question

Ambulatory Payment Classifiacton (ACP)

answer

prospective payment system used to calculate reimbursement for outpatient care according to similar clinical characteristics and in terms of resources required

question

American Recovery and Reinvestment Act of 2009

answer

authorized an expenditure of $1.5 billion for grants for construction, renovation and equipment, and for the acquiaition of health information technology systems.

question

Balance budget ACT of 1977 (BBA) Chapter 2

answer

address healthcare fraud and abuse issues, and provides for department of Health and Human Services (DHHS) office of inspector general (OIG) investigative and audit services in helathcare fraud cases

question

base period

answer

period of time that usually covers 12 months: and is divided in to four consecutive quarters

question

CHAMPUS Reform Initiative

answer

conductedin 1988; resulted in a new health program called TRICARE wich includes three options; TRICARE Prime, TRICARE Extra, and TRICARE Standard

question

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

answer

program that provides health benefits for dependents of veterans rated as 100 percent permanently and totally disabled as a result of service connected condtions, vererans who died as a result of service-connected conditions, and veterans who died on duty with less than 30 days of active service

question

Civilian Health and Medical Program - Uniformed Services (CHAMPUS)

answer

originally designed as a benefit for dependents of personnel serving in teh armed forces and uniformed branches of the Public Health Service and the National Oceanic and Atmospheric Administration; now called TRICARE

question

Clinical Laboratory Improvement ACT (CLIA)

answer

established qualitiy standards for all laboratory testing: to ensure the accuracy, reliability, and timliness of patient test results regadless of where the test was performed

question

CMS-1500

answer

a form used to submit medical claims: previously called HCFA-1500

question

coinsurance

answer

also called coinsurance payment; the percentage the patient pays for covered sercvices after the deductible has been met and the copayment has been paid

question

Consolidated Omnibus Budget Reconciliation ACT of 1985 (COBRA)

answer

allows enployees to continue healthcare coverage beyond the benefit termination date

question

consumer driven health plan

answer

also called Consumer-Directed Health Plan, a healthcare plan that encourages indiviuals to locate the best healthcare at the lowest possible price, with the goal of holding down cost; also called consumer-directed health plan

question

continuity of care

answer

documenting patient care services so that others who treat teh patient have a source of information on which to base additional care and treatment

question

copayment (copay)

answer

provision in an insurance policy that requires the policy holder or patient to pay a specified dollar amount to a healthcare provider for each visit or medical service received.

question

deductible

answer

the amount for which the patient is financially reponsible before an insurance policy provides coverage

question

diagnosis-related group (DRG)

answer

prospective payment system that reimburse hospitals for patient stays

question

electronic health record (EHR)

answer

Global concept that includes the collection of patient information documentation by a number of providers; at a different facilities regarding one patient

question

electronic medical record (EMR)

answer

considered part of the electronic health record, the EMR is created on a computer using a keyboard, a mouse, an optical pen device, a voice recognition system, a scanner, or a touch screen; records are created using vendor software, which assists in provider decision making; numerous vendors offer EMR software, mostly to physician office practices that require practice management solutions

question

Employee Retirement Income Security ACT of 1974 (ERISA)

answer

mandated reporting and disclosure requirement for group life and health plans (including managed car plans), permitted large employers to self insure employee health care benefits, and exempted large employers from taxes on health insurance premiums

question

employer-based self-insurance plans

answer

Note: not in glossary

question

Evaluation and Management (E/M)

answer

services that describe patient encounters with providers for evaluation and management of general health status

question

Federal Employee's Compensation Act (FECA)

answer

replaced the 1908 worker's compensation legislation; civilian employee of federal government are provided medical care, survivors' benefits, and compensation for lost wages

question

fee schedule

answer

is a list of predetermined payments for healthcare services provided to patients (e.g: a fee is assigned to each CPT code) Alternate definition: payment fee for physicains

question

Financial Services Modernization Act

answer

prohibits sharing of medical information among health financial institutions for use in making credit decisions; also allows banks to merge with the investment and insurance houses, which allows them to make a profit no matter what the status of the economy; because people usually house their money in one of the options; also called the Gramm-Leach-Bliley Act

question

Gramm-Leach-Bliley Act

answer

same as Financial Services Mordinization Act

question

group helath insurance

answer

traditional healthcare coverage subsidized by employers and other organizations (e.g., labor unions, rural and consumer health cooperatives), whereby part or all the premium cost are paid for and/or discounted group rates are offered to eligible individuals

question

heathcare

answer

expands the definition of medical care to include preventative services.

