Healthcare Insurance Review

Flashcards based on the Healthcare Insurance Review notes covering healthcare models, managed care, Medicare parts, reimbursement methodologies, and key industry definitions.

Employee-Employer Transaction

A healthcare transaction where an employee pays a portion of the insurance premium (e.g., $40\%$) through payroll processing.

Provider and Third-Party Payer Transaction

A healthcare transaction where a physician office submits an invoice/claim for payment when the patient has health insurance.

Risk Pool

A group of people whose healthcare risks and costs are combined and shared among the members.

Health Insurance

A contract in which an insurance company agrees to pay some or all covered healthcare costs in exchange for a premium.

Revenue Integrity

A practice aimed at producing clean, complete, and compliant claims by promoting collaboration among departments and emphasizing an education strategy for all members.

National Health Insurance Model

A healthcare model that uses taxes to fund universal healthcare coverage.

Social Insurance Model

A healthcare financing model funded through contributions from employees, employers, and/or government.

Affordable Care Act (ACA) Dependent Age Limit

The age limit for dependent health insurance coverage under the ACA, which is $26$ years old.

Out-of-Network Services

Healthcare services received outside of a plan's designated network, where healthcare costs are generally higher.

Maximum Out-of-Pocket Amount

A financial threshold for covered services that, once reached, generally means the deductible has also been met.

Special Enrollment Period / Qualifying Life Event

A rule allowing an employee to alter coverage (such as adding a spouse immediately after marriage), provided they adhere to the employer's enrollment deadline.

Other Party Liability

A determination that an insurance company needs to make regarding financial responsibility when an accident is involved.

Point-of-Service (POS)

A managed care plan that allows members to choose how they receive services at the time they need them.

Managed Care Cost-Control Mechanisms

The three major mechanisms used by managed care plans: financial incentives, prospective payment, and service management tools.

Exclusions

The section of a healthcare insurance policy that identifies situations, conditions, injuries, or treatments that the plan will not cover.

Gatekeeper

A healthcare provider or entity responsible for determining what healthcare services a patient may access.

Adverse Selection

The enrollment of an excessive proportion of people with poor health status in a healthcare plan.

Principles of Managed Care

Four main principles focused on providing high-quality patient care: selection of providers, health of populations, care management, and quality.

Medicare Part A

A part of Medicare that primarily covers inpatient/hospital services.

Medicare Part B

A part of Medicare that covers outpatient and physician services.

Medicare Part C

Medicare Advantage.

TRICARE

A healthcare program for military members and dependents that is NOT the nation's largest integrated healthcare system.

Indian Health Service (IHS)

A government-sponsored healthcare program that provides benefits and coverage for American Indian and Alaska Native people.

PACE

Program of All-Inclusive Care for the Elderly.

Retrospective Reimbursement Methodologies

Payment methodologies that include per diem, percentage of billed charges, and fee-for-service.

Prospective Reimbursement Methodologies

Payment methodologies that include bundled payment, global payment, case rate, and capitation.

Attribution

The process of assigning a beneficiary/patient to an Accountable Care Organization (ACO).

Two-Sided Risk Agreement

An agreement in which the provider or organization shares both savings and losses.

CMS-HCC Model

A model used by CMS that relies on patient health status and demographic information to predict healthcare costs.

CMS-HCC Risk Score

A score where a value greater than $1$ indicates higher expected healthcare costs.

Per Diem

A term used by CMS to mean 'per day'.

Capitation / PMPM Capitation

A reimbursement method where a provider contracts with a Medicare Advantage payer to care for Medicare beneficiaries under Part C using a per-member-per-month payment.

Fee-for-Service / Fee Schedule

A reimbursement method where a physician receives a specific payment for each service provided during a clinic visit.

Global Payment

One payment covering a broad package of healthcare services/providers.