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Phlebotomy Chapter 1

The Healthcare Financing

Third-party payers Any insurance company or government program that pays for healthcare services on your behalf
Prospective payment system (PPS) Attempted to limit and standardize Medicare/Medicaid payments made
Diagnostic-related groups (DRG) Defined the amount of reimbursement a facility received for admissions
Ambulatory patient classification (APC) A new classification implemented in 2000 for payment to hospitals for outpatient services
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Coding of diagnoses that groups together similar diseases and operations for reimbursement
Center for Medicare and Medicaid Services (CMS) Was Health Care Financing Administration, is developing a new system called ICD-10
CMS Comon Procedure Coding System A system that has 3 levels
Current Procedural Terminology (CPT) Level 1 of CMS system that was developed in the 1960's by the American Medical Association for doctor's billing
Health Insurance Portability and Accountability Act (HIPAA) Designed to improve the efficiency of the healthcare system by establishing standards for electronic data exchange
Entitlement programs Include Medicare and Medicaid
Medicare Enacted in 1965 to provide healthcare for individuals over 65 and the disabled
Medicaid Enacted in 1965 to provide healthcare for the poor
Arizona Healthcare Cost Containment System (AHCCCS) Is the state's form of Medicaid and providers must bid annually for contracts to serve the population, the people get to choose their healthcare provider
Health Maintenance Organizations (HMO) Group practices that are reimbursed on a prepaid, negotiated, and discounted basis of admission
Preferred Provider Organizations (PPO) Independent groups that offer services to employers at discounted rates in exchange for a steady supply of patients
Gatekeeper A patient's advocate responsible for advising the patient on healthcare needs
Managed care organizations (MCO) Has a contract with local providers to establish a complete network of services and reimburse providers based on the number of enrollees served
Created by: dautcalm