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S&PR5
Fee for Service versus Managed Care
| Question | Answer |
|---|---|
| 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
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