question

health insurance

answer

a contract between the policyholder and a third-party payer or government program to reimburse the policyholder for all or portion of the cost of medically necessary treatment or preventative care provided by a healthcare professionals

question

Hill Burton Act

answer

provided federal grants for modernizing hospitals after the Great Depression nad WWII (1929-1945); facilites were required to provide services free, or at reduced rates, to patients unable to pay for care

question

individual health insurance

answer

private healthcare insurance policy purchased by individuals or families who do not have access to group health coverage; appplicants can be denied coverage, and they can also be required to pay higher premiums due to age, gender, and/or preexisting medical conditions

question

International Classification of Diseases (ICD)

answer

the classification system used to collect data for statistical purposes

question

lifetime maxium amount

answer

maxium benefit payable to a health plan participant

question

major medical insurance

answer

coverage for catastrophic or prolonged illness and injuries

question

problem-oriented record (POR)

answer

a systematic method for documentation that consist of four components: database, problem list, initial plan, and progress notes

question

public health insurance

answer

state and federal health programs (e.g.; Medicare, Medicaid, SCHIP, and TRICARE) available to eligible individuals

question

medical/patient record

answer

documents helathcare services provided to a patient; also called patient record

question

record linkage

answer

allows patient information to be created at different locations according to a unique patient identifier or identification number

question

self-insured (or self-funded) employer-sponsored group health plans

answer

allows a large employer to assume the financial risk for providing healthcare benefits to employees; employer does not pay a fixed premium to a health insurence payer, but establishes a trust fund (of employer and employee contributions) out of which claims are paid

question

single-payer plan (system?)

answer

centeralized healthcare system adopted by some Western nations (e.g.; Canada, Great Britain) and funded by taxes; the government pays for each residient's health care, which is considered a basic social service.

question

socialized medicine

answer

a type of single-payer system in which the government owns and operates the healthcare facility and providers (e.g.; physicans) recieve saleries. The VA helathcare plan is a form of socialized medicine

question

third-party administrator (TPA)

answer

company that provides health benefits claims administration and other outsourcing service for self-insured companies; provides administrative services to healthcare plans; specializes in mental health case management; and processes claims, serving as a system of "checks and balances" for labor-management

question

total practice management software (TPMS)

answer

used to generate EMR, automating medical practice functions of registered patients, scheduling appointments, generating insurance claims and patient statements, processing payments from patient and third-party payers, and producing administrative and clinical records

question

universal healthcare insurance

answer

the goal of providing every individual with access to health coverage, regardless of the system implemented to acheive that goal

question

World Health Organization

answer

United Nations health agency established in 1984 to develop the International Classification of Diseases (ICD), a classification system health care providers use to code and report inpatient/outpatient diseases and inpatient procedures for reimbursement purposes.

question

RGRVS

answer

the fee schedule for Medicare physican office fees

question

risk contract

answer

an arrangement among providers to provide capitated (fixed, prepaid basis) heatlhcare service to Medicare beneficiaries

question

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

answer

Law that mandates regulations governing privacy, security, and electronic transaction standards for health care information.

question

Home Health Prospective Payment System (HH PPS)

answer

Reimbursement method for home health agencies that uses a classification system called home health resource groups (HHRGs). Establishes a predetermined rate for health care services provided to patients for each 60-day episode of home health care.

question

Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)

answer

Patient classification system implemented January 1, 2005, that reflects differences in patient resource use and costs. Replaces the cost-based payment system with a per diem cost.

