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S&PR5

Fee for Service versus Managed Care

QuestionAnswer
Fee for Service Payers assume primary financial risk
Fee for Service Provides enrollees with freedom of choice
Fee for Service Unlimited access to specialty providers
Fee for Service Co-payments often in the form of 80% / 20%
Fee for Service Limited internal/external cost controls
Fee for Service Minimal emphasis on health promotion and education
Managed Care Providers share in financial risk
Managed Care Services provided by a specific pool of providers
Managed Care Primary care provider serves as a gatekeeper
Managed Care Provides services for a fixed, prepaid monthly fee
Managed Care Formal quality assurance and utilization review
Managed Care Health education and preventive medicine emphasized
Medicare provides health insurance for individuals over 65 years of age and the disabled.
Medicare is a nationwide program . operated by the Centers for Medicare and Medicaid Services
Established in 1966, Medicare was the second mandated health insurance program in the United States (Workersʼ Compensation was the first).
In 1972 Medicare coverage was expanded to include certain categories of the disabled, renal dialysis, and transplant patients.
Medicare Part A: Provides benefits for care provided in hospitals, outpatient diagnostic services, extended care facilities, hospice, and short-term care at home required by an illness for which the patient is hospitalized.
Enrollment in Medicare Part A is automatic and funding is through payroll taxes.
Medicare Part B: Provides benefits for outpatient care, physician services and services ordered by physicians such as diagnostic tests, medical equipment, and supplies.
Enrollment in Medicare Part B is voluntary and funding is through premiums paid by beneficiaries and general federal tax revenues.
The Medicare program requires beneficiaries to share in the costs of health care through deductibles and coinsurance.
Medicare Deductibles require beneficiaries to reach a predetermined amount of personal expenditure each 12-month period before Medicare payment is activated.
Medicare Coinsurance requires that 20% of the costs for hospitalization is covered by the patient. Medicare sets limits on the total days of hospital care that will be paid based on a lifetime pool of days.
Medicare payments for post-hospital stays in extended care facilities are limited to 100 days. Providers are reimbursed for Medicare services through intermediaries such as Blue Cross.
Medicaid provides basic medical services to the economically indigent population who qualify by reason of low income or who qualify for welfare or public assistance benefits in the state of their residence.
Medicaid is a jointly funded program through the federal and state governments.
Established in 1965, Medicaid is funded through personal income, corporate, and excise taxes. Federal and state support is shared based on the stateʼs per capita income.
Medicaid Rate setting formulas, procedures, and policies vary widely among states. All state Medicaid operations must be approved by the Centers for Medicare and Medicaid Services.
The Medicaid program reimburses providers directly. The Medicaid program covers inpatient and outpatient hospital services, physician services, diagnostic services, nursing care for older adults, home health care, preventative health screening services, and family planning services.
Workersʼ Compensation First designed in 1911 to provide protection for employees that were injured on the job. This legislation provides continued income as well as paid medical expenses for employees injured while working.
Workersʼ compensation is a joint federal and state program that is regulated at the state level. Recently case managers have assisted this process by monitoring the rehabilitation process and controlling potential abuse.
Employers with 10 or more employees or high risk employers must pay a percentage of each employee salary to the workerʼs compensation board of the state. The exact payment is based on the risk rating of the job or institution.
Independent health plans Health maintenance organizations and self-insurance plans are examples of independent health plans. Reimbursement is typically based on fee-for-service or a predetermined fixed fee.
Independent health plans Managed care: A concept of health care delivery where subscribers utilize health care providers that are contracted by the insurance company at a lower cost.
Independent health plans Managed care Health maintenance organizations (HMO) and preferred provider organizations (PPO) are two examples of a managed care system.
Independent health plans Managed care This concept attempts to attain the highest quality of care at the lowest cost.
Independent health plans Health maintenance organization: Subscribers to these insurance plans agree to receive all of their health care services through the predetermined providers of the HMO.
Independent health plans Health maintenance organization The primary physician of the subscriber controls health care access through a referral system. Cost containment is a high priority and subscribers cannot receive care from providers outside of the plan except in an emergency.
Independent health plans Preferred provider organization: Subscribers can choose their health care services from a list of providers that contract with the insurance plan. These contracts provide extreme discounts for health care.
Independent health plans Preferred provider organization Subscribers can use a health care provider that is not associated with the PPO, however, they will absorb a greater portion of the cost.
Current Procedural Terminology Codes
Current Procedural Terminology (CPT) codes areprofessionals to describe the interventions that were provided to a given patient. procedure codes used by physical therapists and other health care
The majority of codes used by physical therapists are in the CPT 97000 series. Examples of commonly used CPT codes by physical therapists include: 97530 – Therapeutic Activities; 97035 – Ultrasound; 97012 – Traction, mechanical. CPT is a registered trademark of the American Medical Association.
The International Classification of Diseases (ICD) codes are designed to describe a patientʼs infirmity through 17 categories based on etiology and affected anatomical systems.
ICD) codes The codes consist of five distinct digits (e.g., 755.12). The first three digits indicate the basic diagnosis.
ICD) codes The fourth digit and in some cases the fifth digit serve to differentiate the basic diagnosis or anatomical area affected.
ICD) codes Physicians are required to make the medical diagnosis, however, in some cases a physical therapist may need to utilize the ICD manual to determine an appropriate ICD code.
ICD) codes This action is within a physical therapistʼs scope of practice and would not be considered equivalent to making a medical diagnosis.
Subjective: Refers to information the patient communicates to the therapist. This could include social or medical history not previously recorded. It could also include the patientʼs statements or complaints.
Objective: Refers to information the therapist observes. Common examples include range of motion measurements, muscle strength, and functional abilities. It also includes manual techniques and equipment used during treatment.
Assessment: Allows the therapist to express their professional opinion. Short and long-term goals are often expressed in this section as well as changes in the treatment program.
Plan: Includes ideas for future physical therapy sessions. Frequency and expected duration of physical therapy services can also be incorporated into this section.
Created by: micah10