question

Ambulatory payment classification (APC's)

answer

Used to calculate reimbursement, is implemented for billing of hospital-base Medicare outpatient claims.

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American Recovery and Reinvestment Act of 2009 (ARRA)

answer

Authorized the expenditure of $1.5 billion for grants for construction, renovation, and equipment, and for the acquisition of health information technology systems. DHHS established electronic health records (EHR) meaningful use objectives and measures during three stages to achieve the goal of improved patient care outcomes and delivery as well as data captured and sharing (2011 to 2012) advanced clinical processes (2014), and improved outcomes (2016) affected 2011 Medicare provided annual incentive to physicians group practices for being a "meaningful EHR user"; Medicare will ultimately decreased Medicare Part B payments to the physicians who are eligible to be, but fail to become, "meaningful EHR users".

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Balanced Budgets Act of 1997 (BBA)

answer

This address is health care fraud and abuse issues. The DHS Office of the Inspector General (OIG) provide investigator and audit services in health care fraud cases.

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CHAMPUS Reform Initiative (CRI)

answer

In a new program, TRICARE, which includes options such as Tricare Prime, TRICARE extra, TRICARE Standard. (Chapter 16 covers TRICARE claim processing).

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Civilian health and medical program of the Department of Veterans Affairs (CHAMPVA)

answer

The Veterans Health Care Extension Act of 1973 authorized devotions Affairs VA to establish this to provide health care benefits for dependents of veterans rated as a hundred percent permanently and totally disabled as a result of service connected connected condition, that's right who died as a result of service - connected conditions, and veterans who died on duty with less than 30 days of after service.

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Civilian Health and Medical Program- Uniformed Services

answer

Amendments to the pendant Medicare Act of 1956 created the civilian health and medical program - uniformed services champ us which was designed as a benefit for dependents of personal service in the Armed Forces as well as uniform branches of the public servant Health Service and the National Oceanic and Atmospheric Association the program is now called TRICARE

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Clinical Laboratory Improvement Act (CRI)

answer

This resulted in a new program, TRICARE, which includes options such as TRICARE Prime, TRICARE extra, and TRICARE Standard. (Chapter 16 covers TRICARE claims processor.)

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CMS - 1500

answer

Form used to submit Medicare claims; previously called the HCFA-1500.

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Coinsurance

answer

The percentage of payment patient share with the health plan, for example, the plan pays 80 percent of the cost and the patient pays 20 percent.

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Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

answer

Allow employees and/or their loved ones to continue health care coverage beyond the benefit termination date, out of pocket.

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Customer Driven Health Plan (CDHP)

answer

This is introduced as a way to encourage individuals to locate the best health care and the lowest possible price with the gold of holding down health care costs. These plants are organized into three categories: 1. Employer-paid high deductible insurance plans with special health spending accounts to be used by employees to cover deductibles and other medical costs when coverage amounts are exceeded. 2. Defined contribution plans with you provide a selection of insurance options semicolon employees pay the difference between what the employer pays and the actual cost of plans that they select. 3. After-tax savings account which combine a traditional health insurance plan for major medical expenses switch a savings account that the employee uses to pay for routine care.

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Continuity of care

answer

Involves documenting patient care services so that others who treat the patient may have a source of information to assist with additional care and treatment.

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Copayment (copay)

answer

A provision in the insurance policy that requires the policyholder or patient to pay a specific dollar amount to a healthcare provider for each visit or medical service received.

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deductible

answer

The amount for which a patient is financially responsible before an insurance policy provides payment.

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Diagnosis Related Group (DRG)

answer

Reimburses hospital for inpatients days.

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Electronic Health Record (EHR)

answer

This is a more global concept that include the collection of patient information documented by a number of providers at a different facilities regarding one patient. The EHR uses multidisciplinary (many specialties) and multi enterprise (many facilities) recordkeeping approaches to facilitate record linkage, which allows patient information to be created at a different location according to the Unique patient identifiers for identification number.

question

Electronic medical records (EMR)

answer

It is a patient record created for a single medical practice using a computer, keyboard, mouse, , voice recognition system, scanner, and / or touch screen. The electronic medical record: include the patient's medical list, problem list, clinical notes, and other documentation. Allows providers to prescribe medications, as well as order and view results of ancillary test (e.g., laboratory, radiology). alert the provider about drug interactions, abnormal ancillary test results, and went ancillary tests are needed.

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Employee Retirement Income Security Act of 1974 (ERISA)

answer

Mandated reporting and disclosure requirements for group life and health plans (including managed care plans), permitted large employers to self-insure employee health care benefits, and the attempt exempt large employers from taxes on health insurance premiums.

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Evolution and Management (E/M)

answer

Which describes patient encounters with providers for the purpose of evaluation and management of general health status.

