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ALH Midterm
Financing and Reimbursement
| Term | Definition |
|---|---|
| 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
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