HFMA Florida Chapter



Module I, Course 1: The Business of Health Care – The “Big Picture”Provider - GeneralA party rendering medical care such as a physician or hospitalFacilities ProviderIncludes hospitals, skilled nursing facilities, assisted living facilities, home health agencies, and ambulatory surgery centersPrimary CarePrimary 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.SpecialistSpecialists normally do not provide primary care services, instead focusing their work based on in-depth training in different diseases, body systems or types of healthcare service.Third Party PayerA health insurance plan paying for the services.Out-of-Pocket PaymentPayments by patients that can be required as a part of a health insurance plan are: deductible, copayment, and coinsuranceDeductibleThe deductible is a pre-determined amount that the patient pays before the insurer begins to pay for service.CoinsuranceCoinsurance is a percentage of the insurance payment amount that is paid by the patient, along with the amount paid by the insurer.IndemnifyPayment on behalf of the patient – costs covered under the insurance contract between the patient and the insurer.ClaimA bill for services providedPre-authorizationPermission 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 PaymentOnce the insurer has determined the claim is appropriate, a payment is made to the provider. This payment is officially termed a benefit payment.BeneficiaryInsurers usually refer to the patient for which services are paid as the beneficiary.Covered BenefitThe services for which the insurer will pay are usually referred to as a covered benefit.DenialThe insurer may determine that the claim from the provider is not a covered benefit and will not pay the claim to the provider.Remittance AdviceThe information an insurer provides on the payment decision.Medicare Part AMedicare Part A is funded primarily by Medicare taxes paid by current workers to fund the costs of current beneficiaries. Patients are usually eligible for Medicare Part A if they are a US citizen over age 65, disabled or have End Stage Renal Disease and have paid Medicare wage taxes for at least forty (40) calendar quarters – known as categorical eligibility. Medicare Part A covers inpatient hospital services, certain organ transplants, ESRD treatment, inpatient skilled nursing facility care, home health care and hospice care.Medicare Part BMedicare Part B 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 B but not Medicare Part A.Medicare Part DThe Medicare Part D program covers outpatient prescription medicines for persons otherwise eligible for Medicare benefits.Medicare AdvantageMedicare Advantage 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.Centers for Medicare and Medicaid Services (CMS)The federal government, through the Centers for Medicare and Medicaid Services or CMS, oversees all parts of the Medicare program, including Medicare Part A and Medicare Part BMedicare Trust FundThe Medicare Trust Fund is the overall pool of money used to finance the Medicare program.Fiscal IntermediaryAn organization acting on behalf of CMS to administer Medicare payments is known as a fiscal intermediary.MedicaidThis 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 NetworksProvider networks are groups of selected providers contacted with insurers 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 (VBP)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 of care. VBP is but one change brought about through the PPACA.Patient Protection and Affordable Care Act (PPACA)Ultimately these multiple perspectives 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 RatioMedical Loss Ratio is the requirement that insurance plans spend a minimum amount of collected revenues to pay for medical care of patients.Individual MandateThe Individual Mandate 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.Employer MandateThe Employer Mandate was a provision of PPACA requiring employers with more than 50 employees to make health insurance benefits available to employees.Insurance ExchangeInsurance Exchanges are state-run health insurance markets designed to make health insurance affordable and broadly available. ................
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