Case Studies
Billy is due for his yearly eye appointment and new glasses this is the ideal service for him.
What is a Bundled Payment?
A number of related services included in one price.
What is a bundled payment?
The books idea for the next recommended change to the U.S. health care delivery system.
What is value based payment?
The default marketplace type.
What is Federally-facilitated?
Small firms with higher claims experience have more incentive to purchase coverage over firms with low claims experience.
What is adverse selection?
Sasha is looking for a new insurance plan and is clueless on where to look. This function of the marketplace website would be her ideal tool.
What is customer assistance?
Reimburses physicians based on the relative value assigned to each physician service.
What is a Resource-based Value Scale (RSRVS)?
The highest percentage of care for national health expenditure in 2013.
What is hospital care?
The two exchanges that exist within insurance.
What is the individual exchange and a Small Business Health Options Program (SHOP)?
This subsidy reduces out of pocket payments for those with lower incomes
What are Cost-Sharing subsidies?
Many states went with a federally facilitated marketplace because of this reason.
What is cost and public perception?
The number of services DRG's cover.
What is 500?
The national health expenditure in 2013 in relation to a % of GDP.
What is 17.4% of total GDP?
Eligibility Determination
Enrollment
Plan Management
Consumer Assistance
Financial management
What are the five marketplace functions?
Under this program plans with large numbers of lower risk subscribers will pay assessment fees to the the government who will then distribute the fees to plans with large numbers of high risk subscribers
What is Risk Adjustment?
Carl owns a construction company and last year over 50% of his employees were injured. He needs to make sure his insurance plan includes this.
What is risk adjustment?
One of the four main methods of prospective reimbursement.
What are:
Diagnosis-Related Groups (DRGs)
Ambulatory Payment Classifications (APCs)
Resource Utilization Groups (RUGs)
Home Health Resource Groups (HHRGs)
The DHHS goal for medicare payments in 2016.
What is to have 30% of payments tied to quality?
Tax credit is provided to people within this poverty level range.
What is 100%-400%?
This policy pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.
What is Capitation?
Great Samaritan Clinic has about 300 patients each month but their no-show rate can be as high as 45%. To get the best payment they would like to utilize this program.
What is capitation?
A complex mathematical equation used by home health to calculate how much services will cost.
What is the OASIS calculation?
The results of scenario one of the Comprehensive Care for Joint Replacement Program (CJR).
What is no significant association between reconciliation payments and risk scores?
Employees with less than this amount are not required to offer health insurance.
What is 50?
What is prospective reimbursement?