question

Inpatient Rehabilitation Facilities Prospective Payment System (IRF PPS)

answer

System implemented as a result of the Balanced Budget Act (BBA) of 1997, which uses information from patient assessment instruments to classify patients based on clinical characteristics and expected resource needs.

question

insurance

answer

Contract that protects the insured from loss.

question

medical care

answer

Care that includes the identification of disease and the provision of care and treatment as that provided by members of the health care team to people who are sick, injured, or concerned about their health statuses.

question

Medicaid

answer

Cost-sharing program between the federal and state governments to provide health care services to low-income Americans. Originally administered by the Social and Rehabilitation Service (SRS).

question

Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2003 (BIPA)

answer

Law that requires implementation of a $400 billion prescription drug benefit, improved Medicare Advantage (formerly called Medicare+Choice) benefits, faster Medicare appeals decisions, and more.

question

Medicare Prescription Drug Improvement and Modernization Act

answer

Law that adds new prescription drug benefits and provides extra assistance to people with low incomes. Established the Medicare contracting reform (MCR) initiative to replace current Medicare carriers and fiscal intermediaries with Medicare administrative contractors (MACs).

question

minimum data set (MDS)

answer

Data elements collected by long-term care facilities.

question

National Correct Coding Initiative (NCCI)

answer

Effort undertaken by the Health Care Financing Administration (HCFA), now called the Centers for Medicare & Medicaid Services (CMS), to promote national correct coding methods and eliminate improper coding.

question

Occupational Safety and Health Administration Act of 1970 (OSHA)

answer

Legislation designed to protect all employees against injuries from hazards in the workplace.

question

Omnibus Budget Reconciliation Act of 1981 (OBRA)

answer

Federal law that requires physicians to keep, for 5 years, copies of any government insurance claim forms and copies of all attachments filed by a provider. Also expands Medicare and Medicaid programs.

question

Outcomes and Assessment Information Set (OASIS)

answer

Group of data elements that represent the core items of a comprehensive assessment for an adult home care patient. These form the basis for measuring patient outcomes for the purpose of outcome-based quality improvement.

question

Outpatient Prospective Payment System (OPPS)

answer

System that uses ambulatory payment classifications (APCs) to calculate reimbursement. Implemented to bill hospital-based Medicare outpatient claims.

question

per diem

answer

Latin term meaning "for each day," which is how retrospective cost-based rates were determined: Payments were issued based on daily rates.

question

prepaid health plan

answer

Contract between an employer and a health care facility or physician whereby specified medical services are performed for a predetermined fee that was paid monthly or yearly.

question

prentitive services

answer

Services designed to help individuals avoid health and injury problems.

question

prospective payment system (PPS)

answer

System that issues a predetermined payment for services.

question

quality improvement organizations (QIOs)

answer

Groups that perform utilization and quality control reviews of health care furnished, or to be furnished, to Medicare beneficiaries. Previously called peer review organizations (PROs).

question

resource utilization groups (RUGs)

answer

Groups based on data collected from resident assessments using data elements called the minimum data set (MDS) (see preceding entry) and relative weights developed from staff time data.

question

Resource-Based Relative Value Scale (RBRVS)

answer

Payment system that reimburses physicians' practice expenses based on relative values for three components of each physician's services: (1) physician work, (2) practice expense, and (3) malpractice insurance expense.

question

Skilled Nursing Facility Prospective Payment System (SNF PPS)

answer

System mandated by the Balanced Budget Act (BBA) of 1997 to cover all costs (routine, ancillary, and capital) for services rendered to Medicare Part A beneficiaries.

question

State Children's Health Insurance Program (SCHIP)

answer

Program that provides health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.

question

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

answer

Law that creates Medicare risk programs which allow federally qualified HMOs and competitive medical plans meeting specified Medicare requirements to provide Medicare-covered services under a risk contract.

question

usual and reasonable payments

answer

Payments based on fees typically charged by providers in a particular region of the country.

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