APPROVED AMOUNT

A reimbursement method in which a payer only pays a fixed amount per service; however, providers cannot seek patient contributions for charges that exceed approved amounts or allowed amount . Approved Amount = Insurance Payment + Patient Responsibility = Total Charges - Contractual Adjustment.

Bill Hold

Time frame established by hospitals as reasonable amount of time that would be necessary to have a claim ready to be billed. Within this time frame the following key billing functions must be performed; insurance assignment, insurance verification, charge capturing/posting, utilization review and medical records coding.

Primary care physician

Primary Care Physician(PCP) in general term is a family doctor or the doctor one who is visited by the patient first for any kind of health problem. Primary care physicians are also called Gate Keepers, as they are the ones who are contacted first by the patient. PCP is also called referring doctor

MEDICAID

Medicaid is a program that pays for medical assistance for certain individuals and families with low incomes and resources. It originates from title XIX of Social Security Act. It is jointly funded by Federal and State governments to assist states in furnishing medical assistance to eligible needy persons. Medicaid is the largest source of funding for medical and health-related services for America’s poorest people and covers 36 million individuals.

Within certain federal guidelines, each state operates its own Medicaid Program. Thus each states Medicaid Program has its own features, benefits, costs, and regulations. Within broad national guidelines established by federal statutes, regulations, and policies, each state.

Establishes its own eligibility standards.
Determines the type, amount, duration, and scope of services.
Sets the rate of payment for services.
Administers its own program.

Medicaid policies for eligibility, services, and payment are complex and vary considerably, even among States of similar size or geographic proximity. Thus, a person who is eligible for Medicaid in one State may not be eligible in another State, and the services provided by one State may differ considerably in amount, duration, or scope from services provided in similar or neighboring State. Generally the State offers coverage to one or more of the following groups.

Mandatory Needy
Categorically Needy
Medically Needy

SERVICES OFFERED BY NURSING FACILITIES

Nursing and Rehabilitative Services: Nursing procedures require the professional skills of a registered or a licensed practical nurse. These skills include assessment, conducting treatments, injections and coordination care. Post-hospital stroke, heart, or orthopedic care is available with related services such as physical therapy, occupational therapy, speech therapy, dental services, dietary consultation, laboratory and x-ray services, and a pharmaceutical dispensary.
Personal Care: These services include help in walking, getting in and out of bed, bathing, toileting, and dressing, eating, and preparing special diets as prescribed by a physician.
Residential Services: These include general supervision and a protective environment, such as room and board and a planned program for the social and spiritual needs of the resident.
Medical Care: Each patient in a nursing facility is under the care of a physician, who visits periodically and is responsible for the patient's overall plan of care. In most cases, the patient's personal physician refers the patient to the facility and certifies the need for admission. Once the patient is admitted, the physician writes orders for any necessary medication and plays a role in the development of patient care plan, including restorative and rehabilitative procedures, special diets, and other treatments. Every nursing facility has at least one physician on staff or on call to handle emergencies.

SKILLED NURSING FACILITY

Skilled nursing facility (SNF) is a facility that primarily provides inpatient, skilled nursing care and related services to patients at a lesser intensity than an acute facility . SNF’s are used for patients who need medical, nursing care, or rehabilitation services.
Patients are usually treated on a long term basis and care is less expensive than in a hospital. The most common SNF facility is a nursing home. These facilities are usually run by nurses and would just have a visiting doctor on call.

AMBULATORY SURGERY CENTER (ASC)

Ambulatory surgery is surgery that does not require an overnight hospital stay. It is also called ‘Day Surgery’, ‘Same Day Surgery’ (SDS), or ‘Short Procedure Unit’ (SPU). ASC may either be affiliated with a hospital or have no affiliation with a hospital. Ambulatory Surgery Centers act as autonomous units and are treated as separate entities.
Ambulatory programs offer patients the convenience of being treated and released the same day without being admitted to the hospital. This means that eligible patients come to the hospital either in the morning or afternoon of the day of surgery, undergo the operation, and are discharged within the same day to recover in the comfort of their home.
Ambulatory surgery centers, or freestanding ambulatory centers, provide outpatient services. This day-care or ambulatory technique provides an efficient and flexible approach to provision of many surgical and therapeutic procedures. It is a freestanding facility, other than a physician’s office, that operates exclusively to provide surgical services to patients who do not require hospitalization.

OBJECTIVES OF MANAGED CARE

Quality Improvement: Health care is monitored for quality and necessity. Consequently, services rendered are more effective and efficient. Physicians are encouraged to render appropriate and timely care.

Prevention: Managed care plans encourage preventive care by covering procedures such as annual physical check-ups, cancer screening, prenatal examinations so that doctors can help either prevent illnesses or detect diseases in their early stages. Diseases can be easier and cheaper to treat when detected early.

Accountability: Managed care plans make the physicians and hospitals more accountable for the services they render. Physicians are prevented from wasting money on costly, inappropriate or unexplained services. They are encouraged to adhere to certain treatment standards and conserve health care resources.

Affordability: By reducing the burden of out-of-pocket expenses on the member, managed care plans aim to make high quality care affordable. They offer insurance at reduced costs, despite the ever-growing cost of health care.

Care Coordination: Due to the wide range of medical services available, and the growth of medical technology, a patient may need help in deciding what sort of care he/she needs. The patient must be advised of the best methods of treatment or the best facilities available to attend to his/her health needs. Managed care plans provide the concerned medical professionals to ensure that each patient receives the best health care available under the plan.