to the fact that much of the care is not provided by the caregiver but, rather, by the patient and the family. T/F

ambulatory care setting: the process of utilization is more likely to be focused on how necessary a service is, such as a referral to a specialist or a special expensive procedure, or even the appropriateness of a referral for hospitalization

the hospital setting: utilization management is focused on whether or not the patient needs to be hospitalized.

How does utilization management within the hospital setting differ from utilization management in the ambulatory care setting?

birth center: which provides labor services when the delivery is considered to be "uncomplicated".

urgent care center: where no appointments are needed and people seeking immediate care can just walk in.

university health center: medical care is provided to students and sometimes even university faculty on-campus.

List and describe three types of freestanding ambulatory care settings.

encounter: face-to-face contact between the patient and the provider.

nurse practitioner: a registered nurse who also has additional training that allow for some independent practice.

The reason for a visit: the patient's reason for seeking care.

superbill: a form that is used for billing that includes the services the patient received, the diagnosis, the procedure codes, and the charges.

Define the following terms used in ambulatory care: encounter, nurse practitioner, reason for visit, superbill.

The Joint Commission

The Accreditation Association for Ambulatory Health Care Inc.

Name the two main organizations that accredit ambulatory care.

1. Registration

2. History and physical (reason for visit)

3. lab/radiography reports

4. progress notes

5. encounter form or superbill

6. copies of hospital records (if patient has been hospitalized)

List the major types of documentation that are basic to all ambulatory care encounters and settings. (6)

They have different documentation standards like:

• physical examinations once hired and being placed on the job

• return-to-work physical when injured on the job

• health monitoring to check for exposure to toxic substances and something like loud noises

• Vision checks since vision is really important for the job

How does documentation in an industrial health center differ from that in a physician's practice and why?

freestanding ambulatory care

outpatient care provided to patients in a non-hospital setting

1. out-of-pocket payments (pay entirely or partially for services)

2. health insurance plans (through work, etc.)

3. public/government funding (medicare or medicaid)

4. health savings account (account at bank to put money in to save for healthcare which is through your employer)

what are 4 ways that US citizens pay for health care services (since we do not have a universal healthcare system)?

health insurance

financing mechanism that protects the insured from using their personal funds when expensive care is required

1. comprehensive health insurance: outpatient/inpatient services, labs, surgery, equipment, therapies, mental health, rehab, prescription drugs

2. major medical: surgeries, expenses related to hospitalization only

3. catastrophic health insurance: cover unusual illnesses

4. disease specific: cancer, etc.

5. medigap/medicare supplement: supplement insurance for medicare patients

what are the different health insurance policy types? (benefits) There are 5.

managed care

the provision of comprehensive healthcare services coordinated through a PCP

primary care physician

PCP

health maintenance organizations

HMO

preferred provider organizations

PPO

point of service organizations

POS

integrated delivery system

IDS

HMO

Provides health services for a fixed premium, covering a group in a specific geographic area.

staff model

HMO owns facilities, employs providers with fixed salaries, and only serves HMO patients. Profits go to the HMO.

group model

Contracts with a multispecialty medical group for services; providers may receive unused premiums as bonuses

network model

Contracts with multiple physician facilities; providers can serve non-HMO patients.

network model

Contracts with multiple physician facilities; providers can serve non-HMO patients.

IPA model

Designed for independent practitioners to participate in managed care.

mixed model

Combines multiple HMO structures for flexibility

Preferred Provider Organization (PPO)

Definition: A network of providers offering cost-effective care options. Patients can see both in-network and out-of-network providers, but in-network care is usually less expensive.
Key Feature: Encourages the use of participating providers by offering lower costs for in-network services

Point of Service Plan (POS)

Definition: A hybrid of HMO and PPO models. Patients pay a premium and use a PCP for care but have the option to seek out-of-network services at a higher cost.
Key Features:

• Requires PCP referrals for certain services.

• Offers flexibility to see out-of-network providers, albeit with higher coinsurance and reduced reimbursement.

Flexible Spending Account (FSA)

A pre-tax account set up by employees through their employer to cover health care expenses.

Flexible Spending Account

FSA

• Funded with pre-tax salary deductions.

• Unused funds at the end of the year are forfeited to the employer.

• Provides tax advantages for health care spending

What are some features of an FSA?

