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Healthcare

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Submitted By kep1959
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1. Who are the first, second, and third parties in healthcare situations? First party is the patient, second party is the provider and 3rd party is the Insurance companies.

2. Compare the UCR and CPR payment systems? UCR and CPR: Both or methods of payment within the type of tradition retrospective payment system. Both or based on data from past claims. Private Insurance companies use the UCR and Medicare uses the CPR.

3. Describe the two purposes of managed care? The two (2) purposes of Manage care are to control and reduce c\ost while ensuring continuing quality of care.

4. Why have many insurers replaced retrospective health insurance plans with group plans such as HMOs and PPOs? Provider get paid up front with controlled cost while providing quality care no risk, they get paid for level 1,2, or 3 preset price and no risk for Insurance companies.

5. What are advantages of capitated payments for providers and payers? The provider has a guaranteed customer base and the third party payer know the exact cost of the healthcare group payment.

6. Describe the major benefits of episode-of-care reimbursement according to its advocates and the major concern s about episode of care reimbursement expressed by its critics? The benefit is for the provider their paid upfront for all services provided over period of time or specific amount of days. They can’t add any individual fees or charges. The Insurance company/administrators are predicting or making healthcare decision rather than the Doctor.

7. How do their-party payers set per diem payment rates? Third-party payer set per diem using historical data. Total cost for all inpatient services for a population during a period are divided by the sum of the length of stay in the period to determine per diem payment the per diem rate is multiplied by number of days in the hospital.

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