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ALH Midterm

Financing and Reimbursement

TermDefinition
Physician Assistant Dependent health care providers who practice collaboratively with a supervising physician
Billing may include reimbursement for PA= provided services
PPACA Patient Protection and Affordable Care Act. Obama Care
The United States spends (more/less) per year on health care compared to other countries more
Prior to enactment of the PPACA laws... 45 million people were uninsured
Statistics prove gaps and absence of health care is associated with increased deaths and illness
The elderly require (more/less) frequent and often expensive care for health maintenance and chronic disease care more
Currently, most of the health care dollars are spent on terminal care
Quality-of-life health care promotion model to keep patients as healthy as possible by screening and proper immunization
Federal mandates must be established to monitor how health care services are delivered and financed
Factors that should be considered when reforming health care how care is delivered what type of care is provided the geographic areas that health care providers practice in Patient access to health care
Impoverished areas have (more/less) access to quality health care less
PA clinicians provide medical and surgical care (similar/different) to physicians similar
Tor F: PAs and doctors are interchangeable True
State laws and guidelines mandate that patients are ______ _______ that physician services can be delivered by PAs made aware
Medicare programs are administered by federal government
Medicare is funded through a combination of: medicare premiums general fund revenues patient deductibles and co-payments
Medicare Part A pays for hospital facility medical equipment and supplies inpatient skilled nursing facility (SNF) care home health care hospice
Medicare Part A does NOT pay for professional services delivered by physicians and PAs
Medicare Part B pays is a "_____ _______ ______" payment fee for service
Medicare Part B pays for professional services delivered by Physicians, PAs, other health care professionals and "incident to" services
"Incident to" services allows PA to treat patient, bill the service to Medicare under the physician's name and receive reimbursement at 100% of the fee schedule.
Medicare Part C is an option for patients to receive Medicare-eligible services through Health Maintenance Organizations (HMO's) or other types of Managed Care Organizations
Medicare Part C offers enhanced benefits including routine physicals, eyeglass coverage and no co-payments or deductible for patients to pay
Medicare Part D is prescription drug plan created as part of the Medicare Prescription Drug Improvement and Modernization Act
Shared Services When both an MD and PA perform patient evaluation and management service. 100% reimbursement fee
Shared Services inclue inpatient, outpatient and emergency department
Requirements of Shared Service MD required to have provided "face-to-face" patient care on SAME calendar day MD and PA must be employed by same organization
Certified Rural Health Clinics (RHC) must be designated a health shortage area
Federal certification of a clinic as RHC allows clinic to be reimbursed on a "________" and not "_________" "cost-based" scale not a "fee-for-service"
At RHCs, PAs and doctors are reimbursed 100%
At RHCs, doctors receive an additional 10%
At RHCs, PAs (are/are not) eligible for the additional 10% are not
Medicaid is authorized by Title ____ of the Social Security Act XIX
Reimbursement for Medicaid is paid at a "__________" rate "fee-for-service"
Medicaid beneficiaries are assigned a primary care provider (PCP) which provides continuity of care increased access to health care facility and personnel Easier referral to specialists of inpatient care (in-network)
Can a PA serve as a PCP? yes, but only in some states
Disadvantages of fee-for-service coordination of care is lacking unnecessary testing improper and inefficient screening for individual risk factors
Accountable Care Organizations ACOs. Patient-centered medical homes Insurance exchanges
Definition of ACO local organization consisting of health care professionals in 1 or more hospitals and related health organization that have formal and informal relationships to provide the most comprehensive patient care and improve health conditions
Patient-Centered Medical Home care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand.
Advantages of Patient-Centered Medical Home Team based, family-centered, culturally appropriate,committed to quality and safety, cost-effective.
True or False- The Federal government has the right to create a health exchange if a State fails to do so. True
Benefits of insurance exchange increase selection plans, competitive pricing, portability, ability to directly compare plans, and insurers unable to deny coverage to individuals with "pre-existing" conditions.
Problems with Insurance Exchanges Initial crash of website, inexperienced advisors, initial motivation to sign up was slow, support by government was split
Pay for Performance (P4P) Value-based purchasing, quality-based purchasing, etc. Program purposed to use financial incentives to improve medical outcomes. Clinician and patient bonuses Poor outcomes= penalties Some Medicare
Physician Quality Reporting System (PQRS) Pay for performance program. Pays a bonus on the practice's total billing if the practice reports up to three quality measures and at least 80% of the time the measures are met. Measures listed on website
Concerns with Pay for Performance incentives falsified data, increased medical errors, lack of adherence to most updates standards, etc.
Created by: Gianna B