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Federal Employee's Compensation Act (FECA)

answer

This at created in 1916 provide civilian employees of the federal government with Medicare survivors benefits, and compensation for lost wages. The office of workers compensation program administers FECA as well as the longshore and harbor Workers Compensation Act of 1927 and the Black Lung benefits Reform Act of 1977

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Financial Services Modernization Act (FSMA)

answer

(Gramm-Leach-Bliley Act) prohibits sharing of medical information among health insurance and other financial institutions for the used in making credit decisions.

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Federal Employees' Liability Act (FELA)

answer

President Theodore Roosevelt signs this act in 1908 legislation that processes and compensation railroad workers were injured on the job

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Graham-Leash-Blilly Act

answer

Prohibits sharing of medical information among health insurers and other financial institutions for use in making credit decisions. (A.k.a the Financial Services Modernization Act [FSMA]).

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Health insurance

answer

A contract between policy holder and a third party payer or government health program to reimburse the policyholder for all or a portion of the cost of medically necessary treatment or preventive care provided by the health care professional.

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Health care and Education reconsiliation Act (HCERA)

answer

Implement healthcare reform initiatives, such as increasing tax credit to buy healthcare insurance, eliminating special deals provided to senators, closing the Medicare "donut hole", delaying taxes on "Cadillac health care plans" until 2018, implementing review charges (e.g., 10% tax on indoor tanning services affected 2010), and so on. HCERA EW also modifies higher education assistance provisions, such as implementing student loan reform.

question

Health Information Technology for Economic and Clinical Health Act (HITCH Act)

answer

(Included in the American Recovery and Reinvestment Act of 2009) amended the Public Health Service Act to establish an Office of National Coordinator for Health Information Technologies (ONC) with in HHS to improve health care quality, safety, and efficiency. HealthIt rules and regulations include the CLIA Program and HIPAA Privacy/Patient Access to Test Reports (amended CLIA of 1988 to specify that a laboratory may provide patient access to complete test reports that use the laboratories authentication process can be identified as belonging to that patients; HIPAA privacy, security, and enforcement rules modifications; HITECH breach notification; standards and certification criteria for electronic health records; and Meaningful Use of Electronic Health Records.

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Health insurance

answer

...

question

Health insurance exchange

answer

Americans will purchase health coverage that fits the budget and meet their needs by accessing this also known as the health insurance marketplace.

question

Health insurance marketplace

answer

Americans will purchase health coverage that fits their budget and meet their needs by accessing this also known as the health insurance exchange

question

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

answer

Mandates regulations that govern privacy, security, and electronic transactions standards for healthcare information. The primary content of HIPAA is to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs.

question

Hill-Burton Act

answer

this Act created in 1946 provided federal grants for modernizing hospitals that had become obsolete because of a lack of capital investment during the Great Depression and World War 2 1929 to 1945. in return for federal funds, facilities were required to provide services free or at reduced rate to patient unable to pay for care.

question

Home Health Prospective Payment System (HH PPS)

answer

Reimburses home health agencies at a predetermeant rate for health care services provided to patients. This was implemented in October 1st, 2000.

question

Individual health insurance

answer

Private health insurance policy purchased by individuals or families who do not have access to group health insurance coverage. Applicants can be denied coverage, and they can also be required to pay higher premiums due to age, gender, and / or pre existing medical conditions

question

Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)

answer

Implemented as a requirement of the Medicare, Medicaid, & SCHIP balanced budget refinement act of 1999 (BBRA). The IPF PPS includes a patient classification system that reflects differences in the patient resources used ad cost semicolon the new system replaces the space payment system with a per diem IPF space TPS. About 1,800 inpatient psychiatric facilities, including freestanding psychiatric hospitals and certified psychiatric units is general acute care hospitals, are impacted.

question

Inpatient Rehabilitation Facility Prospective Payment System (IPF PPS)

answer

Implemented as a result of the BBA of 1997, which utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resources needed. Separate payments are calculated for each group, including the application of case - and facility - level adjustments.

question

International Classification of Diseases (ICD)

answer

In 1948 the World Health Organization (WHO) developed the International Classification of Disease a classification system used to collect data for statistical purposes.

question

Investing in Innovation (i2) Initiative

answer

This was designed to spur innovations and health information technology (health it) by promoting research and development to enhance competitiveness in the United States. Examples of Health it competition topics include applications that: allow an individual to securely and effectively share health information with members of his or her social network. Generate results for patients, caregivers, and / or clinicians by providing them with access to rigorous and relevant information that can support real needs and immediate decisions. Allow individuals to connect during the actual disasters and other. Of emergency. Facilitate an exchange the health information while allowing individuals to customize the private allowances for their personal health records.

