NHA CCMA HEALTHCARE SYSTEMS AND SETTINGS

Accountable Care Organization (ACO)

Groups of physicians, hospitals, and other healthcare providers that come together voluntarily to provide coordinated high-quality care to their Medicare patients; when they succeed in delivering high-quality care and spending healthcare dollars wisely, it will share in the savings it achieves for the Medicare program.

Capitation (partial or full)

Patients are assigned a per-member, per-month payment based on their age, ​race, sex, lifestyle, medical history, and benefit design. Payment rates are tied to expected usage regardless of how often the patient visits. Under partial models, only specific types or categories of services are paid.

Global Budget

Fixed dollar amount paid annually for all care; participating providers can determine how much money is spent. Limit level and rate of increase of healthcare costs. Typically include quality components.

Health Maintenance Organization (HMO)

Contracts with a medical center or group of providers to provide preventative and acute care for the insured person; require referrals to specialists and precertification or preauthorization for hospital admissions, outpatient procedures, and treatments.

Patient-Centered Medical Home (PCMH)

PCP coordinates treatment to make sure patients receive the required care when and where they need it and in a way they can understand; healthcare delivery models coordinated through a patient's PCP. The 5 core attributes are comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety.

Pay for Performance

Reimbursement model that compensates providers only if they meet certain measures for quality and efficiency. Generating quality benchmark measures connects provider reimbursement directly to the quality of care they provide.

Preferred Provider Organization (PPO)

Insured person doesn't need PCP but can go directly to specialty w/o referrals. Can see providers in or out of the network, but in-network usually costs less.

Government insurance plans

Medicare, Medicaid, Tricare, CHAMPVA, managed care plans, workers' compensation

Private insurance plans

Blue Cross Blue Shield, Aetna, United Healthcare

United State's oldest and largest systems of independent health insurers

Blue Cross Blue Shield

Advance Beneficiary Notice

A form provided to the patient when the provider believes Medicare will probably not pay for services received.

Allowed Amount

The maximum amount a third-party payer will pay for a particular procedure or service.

Copayment

The amount of money the patient has to pay out of his or her own pocket at the time of medical service.

Coinsurance

Policy provision frequently found in medical insurance whereby the policyholder and insurance company share the cost of covered losses in a specified ratio (i.e. 80:20).

Deductible

Specific amount of money the patient must pay out of pocket before the insurance carrier begins paying.

Explanation of Benefits

A statement from the insurance carrier detailing what was paid, denied, or reduced in payment; also contains information about amounts applied to the deductible, coinsurance, and allowed amounts.

Participating Provider (PAR)

Providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer.

Medicare

Generally covers patients > 65 y/o by Part A (hospitalization) or Part B (routine medical office visits) benefits.

Tricare

Authorizes dependents of military personnel to receive treatment from civilian providers at the expense of the federal government.

CHAMPVA

Covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities.

Medicaid

Provides health insurance to medically indigent population through a cost-sharing program between federal and state governments for those who meet specific eligibility criteria.

Managed Care

Umbrella term for plans that provide healthcare in return for preset scheduled payments and coordinated care through a defined network of providers/hospitals.

Workers' Compensation

Protects wage earners against loss of wages and cost of medical care resulting from an occupational accident or disease as long as the employee is not proven negligent.

CMS-1500 Form

Used for claims submitted by a provider/supplier. 33 blocks/items divided into 3 sections:

1. Carrier Block = address of insurance carrier (top)

2. Patient/Insured Section = information about the patient or insured (boxes 1-13)

3. Physician/Supplier Section = information about the physician/supplier (boxes 14-33)

ASCA requires claims to Medicare to be transmitted electronically; clearinghouse draft may be completed on paper. Any new version needs to be approved by White House OMB.

Direct billing

Process by which insurance carrier allows a provider to submit insurance claims directly to the carrier electronically.

Claims clearinghouse

Allows providers to submit all insurance claims using distinctive software; audits and sorts claims and sends them in batches electronically to each of the insurance companies. Once services have been rendered, provider must submit claims claims within timely filing limits.

Ancillary Services

urgent care, lab testing, diagnostic imaging, PT, OT

How a physician obtains their license

Examination

Reciprocity (requirements met from another state)

Endorsement

AAMA (American Association of Medical Assistants)

Offers membership opportunities to medical assistants as students or graduates

Field of medical assisting is expected to grow

23-29%