Term
| Most Important provider reimbursement method |
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Definition
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Term
| Reasons for rise in health care in US |
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Definition
| Increased service intensity, Increased demand, Increased proces, changing demographics |
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Term
| Not a risk sharing model for DR |
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Definition
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Term
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Definition
Cost-Price X Use
Manage care must addfress price mgt and provider reim. and utilization mgt |
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Term
| Hospital reimbursement Strategies |
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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 |
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Term
| Fee-for -Service vs Discounted fee for service |
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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 |
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Term
| Fee for Service Reimbursement methods(3) |
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Definition
| Reasonable and Customary, Fee schedule, Resource Based relative Value Scale(RBRVS) |
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Term
| Churning, Upcoding, Unbundling |
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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 |
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Term
| Risk Sharing as Reimbursement strategy |
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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 |
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Term
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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 |
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Term
| Risk sharing models for reimbursing Dr's in a managed care environment |
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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 |
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Term
| Utilization Management-principle function |
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Definition
| Ability to reduce rate of LT heath care costs, focus on controlling hospital stays but reducing number of admissions or length of stay |
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Term
| Expanded Utilization management programs with stronger forms of Managed Care |
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Definition
| Referral Managemen, Outpatient Precert, Managed Second Opinion, On-site Concurrent review, Centers of Excellence, Prenatal adv. |
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Term
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Definition
| Health Ennhancement Programs, Disease Management for chronic conditions, Case Management |
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Term
| New Development in Patient Care |
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Definition
| Clinical Specialists-AIDS, cancer, spine, cardio, for primary care to highly specialized |
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Term
| Sources of Net Savings 2001 |
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Definition
| PPO Planlower non-network reimbursements |
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