HFMA terms Questions and Answers 2023

HFMA terms Questions and Answers 2023 provider - general A party rendering medical care such as a physician or hopsital facilities provider Includes hospitals, skilled nursing facilities, assisted living facilities, home health agencies, and ambulatory centers professional provider includes physicians, pharmacists, nurses, therapists, and allied health professionals primary care primary care physicians are usually trained in family practice, general practice, general internal medicine, and pediatrics. Physicians serving in primary care roles usually treat common medical conditions or injuries, and often provide preventive health screenings. They are often viewed as serving as a coordinator of a patient's care, assessing a patient's condition, and treating if a simple condition, or referring a patient to a specialist physician. specialist specialists normally do not provide primary care services, instead focusing their work based on in-depth training in different diseases, body systems or types of health care service third party payer a health insurance plan paying for the services out-of-pocket-payment payments by patients that can be required as a part of a health insurance plan are: deductible, copayment, and coinsurance deductible the deductible is a pre-determined amount that the patient pays before the insurer begins to pay for service coinsurance corinsurance is a percentage of the insurance payment amount that is paid by the patient, along with the amount paid by the insurerer indemnify payment on behalf of the patient - costs covered under the insurance contract between the patient and the insurer claim a bill for services provided pre-authroization permission by the insurer to render services to the patient before actually treating the patient. This includes verification of payment for the service by the insurer benefit payment once the insurer has determined the claim is appropriate, a payment is made to the provider. This payment is officially termed a benefit payment beneficiary insurers usually refer to the patient for which services are paid as the beneficiary a covered benefit the services for which the insurer will pay are usually referred to as a covered benefit denial the insurer may determine that the claim from the provider is not a covered benefit and will not pay the claim to the provider remittance advice the information an insurer provides on the payment decision Medicare A funded primarily by Medicare taxes paid by current workers to fund the costs of current beneficiaries. Patients are usually eligible for Medicare Part _ if they are a US citizen over age 65, disabled or have End Stage Renal Development and have paid Medicare wage taxes for at least forty (40) calendar quarters - known as categorical eligibility. Medicare Part _ covers inpatient hospital services, certain organ transplants, ESRD treatment, inpatient skilled nursing facility care, home health care and hospice care Medicare B Medicare Part _ is a voluntary program where a patient that meets the age or medical condition requirements for Medicare Part A (but not the requirement to pay taxes for 40 calendar quarters) may participate in this insurance benefit. It is possible for a patient to be covered by Medicare Part _ but not Medicare Part A. Medicare Part D The Part _ program covers outpatient prescription medicines for persons otherwise eligible for Medicare benefits. Medicare Advantage Medicare _ plans market to Medicare beneficiaries by offering benefits above those provided through traditional Medicare Part A or Medicare Part B programs in exchange for the patient being willing to obtain services from a select panel of providers and to be subject to utilization management programs that may limit the patient's access to certain high cost services. Center for Medicare and Medicaid Services (CMS) The federal government, through the Centers for Medicare and Medicaid Services/CMS, oversees all parts of the Medicare program, including Medicare Part A and Medicare Part B Medicare Trust Fund The Medicare Trust Fund is the overall pool of money used to finance the Medicare program Fiscal Intermediary Organizations acting on behalf of CMS to administer Medicare payments is known as a fiscal intermediary Medicaid There is an insurance program for the poor and medically needy that is operated as a joint program between the federal government CMS and the individual states known as Medicaid Provider networks Provider networks are groups of selected providers and contracted with insurer as "preferred" or "in-network" by the insurer. Under this relationship, the insurer will pay a higher proportion of the patient's costs of care in exchange for the patient going to the "in-network" provider Value-based purchasing Medicare's Value Based Purchasing (VBP) program as a part of the Patient Protection and Affordable Care Act (PPACA) can reduce payments to providers that do not meet or exceed their standards of quality care. VBP is but one change brought about through the PPACA Patient Protections and Affordable Care Act (PPACA) Ultimately these multiple perspective on health reform influenced the current provisions of PPACA. Much of the reform effort ultimately was aimed at reforming health insurance markets where major changes were applied to the way that health insurers operated with some changes to influence more persons to get access to health insurance coverage Medical Loss Ratio Insurance plans were required to spend a minimum amount of collected revenues to pay for medical care of patients called _______ the individual mandate the _______ was a change to require individuals without employer-provided insurance to purchase health insurance through health insurance exchanges in each state or face tax penalties the employer mandate the ________ was a provision of PPACA where employers with more than 50 employees to make health insurance benefits available to employees insurance exchange state run health insurance markets designed to make health insurance affordable and broadly available accountable care organization ACO _________ are various providers of care to work together to manage the healthcare of a select population of patients and to receive financial benefit from reducing the cost of care while improving the quality of care for those patients-i.e. population health bundled payments related to the ACO was the addition of bundled payments to groups of providers for a single occasion of service to a specified patient