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Medical Financial Definition of Terms Name Instructor Name of Institution A Definition of Medical Terms PMPM Billing for Medicaid Patients with chronic diseases (AIDS/HIV) The Per Member per Month is a payment methodology, which is applied by the New York Medicaid Health program to pay health providers…
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Download file to see previous pages The PMPM is used in the analysis of the parameters of the different health status of the patients. The PMPM feed paid to the health home care providers is determined by several factors (Wodchis, Hirth & Fries, 2007). The health home program in the New York Medicaid adjusts the PMPM that is paid to the health care providers according to the enrollment volume, region, and the case mix. There are plans to incorporate the patient’s functional status in the near future by the New York Medicaid program as one of the determinants of the consideration in paying the Health Home providers. The New York Medicaid program provides for payment of a case finding Per Member per Month bill, which is a cheaper amount. “The case finding PMPM is provided during the first few weeks of the program to cater for reimbursement of engagement and outreach services” (Centers for Medicare and Medicaid services, 2011). The provisions of the New York Medicaid are that the billing of active medical care management of the enrolled patients is only made when a health care manager is assigned to the patient. “The New York Medicaid health home program has various managed care plans, which give the guidelines for the payment if the contracted medical professionals” (Centers for Medicare and Medicaid services, 2011). ...
cost of medical care in Medicaid, the capitalization is used to ensure that all medical expenses including the payment of the providers and the expenses of purchase of drugs are paid for and accounted for (Centers for Medicare and Medicaid services, 2011). Acuity score in Case Management Medicaid “The term acuity score in case management stands for the levels into which patients are assigned depending on their health status” (Sparer, Brown & Cover, 1999). In Medicaid, a specified criterion is used to categorize patients into levels with point values called equity scores which very according to the life area that the condition of the patient is allocated to. The acuity score of the patient is assigned under two life areas. These are the basic and medical needs. Each one of the life areas has different levels with corresponding points or acuity scores (Sparer, Brown & Cover, 1999). According to Meade and Pope (2007), in Medicaid, the first level of the basic needs life area has one point and it includes various basic needs. These are sustenance items such as clothing and food. The Medicaid provides that the items in this level are made available through the means of the patient. The second level in the basic needs life area has an acuity score of 4 points. The needs in this level are for the sustenance of the patient. According to the provisions of the Medicaid program, the patient should be able to meet these needs with occasional assistance. “This means that emergence assistance is not required in this level. The assistance needed to perform the ADL by the patient who scores 4 points is usually weekly” (Meade & Pope, 2007). The third level of the basic needs life area is where the acuity score of the patient is six points. At this level, the patient requires ...Download file to see next pagesRead More
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