question

Lifetime maximum amount

answer

The maximum benefits payable to the health plan participants

question

Major medical insurance

answer

Provided coverage for catastrophic and prolonged illness and injury starting in 1950. most of these programs incorporate large deductibles and lifetime maximum amount.

question

Meaningful EHR user

answer

Defined by Medicare physician to demonstrate that certified EHR technology is used for the purposes of electronic prescription, electronic exchange of health information in accordance with the law and health information technology hit standard, and submission of information on clinical quality measures. Hospitals that demonstrate the certified EHR health technology is connected to a manner that provides for the electronic exchange of health information to improve the quality of health care e.g., promoting care coordination and that certified eh our technologies used to submit information on clinical quality measures according two stages of meaningful use

question

Meaningful user

answer

Objectives and measures that achieve goals of improved patient care outcomes and delivery through data capture and sharing, advanced clinical processes, and improved patient outcome.

question

Medicaid

answer

Medicaid title XIX of the soul security amendment of 1965 is a cost sharing program between the federal and the state government to provide health care services to low-income families. It was originally administered by the Social and Rehabilitation Services SRS

question

Medical care

answer

The identification of disease and the provision of care and treatment to persons who are sick, injured, were concerned about their health status.

question

Medical record

answer

Also known as a Patient's Record, documents health care services provided to a patient and includes patient demographic (or identification) data, documentation to support diagnosis and justify treatment provided, and the results of treatment provided. The primary purpose of the record is to provide for continuity of care, which involves documents in patient care services so that others who treat the patient have a source of information to assist with additional care and treatment.

question

Medicare

answer

Created in 1966 title XVIII other so security amendments 1995 provides healthcare services to Americans over the age of 65. it was originally administered by the Social Security Administration

question

Medicare catastrophic coverage act

answer

Mandated the reporting of ICD-9-CM (now ICD-10-CM) diagnosis codes on Medicare claims semicolon in subsequent years, third-party payers adopted similar requirements for claim submission.

question

Medicare Contracting Reform (MCR) initiative

answer

This was established to integrate and administration of Medicare Part A & B fee-for-service benefits with new entities called Medicare administrative contractors (MAC's). MAC's replace Medicare carriers, DMERC's, and fiscal intermediaries to improve and modernize Medicaid fee for service system and established a competitive bidding process for contracts.

question

Medicare Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)

answer

This required implementation of a $400 billion prescription drug benefit, improved Medicare Advantage formerly called Medicare+Choice benefits, required faster Medicare Appeals decisions, and more.

question

Medicare Prescription Drug, Improvement, and Modernization Act (MMA)

answer

This adds new prescription drug and preventive benefits, provides extra assistance to people with low incomes, and calls for implementation of a Medicare contracting reform MCR initiative to improve and modernize the Medicare fee for service system and to establish a competitive bidding process to appoint a MAC's. The Recovery Audit Contractor (RAC) program was also created to identify the recover improper Medicare payments paid to health care providers under fee-for-service Medicare plans. (RAC programs details are in chapter 5 of this textbook.)

question

Minimum data set (MDS)

answer

Data collected from resident assessment using data elements and relative weights development from staff time data.

question

National Correct Coding Initiative (NCCI)

answer

This was created to promote national correct coding methodologies answer eliminate improper coating.

question

Omnibus Budget Reconciliation Act of 1981 (OBRA)

answer

Was a federal legislation that expanded the Medicare and Medicaid programs started in 1981.

question

Outpatient prospective payment system (OPPS)

answer

Which uses Ambulatory Payment Classifications (APC's) to calculate reimbursement, is implemented for billing of hospital-base Medicare outpatient claims.

question

Patient Protection and Affordable Care Act (PPACA)

answer

This focuses on private health insurance reform to provide better coverage for individuals with pre-existing conditions, improve prescription drug coverage under Medicare, and extend the life of Medicare trust fun but at least 12 years. Its goal is to provide quality affordable health care for Americans, improve the role of public programs, improve the quality and efficiency of care, and improve public health. Americans will purchase health coverage that fits their budgets and meet their needs by assessing the health insurance marketplace or health insurance exchange in their state. Individuals complete one application that allows them to view all options and enroll individuals will be able to determine if they can lower the cost of current monthly premiums for private insurance plan out of pocket cost. The marketplace also indicates if individuals qualify for free or low cost coverage available through Medicaid or the Children's Health Insurance Program (CHIP)

question

Patient record

answer

Aka the Medical Record, documents healthcare services provided to a patient and include patient demographic (or identification) data, documentation to support diagnosis and justify treatment provided, and the results of treatment provided. The primary purpose of the record is to provide for continuity of care, which involves documenting patient care services that others who treat the patient have a source of information to assist with additional care and treatment.

question

Per diem

answer

Issue payment based on daily rates.

