Chapter 2 & 3

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Introduction to Health Insurance

Chapter 2


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)


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


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.


Medical Documentation

• “If it wasn’t documented, it wasn’t done.”


Problem-Oriented Record

• Systematic method of documentation consists of four components:– Database– Problem list– Initial plan– Progress notes


Progress Notes

• SOAP format– Subjective– Objective– Assessment– Plan


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.


Managed Health CareChapter 3


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”


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.


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


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


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


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


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.


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


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


Impact of Managed Care on Physician Office

• Separate bookkeeping systems• Tracking system for preauthorizations• Preauthorizations/precertifications• Referrals• Special administrative procedures• Copayments

Chapter 2 & 3

Education

Transcript of Chapter 2 & 3