| ACO (Accountable Care Organization) | primary care-led physician and hospital organizations that voluntarily form networks |
| adjudication is the process where | the payer verifies that their billing requirements have been met, and then they determine which services are eligible for reimbursement |
| per capita means | per head or per person |
| In capitation (AKA, the capitated payment method), a 3rd party payer reimburses providers based on | a fixed, per person amount for a period (usually a month) |
| PMPM stands for | per member per month |
| Another term for capitation is | global capitation |
| In capitation, the volume or intensity of services provided to a patient | have no effect on the payment |
| prospective reimbursement methodologies include | capitation, case rate, global payment, and bundled payment |
| prospective reimbursement is a payment method where | providers receive a predetermined amount for all the services they provide during a timeframe |
| The unit of payment in prospective reimbursement is | the encounter, established period of time, or covered life |
| Case-rate methodology is a payment method where | the 3rd party payer reimburses the provider one amount for the entire visit or encounter |
| Case-rate methodology is also known as | case-based payment |
| Case-rate methodology is most often used for | inpatient admissions |
| case-rate payment rates are based on | historical data about typical costs for patients within a group |
| The global payment method is a payment method where | a 3rd-party payer makes one combined payment to cover services of multiple providers who are treating a single episode-of-care. |
| The global payment method is typically used for | physician services and outpatient care |
| The contracting unit in the global payment method is | the episode of care |
| In a bundled payment methodology, a predetermined payment amount is provided for | all services required for a single predefined episode-of-care |
| In bundled payment, there is usually a ________ that initiates the episode-of-care. | trigger, such as a service or onset of a condition |
| 2 criticisms of prospective payment are | 1) this method creates incentive to use less expensive diagnostic tests, therapeutic procedures, etc 2) creates incentive to delay or deny procedures and treatments that are costly |
| Retrospective payment methodologies are methods where payment is based on | actual resources expended to deliver services |
| Examples of retrospective payment methodologies include | fee schedule, percent of billed charges, and per diem |
| A fee schedule is based on a | pre-determined list of fees that a 3rd party payer will pay for certain healthcare services |
| Fee schedule is considered a retrospective reimbursement methodology because | which services and the volume of services will not be known until after care has been provided |
| 3rd-party payers negotiate reduced fees for their members or insureds in this retrospective reimbursement methodology | percent of billed charges |
| The contracting unit in percent of billed charges is the | claim |
| The contracting unit in the fee schedule methodology is the | service |
| Third-party payers set per diem rates using | historical data |
| Per diem rates apply to | inpatient days |
| Criticisms of retrospective reimbursement methodologies include | 1) few incentives to reduce costs 2) less incentive to order less expensive services |
| insurance is a system of | reducing a person's exposure to risk of loss by having another party assume the risk |
| A risk pool is | a group of insureds who have a similar risk of loss |
| The premium is | the amount paid by a policyholder for a certain time period of coverage by an insurance company |
| 3 national models of healthcare delivery are | 1) social insurance 2) national health insurance and 3) private health insurance |
| The social insurance model is also known as | the Bismarck model (originated in Germany) |
| The national health service model is also known as | the Beveridge model (originated in UK) |
| The Beveridge model is characterized as | a government-run model that is a single-payer health system |
| Unlike in the Bismarck model, _________ determines the contribution that workers make to insurance coverage, and the contribution is not based on income. | the private insurance company |
| 3 characteristics that are key to understanding the U.S. healthcare sector are | 1) the size 2) the complexity and 3) the intricate payment methods and rules |
| DRGs went into effect this year: | 1983 |
| MS-DRGs went into effect this year: | 2007 |
| The inpatient psychiatric facility prospective payment system (IPF PPS) went into effect this year: | 2005 |
| 2 major trends of the U.S. healthcare sector are | 1) healthcare spending is constantly increasing and 2) efforts to reform the healthcare system |
| The skilled nursing facility PPS went into effect this year | 1998 |
| The home health PPS went into effect this year: | 2000 |
| The inpatient rehabilitation facility PPS went into effect in | 2002 |
| The long-term care DRG (LTC-DRG) went into effect in | 2002 |
| The payment system for hospice went into effect in | 1983 |
| The payment system for ambulance services went into effect in | 2002 |
| The PPS for federally qualified health centers (FQHC) went into effect in | 2014 |
| The PPS for medicare end-stage renal disease facilities (ESRD) went into effect in | 2011 |
| 3 core problems in the US health system are | 1) excessive cost 2) inequitable or unsafe care 3) lack of access |