Health Reimbursement Arrangement (HRA)

Definition: An employer-funded account used to reimburse employees for eligible health care expenses.

Health Savings Account

HSA

• Contributions and withdrawals for medical expenses are tax-free.

• Funds roll over year to year.

• Non-medical withdrawals are penalized by 10% and taxed.

• Supplemental insurance cannot be purchased until the deductible is met

What are some features of an HSA?

Health Reimbursement Arrangement

HRA

• Withdrawals are tax-exempt for employees.

• Employer contributions are tax-deductible.

• Typically, funds cannot be cashed out upon leaving employment, though some employers allow rollovers into retirement accounts

What are some features of an HRA?

Health Savings Account (HSA)

Definition: A tax-advantaged account for individuals or families with high-deductible health plans to save for health care expenses.

reimbursement model used by healthcare providers to establish a fixed payment plan before services are given. negotiated between payer and provider based on classification system.

What is a prospective payment system?

it could be the difference in who they have to cover in a dual-coverage family, depending on who is subscribed and who is not.

Why is coordination of benefits important to an MCO?

quality improvement and cost control through prospective and retrospective review

What is the purpose of utilization management? 

prior authorization: review of payment and approval for service is attained before the service is done

concurrent: done during inpatient care where verification for tests and services is ordered during

What is the difference between prior authorization and concurrent review?

credentialing

_____ is when a provider is approved to a health plan to participate through a review process. To get approved, they have to meet a list of certain criteria.

1. An organized system for providing health care or otherwise assuring health care delivery in a geographic area

2. An agreed-upon set of basic and supplemental health maintenance and treatment services

3. A voluntarily enrolled group of people

What three characteristics are required for an organization to qualify as an HMO?

per member per month

It is important because the payment is usually made monthly from each patient and the providers must use this payment to pay the support staff and other office expenses. That being said, providers who do not practice well and effectively could be at financial risk, while those who do can make money just fine.

What does the abbreviation PMPM mean, and why is it important in manage care? 

Coinsurance is for when the deductible is reached and the expenses have went over that amount. It is the amount that the person who is insured is responsible for paying. It is usually around 20% of the entire charge. On the other hand, a copayment is paid by the covered individual for a service that is paid at the same time of the service and is usually a flat rate.

Explain the difference between coinsurance and copayment.

EOB (Explanation of Benefits)

Statement sent by a health insurance company to
covered individuals explaining what medical
treatments and/or services were paid for on their
behalf

Facilities/physicians can get it wrong sometimes when it comes to billing, so it is important to review your EOB to make sure you are getting billed the correct amount.

why is your EOB important?

deductible

ex. 2000 deductible, you pay 2000 first and then insurance will pay what is left over

A specified amount of money that the insured must
pay before an insurance company will pay a claim

premium

The amount the policy-holder or employer
pays to the health insurance company to
purchase coverage

co-payment

A fixed amount you pay for covered health
services

co-insurance

The percentage of costs of a covered health
care service you pay (20%) after you’ve paid
your deductible

Out-of-pocket maximum

The most you have to spend for covered
services in a year. After you reach this
amount, the insurance company pays 100%
for covered services

Accreditation Association for Ambulatory Health Care

AAAHC

Coordination of Benefits (COB)

Determining who the primary
insurance payer is and assuring that no
more than 100% of the charges are paid
to the provider or reimbursed to the
patient

physician’s private practice

Largest portion of freestanding ambulatory
care

Public health departments

Preventative services
– Notifying contacts of patients with infectious
conditions

not usually apply to physician officers

does usually apply to asc and bc

Licensure does ___ usually apply to ____ ____ and ___ usually apply to ambulatory surgery centers and birth centers

source oriented

record format arranged accodring to source (ex. lab, nursing, etc.)

integrated

record format of chronological order

problem oriented (POMR)

record format of problem list with other documentation keyed to problem number

resource-based relative value scale

RBRVS

Healthcare Common Procedural Coding System

HCPCS

utilization management (UM)

Appropriateness of services and treatment; incident or occurrence report.

what is required by third-party payers

The main factor usually considered in choosing a coding system for ambulatory care is _____

physician quality reporting system (PQRS)

a system for physicians to report quality measures to CMS

freestanding ambulatory care

outpatient care provided to patients in a non-hospital setting