1. 1.03 PP2 Healthcare Finances

2. 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

3. 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

4. Medicaid Govt.
Federally-funded health insurance
low income, children, blind or disabled.

5. Medicare
pts over age 65
Disabled people >2yrs social Security benefits
End stage renal failure
There are several types of Medicare
Type A Type B
Type C Type D

6. Type A Medicare Hospital Insurance
Inpatient care, skilled nursing care and home health care.
funded by Social Security taxes.

7. Type B Medicare Medical Insurance
physician services, outpatient care, etc.
Patient pays premium and 20%
Medicare pays 80% for services.

8. 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

9. 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

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

11. Type D Medicare Medicare prescription drug coverage
Enroll when eligible or you may pay late fee
AKA: “PDPs

12. 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

13. Traditional/Private Health Insurance
Pays for all or part of a person’s 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

14. Tricare AKA Champus
Provides care for military dependents and retired members of the armed service.

15. 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 America’s veterans.

16. Out of Pocket pay all costs for benefits received
Some places offer discount
can be price you are legally responsible for after insurance pays

17. Worker’s 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

18. DIAGNOSTIC RELATED GROUPS
Pts admitted to hospitals classified in one payment group.
Limit is placed on cost of care
If cost of care is < the amount paid, the agency keeps the extra money
If cost of care is > the amount paid, the agency must accept the loss

19. 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

20. 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

21. 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)

22. 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. Avie’s 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 Avie’s Chain of command and what should she do?