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Phlebotomy Chapter 1
The Healthcare Financing
| Payer | Description |
|---|---|
| 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 |
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