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Prospective payment system which means reimbursement has a system that has already established reimbursement for any given patient
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What is a fee for service system? start learning
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A fee for service system reimburses for each procedure completed and billed.
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A health maintenance organization that provides practitioners and services in their own system. Preventative services are emphasized.
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Dexscribe commerical insurance (also known as major medical plans) start learning
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Major Medical plans are generally considered insurance for catastrophic care. Choice of physicians is preserved. Preventative care is limited.
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A fee schedule is a list of the amount of reimbursement agreed upon for various treatments, usually based on CPT codes.
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What is an insurance deductible? start learning
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A deductible is the amount of money the beneficiary must pay before insurance benefits begin.
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What type of healthcare system has the managment theory of keeping all expenses "in house"? start learning
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A preferred provider organization. PPOs provide incentives to practitioners and patients to use their network providers.
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What is an insurance co-payment? start learning
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A co-payment is the amount of money the beneficiary must pay for each visit to a practitioner.
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A case manager is an individual responsible for following and managing cases, attending to details and approving/denying requested treatments.
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Capitation is a fixed and usually flat rate of reimbursement is provided for all services provided.
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What is seamless integration? start learning
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Seamless integration is a continuum of care through the same organization removing any duplication of services.
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What type of healthcare system retains the advantage of choice but also provides incentive to use its network's list of providers? start learning
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What is a case rate as a means for determining reimbursement? start learning
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Case rate reimbursement provides a set amount based on diagnosis/level of symptoms, regardless of services provided.
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What does a policy's out of pocket maximum refer to? start learning
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The out of pocket maximum refers to the total amount of money a beneficiary must spend before insurance covers the full amount up to the policy limit.
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What is a Resource Based Relative Value System? start learning
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Reimbursement based on the amount of resources consumed by providing care.
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What is Worker's Compensation? start learning
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Worker's Compensation is an insurance program providing wage replacement and medical benefits to employees injured on the job.
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What is per diem as a means to determine reimbursement? start learning
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A per diem reimbursement payment includes a set amount per session regardless of treatment provided.
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Describe the Medicare B Therapy Cap. start learning
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The therapy cap was set at $1500 in the BBA of 1997. While it does benefit from a cost of living raise, it continues to limit PT services available to beneficiaries.
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What other changes occurred with the Balanced Budget Act of 1997? start learning
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SNFs, Acute Rehab and Home Care became reimbursed under PPS rather than fee-for-service
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What is a third party payer? start learning
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An individual or corporation that makes a payment on an obligation or debt, but is not party to the contract that created the obligation/debt.
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What are three primary differences between Medicare and Medicaid? start learning
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1. Populations covered; 2. Funding source; 3. Inconsistency of covered services between states
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