Post on 15-May-2015
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Introduction to Health Insurance
Chapter 2
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Announcements
• Library class time meetings• Name tags (first name)• Open Lab (Tuesdays & Thursdays) Rm. 118• Midterm is an exam! (50 pts)• Project (interview 4 people) due same day
asmidterm exam (October 28)
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Defining Health Insurance• Health insurance
– Contract between a policyholder and a third-party payer or government program to reimburse the policyholder for all or a portion of the cost of medically necessary treatment or preventive care provided by health care Professionals
• Medical care– Identification of disease and treatment of those who are sick, injured, or concerned about their health
• Health care– Medical care + preventive service
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Medical Documentation
• A patient record (or medical record) documents health care services provided to a patient, and health care providers are responsible for documenting and authenticating legible, complete, and timely entries according to federal regulations and accreditation standards.
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Medical Documentation
• “If it wasn’t documented, it wasn’t done.”
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Problem-Oriented Record
• Systematic method of documentation consists of four components:– Database– Problem list– Initial plan– Progress notes
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Progress Notes
• SOAP format– Subjective– Objective– Assessment– Plan
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Electronic health record (EHR) is a more global concept that includes the collection of patient information documented by a number of providers at different facilities regarding one patient.
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Managed Health CareChapter 3
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Managed Health Care
• Managed care provides reasonably priced health care for consumers and providers who agree to certain conditions.
• Currently being tested by growing “consumer-directed health plans”
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Primary Care Providers (PCPs)
• Participating providers are liable for supervising, organizing health care services, and approving referrals for specialists and inpatient hospital stays.
• PCP serves as a gatekeeper.
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Managed Care Organizations
• Responsible for group of enrollees– Health plan, hospital,
physician group, or health system
• Capitation payment system– If services rendered cost less: MD profits– If services cost more: MD loses money
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Quality Assurance
• Activities that assess the quality of care in a health care setting
• Types– Government oversight– Patient satisfaction surveys– Data from grievance procedures– Reviews by independent organizations
• NCQA and The Joint Commission
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Utilization Management(Utilization Review)
• System of controlling health care costs and quality of care by evaluating care provided
• Preadmission certification– Review of necessary medical outpatient treatment
• Preauthorization– Prior approval for reimbursements
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Managed Care Models
• EPO – Exclusive Provider Organization• IDS – Integrated Delivery System• HMO – Health Maintenance Organization• POS – Point of Service• PPO – Preferred Provider Organization• TOP – Triple Option Plan
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Managed Care Group Project
• Divide into 6 groups. Select a group reporter.
• Each group will report on one managedmodel group.
• Name 3 things that make this type ofgroupdifferent from the others.
• Present to the class a short explanation using your own words.
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Consumer-Directed Health Plans
• Provide individuals with an incentive to control the costs of health benefits and health care
• Full coverage for in-network preventive care• Freedom to spend up to a designated amount• Members assume responsibility for higher cost
sharing after designated amount is expended
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Accreditation
• Voluntary process that a health care facility or organization (e.g., hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law
• NCQA
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Impact of Managed Care on Physician Office
• Separate bookkeeping systems• Tracking system for preauthorizations• Preauthorizations/precertifications• Referrals• Special administrative procedures• Copayments