A Glossary of Healthcare Financing Terms
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
A Glossary of Healthcare Financing Terms
The financing of health care has given rise to new terminology. Nurses, as providers of care and consumers of services, need to be knowledgeable about these terms to improve their understanding of health care financing.
Terms pertaining to consumers:
Access—Ability to obtain health care services in a timely manner, at a reasonable cost, by a qualified practitioner, and at an accessible location.
Carve-out service—A service (e.g., mental health care) provided within a standard benefit package but delivered exclusively by a designated provider or group.
Charges—The posted prices of provider services.
Coinsurance—Cost sharing required by a health plan whereby the individual is responsible for a set percentage of the charge for each service.
Copayment—Cost sharing required by the health plan whereby the individual must pay a fixed dollar amount for each service.
Deductible—Cost sharing whereby the individual pays a specified amount before the health plan pays for covered services.
Fee schedule—List of predetermined payment rates for medical services.
Flexible spending account (FSA) or health savings account (HSA)—A mechanism by which an employee may pay for uncovered health care expenses through payroll deductions using pretax dollars.
Gatekeeper—Person in a managed care organization who decides whether a patient will be referred for specialty care. Doctors, nurses, nurse practitioners, and physician assistants function as gatekeepers.
Health care provider—An individual or institution that provides medical services (e.g., physicians, hospitals, or laboratories).
Health maintenance organization (HMO)—A managed care plan that acts as an insurer and sometimes a provider for a fixed prepaid premium. HMOs usually employ physicians.
Health plan—An insurance plan that pays a predetermined amount for covered health services.
High-deductible health plans (HDHP)—Insurance plan that uses cost sharing (i.e., high deductibles) to encourage employees to select plans with lower premiums. The intent is to encourage health care consumers to become more proactive in health care decisions from a financial perspective.
Indemnity plan—A health plan that pays covered services on a fee-for-service basis.
Managed care plan—A health plan that uses financial incentives to encourage enrollees to use selected providers who have contracted with the plan.
Medicaid—Joint federal- and state-funded programs that provide health care services for low-income people.
Medicare—A health insurance program for people who are older than 65 years of age, are disabled, or have end-stage renal disease.
Medicare Advantage—Part of Medicare by which recipients may choose to enroll in a coordinated care plan, private fee-for-service, or medical savings account plan created by the Balanced Budget Act of 1997.
Medigap insurance—Privately purchased individual or group health insurance plan designed to supplement Medicare coverage.
Out-of-pocket expenses—Payment made by the individual for medical services.
Point-of-service (POS) plan—A managed care plan that combines prepaid and fee-for-service plans. Enrollees may choose to use the services of an uncontracted provider by paying an increased copayment.
Portability—The guarantee that an individual changing jobs continues to receive health care coverage with the new employer without a waiting period or having to meet additional deductible requirements.
Preferred provider organization (PPO)—A health plan that contracts with providers to furnish services to the enrollees of the plan. Usually no insurance copayment is required.
Premium—Amount paid periodically to purchase health insurance benefits.
Primary care provider—A generalist physician, typically a family physician, internist, gynecologist, or pediatrician, who provides comprehensive medical services.
Terms pertaining to providers:
Ambulatory care—Medical services provided on an outpatient basis in a hospital or clinic setting.
Capitation—Payment mechanism that pays health care providers a fixed amount per enrollee to cover a defined set of services over a specified period, regardless of actual services provided.
Care management—Process used to improve quality of care by analyzing variations in and outcomes for current practice in the care of specific health conditions.
Cost containment—Reduction of inefficiencies in the consumption, allocation, or production of health care services.
Customary charge—Physician payment based on a median charge for a given service within a 12-month period.
Diagnosis-related group (DRG)—A system of payment classification for inpatient hospital services based on the principal diagnosis, procedure, age and gender of the patient, and complications.
Effectiveness—Net health benefit provided by a medical service or technology for a typical patient in community practice.
Full capitation—A stipulated dollar amount established to cover the cost of all health care services delivered for a person.
Maximum allowable costs—Specified cost level established by the health plan.
Outcome—The consequences of a medical intervention in a patient.
Physician’s current procedural terminology (CPT) codes—A list of codes for medical services and procedures performed by physicians and other health care providers that has become the health care industry’s standard for reporting physician procedures and services.
Practice guidelines—An explicit statement of what is known and believed about the benefits, risks, and costs of particular courses of medical action intended to assist decisions made by practitioners, patients, and others about appropriate health care for specific and clinical conditions.
Utilization review—A formal prospective, concurrent, or retrospective assessment of the medical necessity, efficiency, and appropriateness of health care services.
Terms pertaining to third-party payers:
Actuarial classification—Classification of enrollees that is determined by use of the mathematics of insurance, including probabilities, to ensure adequacy of the premium to provide future payment.
Administrative costs—Costs that the insurer incurs for utilization review, marketing, medical underwriting, agents’ commissions, premium collection, claims processing, insurer profit, quality assurance activities, medical libraries, and risk management.
Adverse selection—Procedure in which a larger proportion of people with poorer health status enroll in specific plans or options. Plans that enroll a subpopulation with lower-than-average costs are favorably selected.
Capital cost—Depreciation, interest, leases and rentals, taxes, and insurance on tangible assets.
Carrier—An organization that contracts with the CMS to administer claims processing and make Medicare payments to health care providers.
Cost contract—Arrangement between a managed health care plan and the CMS for reimbursement of the costs of services provided.
Cost shifting—The cost of uncompensated care is passed on to the insured, resulting in higher costs for those with insurance coverage.
Mandate—A state or federal statute or regulation that requires coverage for certain health services.
Risk assessment—Statistical method used to estimate claims costs of enrollees.
Discuss factors that influence the cost of health care.
Identify terms used in the financing of health care.
Discuss public financing of health care.
Discuss private financing of health care.
Discuss health insurance plans.
Describe trends in health care financing.
Describe the effects of economics on health care access.
Identify the future of health care economics.
Review the current National Health Care Quality Report and the National Disparities Report. They can be accessed at http://www.ahrq.gov/research/findings/nhqrdr/index.html. What frameworks or matrices are used to structure the report? What is the status of health care quality and disparities? What can you learn that would affect planning for health care services in a community?
Discuss how critical health care issues (e.g., managed care, quality care, fraud and abuse, diversity, and disparity) affect health care organizations in the community.
Cite examples of health care consumerism in the local community. What are their histories?
Give a personal reaction to health care fraud and abuse. How should the principles found in the Code for Nurses apply in practice?
Visit the following site on health care reform: https://www.hhs.gov/healthcare/about-the-aca/index.html. Review the elements of the law and current status. Discuss implications for nursing in the community. Also review http://www.helpingyoucare.com/21950/hhs-provides-tool-to-find-out-how-the-presidents-health-care-law-benefits-you-your-state. HHS provides this site for comparisons.
RUBRIC
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