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Details

ASSIGNMENT 6
CEBS ASSIGNMENT 6
16
Other
Not Applicable
10/13/2004

Additional Other Flashcards

 


 

Cards

Term
Most Important provider reimbursement method
Definition
Hospital
Term
Reasons for rise in health care in US
Definition
Increased service intensity, Increased demand, Increased proces, changing demographics
Term
Not a risk sharing model for DR
Definition
Per Diem
Term
Health Care Equation
Definition
Cost-Price X Use
Manage care must addfress price mgt and provider reim. and utilization mgt
Term
Hospital reimbursement Strategies
Definition
Straight discount(least favorable-no risk sharing), DRG-Diagnostic Related Group(setting price is a problem), Case Rates, Per Diem, Global rates
**DRG best suited for plans with loose controls-tightly manage utilization
Term
Fee-for -Service vs Discounted fee for service
Definition
FFS-Paid per treatment-no balance billing-easy to initiate & can acquire many providers
DFFS--At a level below the providers usual charge-more services do not necessarily translate into better patient care
Term
Fee for Service Reimbursement methods(3)
Definition
Reasonable and Customary, Fee schedule, Resource Based relative Value Scale(RBRVS)
Term
Churning, Upcoding, Unbundling
Definition
Churning--seeing member more often than necessary,
Upcoding--Billing for a procedure that pays more,
Unbundling-Billing multiple components rather than a single fee
Term
Risk Sharing as Reimbursement strategy
Definition
Providers only concered with price management-not interest in controlling cost,
Risk sharing best for stronger formed managed care plans
Conditions to be met----
PCP for each member, Resk pools of PCP should be developed, PCP should have a min concentration of members, models need to take diff forms depending on community
Term
Capitation
Definition
Pay prospectively for health care services on a basis of the number of plan members who are covered for specific services over a specified period of time.--per person
Advantages-Reward providers for prudent utilization
Disadvantage-Difficult to recruit Dr's-no incentive to complete paperwork
Term
Risk sharing models for reimbursing Dr's in a managed care environment
Definition
Case Management Fee, Physician incentive/bonus, Fee for service with withhold, Capitation for defined services, Capitation with withhold, Capitation for complete services, Budget Capitation, Salaried physicians
Term
Utilization Management-principle function
Definition
Ability to reduce rate of LT heath care costs, focus on controlling hospital stays but reducing number of admissions or length of stay
Term
Expanded Utilization management programs with stronger forms of Managed Care
Definition
Referral Managemen, Outpatient Precert, Managed Second Opinion, On-site Concurrent review, Centers of Excellence, Prenatal adv.
Term
Patient Care Models (3)
Definition
Health Ennhancement Programs, Disease Management for chronic conditions, Case Management
Term
New Development in Patient Care
Definition
Clinical Specialists-AIDS, cancer, spine, cardio, for primary care to highly specialized
Term
Sources of Net Savings 2001
Definition
PPO Planlower non-network reimbursements
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