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Provider revenues are fixed, and each enrolled patient makes a claim against the full resources of the provider. In exchange for the fixed payment, physicians essentially become the enrolled clients' insurers, who resolve their patients' claims at the point of care and assume the responsibility for their unknown future health care costs.
A copayment or copay (called a gap in Australian English) is a fixed amount for a covered service, paid by a patient to the provider of service before receiving the service. It may be defined in an insurance policy and paid by an insured person each time a medical service is accessed.
A prospective payment system (PPS) is a term used to refer to several payment methodologies for which means of determining insurance reimbursement is based on a predetermined payment regardless of the intensity of the actual service provided. It includes a system for paying hospitals based on predetermined prices, from Medicare.
Electronic referral, when a specialist evaluates medical data (such as laboratory tests or photos) to diagnose a patient instead of seeing the patient in person, would often improve health care quality and lower costs. However, "in the private fee-for-service context, the loss of specialist income is a powerful barrier to e-referral, a barrier ...
The terms of a CPA are decided by the collaborating pharmacist and physician, though templates exist online. CPAs can be specific to a patient population of interest to the two parties, a specific clinical situation or disease state, and/or may outline an evidence-based protocol for managing the drug regimen of patients under the CPA.
The EOB is commonly attached to a check or statement of electronic payment. An EOB typically describes: the payee, the payer and the patient; the service performed—the date of the service, the description and/or insurer's code for the service, the name of the person or place that provided the service, and the name of the patient
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