1.03 PP2 Healthcare Finances

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1.03 PP2 Healthcare Finances
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Health Maintenance Organization (HMO) - Private

• Provide HC services for prepaid fee
• Stress prevention
• Cheaper to prevent than treat
• Disadvantage is limitations placed on which
  doctors and facilities can be used

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Preferred Provider Organization (PPO) - private

• A group of doctors or hospital that agrees to
  provide HC at a reduced rate
• Usually offered by large companies
• Offers more flexibility to patients
• Pts pay lower rates if they select participating
  physician and facility

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MedicaidGovt.

• Federally-funded health insurance
• low income, children, blind or disabled.

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Medicare

• pts over age 65
• Disabled people gt2yrs social Security benefits
• End stage renal failure
• There are several types of Medicare
• Type A Type B
• Type C Type D

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Type A Medicare

• Hospital Insurance
• Inpatient care, skilled nursing care and home
  health care.
• funded by Social Security taxes.

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Type B Medicare

• Medical Insurance
• physician services, outpatient care, etc.
• Patient pays premium and 20
• Medicare pays 80 for services.

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Type C Medicare

• Advantage Plans/ MA Plans,
• offered by private companies approved by Medicare
• plan will provide all of your Part A (Hospital
  Insurance) and Part B (Medical Insurance)
• offers extra coverage, such as vision, hearing,
  dental, and/or health and wellness programs
• Medicare pays a fixed amount, usually less than
  your deductible

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Type C Medicare Costs

• Your out-of-pocket costs depend on
• Whether the plan pays your monthly Part B
  premium.
• Whether the plan has a yearly deductible or
  additional deductibles
• How much you pay for each visit or service
  (copayments or coinsurance)
• The type of HC services you need and how often
  you use them

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Type C Medicare Costs

• Whether you follow the plans rules, like using
  network providers
• Whether you need extra benefits and if the plan
  charges for them
• The plans yearly limit on your out-of-pocket
  costs for all medical services
• can only join a plan at certain times during the
  year

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Type D Medicare

• Medicare prescription drug coverage
• Enroll when eligible or you may pay late fee
• AKA PDPs

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Type D Medicare Costs

• Payments throughout the year
• Monthly premium
• Yearly deductible
• Copayments or coinsurance
• Costs in the coverage gap
• Costs if you get Extra Help
• Costs if you pay a Late Enrollment Penalty

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Traditional/Private Health Insurance

• Pays for all or part of a persons health care
• People pay a premium
• Premium monies paid for insurance contract
• Deductible predetermined amount that the
  insured must pay each year before the insurance
  company will pay for an illness or injury. The
  amounts vary and are stated in the policy
• AKA Indemnity

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TricareAKA Champus

• Provides care for military dependents and retired
  members of the armed service.

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Veterans Health Administration

• Mission Statement
• To fulfill President Lincoln's promise To care
  for him who shall have borne the battle, and for
  his widow, and his orphan by serving and
  honoring the men and women who are Americas
  veterans.
• http//www.va.gov

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Out of Pocket

• pay all costs for benefits received
• Some places offer discount
• can be price you are legally responsible for
  after insurance pays

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Workers Compensation

• Administered by the state
• Pays both the medical bills and the wages for
  employee injured on the job
• Payments are made by employers and the state

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DIAGNOSTIC RELATED GROUPS

• Pts admitted to hospitals classified in one
  payment group.
• Limit is placed on cost of care
• If cost of care is lt the amount paid, the agency
  keeps the extra money
• If cost of care is gt the amount paid, the agency
  must accept the loss

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Organizational Structure

• Line of authority/chain of command
• Indicates areas of responsibility
• Goal most efficient operation of facility
• Complex or simple structure determined by size
  and needs of organization
• organizational charts

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Organizational Structure

• line of authority must be clearly indicated
• Workers must identify and understand their
  position in the structure
• To follow proper channels of communication,
  workers must take problems, reports, and
  questions to their immediate supervisor

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Organizational Structure

• Allows problems to be addressed and identified by
  appropriate individuals
• If unsatisfied with a link in the chain, you may
  go above that person (after you have given them
  the opportunity to resolve your issue)

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Create your structure

• Avie is working with her mentor at Fit Kidney.
  Her mentor decides Pt. Chavis is non-deserving of
  his dialysis and decides to stop his tx in 1 ½
  hrs. instead of 4 hrs. Pt. Chavis asks Mentor why
  he is finished so fast. Mentor tells Pt. Chavis
  they have received a new dialysis machine that
  filters the blood in less than half the time as
  the old machine. The pt is excited and eager to
  leave. Upon attempting to leave, the pt c/o being
  light headed and nauseated. Avies mentor tells
  her to tell Pt. Chavis this is normal but it will
  go away. Avie refuses to do so and her mentor
  tells her to go home and not to come back.
• What is Avies Chain of command and what should
  she do?