Capitation
PCP receives a monthly, 1/4, 1/2, or annual payments from the managed care insurance company
- Specialist not included
- Depends on age and sex and not the amount of care
- Moves some of the risk away form the managed care company and onto the PCP who treats the patient, and most providers prefer other payment methods
Fee- For -Service insurance
- Heath care provider is reimbursed for each treatment or procedure performed
- FFS vs managed care is managed care companies often negotiate a fee schedule the is lower then traditional indemnity plans
- Becoming not as common
- BCBS
Indemnity
An obligation to compensate an individual fro loss or damage
Managed care
- Describes the movement to control healthcare cost while improving preventive care
- General term for insurance programs reimbursing care provided in this way
- They negotiate reimbursement and limit patients to those providers who they are in contact with
- HMO plans
Staff Model HMO
Hires its physician directly and pays them a salary for providing health care to members
Network HMO
IN and OUT of network physicians
PPO
Provides coverage for in network and out of network
- Have deductibles and coinsurances or copays
Exclusive Provider organization (EPO)
LIke PPO but only in network service
Independant practice association (IPA)
Work independently in the community but organize formally as a physician association
POS
Combination of HMO and PPO
Medicare Part A
Provides coverage for hospitalization service
Medicare Part B
Covers physician and other provider service
Medicare Part C
Prescription drug benefit
PHI
Personal health information
Reimbursement Requirements
- Each per-certification and most referrals must be authorized by HMO
Preauthorization/ per-certification
Verification from a patient’s insurance carrier that a procedure is covered by the patient’s insurance and/or agreement, after review, that the test or procedure is medically appropriate
National Provider identifier (NPI)
10 digit identifier required for all health care providers
Insurance Claim Forms
CMS-1500
Insurance Claim Forms (CMS-1500)`
- Required form for Medicare claims
- Name and address of carrier
- Paper claims ender in uppercase letter with out punctuation
