Chapter 1
Social Insurance
National Health Service
Private Health Insurance
What are the 3 models for delivering healthcare?
The probability of incurring loss.
What is risk?
Hospitalization Insurance
What is Medicare part A
Predetermination list of fees that a payer allows for payment for a set of healthcare services.
What is a Fee Schedule?
Represents resource intensity of the group.
What is Relative Weight?
Offers 24-hours per day skilled nursing and personal care services.
What is a nursing home?
Compensation or repayment for healthcare services delivered.
What is reimbursement?
Payments that the policyholder must make to an insurerin return for healthcare coverage.
What is a premium?
Voluntary supplemental medical insurance
What is Medicare Part B?
Payer has negotiated to pay a reduced fee for services provided to their insureds
What is Percent of Billed Charges?
The complexity or description of the patient population.
What is Case Mix?
Provides short-term skilled nursing care and rehabilitation services to beneficiaries after an acute-care inpatient hospitalization
What is a skilled Nursing Facility?
A regular set of tasks and activities that produces reimbursement.
What is revenue cycle?
Pre-established percentage of eligible expenses after the deductible has beed made.
What is Coinsurance?
Outpatient prescription drug coverage.
What is Medicare Part D?
Payer reimburses the provider a fixed rate for each day a covered member is hospitalized
What is Per Diem?
The weighted average of the sum of the relative weights of all patients during a specified time period.
What is Case-Mix Index?
NTA
What is Nontherapy Ancillary (NTA) Component?
An individual or entity that purchases health insurance coverage
What is a policyholder?
A fixed dollar amount that may vary by type of service.
What is a copayment?
Medicare Advantage
What is Medicare Part C?
Population-based model for healthcare delivery and payment
What is an Accountable Care Organization?
The extent of physiological decomposition or organ system loss of function.
What is Severity of Illness?
Two levels of base rates
What is Urban & Rural?
An individual who is eligible for benefits from a health plan.
What is a beneficiary?
COB
What are Coordination of Benefits?
Supplementary insurance to cover items & services not covered by Medicare.
What is Medigap?
Assignment of a beneficiary to a particular Accountable Care Organization (ACO)
What is attribution?
VBP
What is Value-Based Purchasing?
SNFVBP
What is Skilled Nursing Facilities Value-Based Purchasing Program?