question

Personal health record (PHR)

answer

Web-based application that allows individuals to maintain and manage their health information (and that of others for whom they are authorized, such as family members) in a private, secure, and confidential environment.

question

Policyholder

answer

A person who signs a contract with a health insurance company and who, thus, owns the health insurance policy.

question

Preventive Services

answer

Designed to help individuals of wealth health and injury problems examinations may result in early detection of health problems, allowing less traffic and less expensive treatment options. Whenever

question

Problem-oriented record (POR)

answer

This is a systematic method of documentation that consists of four components: 1. Database 2. Problem list 3. Initial Plan 4. Progress notes. The POR database contains the following information collected on each patient: 1. Chief complaint 2. present condition and diagnosis 3. Social data 4. Past, personal, medical, and social history 5. Review of systems. physical examinations 7. Baseline laboratory data

question

Prospective payment system (PPS)

answer

PPS which issue a determined payment for inpatient services.

question

Public Health insurance

answer

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

question

Quality improvement organization (QIO)

answer

Will perform utilize a shin and quality control review of healthcare furnished, or to be furnished, to Medicare beneficiaries. QIOs replaced peer review organizations prPROsos, which previously performed this function

question

Record linkage

answer

Allows patient information to be created at a different location according to a Unique patient identifiers for identification number.

question

Resource utilization groups (RUGs)

answer

Is based on data collected from resident assessments (using data elements called the Minimum Data Set (MDS)

question

Resource-Based Relative Value Scale (RBRVS) system

answer

This payment system reimburses physician's practice expenses based on relative values for three components of each position service: position work, practice expense, and Mel practice insurance expensive.

question

Self insured (or self funded) employer-sponsored group help plans

answer

These plans allow large employers to assume the financial risk for providing health care benefits to employees. The employer does not paint a fix premium to the health insurance paid her, but if that was just a trust fund of employer and employee contributions out of which claims are made

question

Single-payer system

answer

Centralized healthcare system adopted by some Western nations (e.g. Canada, Great Britain) and funded by taxes. The government pays for each residence health care, which is considered a basic social service.

question

Skilled nursing facility prospective payment system (SNF PPS)

answer

Was implemented to cover all costs (routine, ancillary, and capital) related to service furnished to Medicare Part A beneficiaries. The SNF PPS generates per diem part diem payments for each admission; these payments are case-mix adjusted using a resident classification system called Resource Utilization Groups (RUGs)

question

Socialized medicine

answer

A type of single payer system in which the government owns and operates healthcare facilities and providers (e.g., physicians) receive salary. The VA health care program is a form of socialized medicine

question

State Children's Health Insurance Program (SCHIP)

answer

Was established with Balanced Budget Act of 1997 (BBA) to provide health assistance to uninsured low-income children, either through separate program through expanded eligibility under state Medicaid program.

question

Tax Equity and Financial Responsibility Act of 1982 (TEFRA)

answer

This is a Medicare risk program, which allowed federally qualified HMOs to competitive medical plans that lets specified Medicare requirements to provide Medicare covered services under a risk contract.

question

Third party administrators (TPA)

answer

The taft-hartley Act of 1947 amended the National Labor Relations Act of 1932, restoring a more balanced relationship between labor and management. An indirect result of taft-hartley was the creation of third party administrators, which administered healthcare plan and process claim those serving the system of checks and balances for labor management.

question

Third-party payer

answer

Is a health insurance company that provides coverage, such as Blue Cross Blue Shield.

question

Total Practice Management Software (TPMS)

answer

Is used to generate the the Electronic Medical Records (EMR), automated the following medical practice functions: registering patients, scheduling appointments, general insurance claims and patient statements, processing payments from patients and third party payers, producing administrative and clinical reports.

question

Universal health insurance

answer

The goal of providing every individual with access to health coverage, regardless of the system impediment to achieve the goals

question

Usual and reasonable payments

answer

Based on fees typically charge by providers according to specialty with a particular region of the country. A Fee Schedule is a list of predetermined payments for health care services provided to patients (e.g., a fee is assigned to each CPT code).

question

World Health Organization (WHO)

answer

This is the organization develop to the international classification of diseases ICD, a classification system used to collect data for statistical purposes

question

Health care

answer

The definition of medical care to include preventive services, which are designed to help individuals avoid health and injury problems.

question

Group health insurance

answer

Health insurance coverage subsidized by employers and other organizations e.g., labor union, rule and customer health cooperatives.

question

A fee schedule

answer

A list of predetermined payments for healthcare services provided to patients (e.g., a fee is assigned to each CPT code). The payment pays a copayment or co insurance amount for services rendered, the payer reimburses the provider according to the schedule, and the remainder is a write off (or lost).

question

Outcomes and Assessment Information Set (OASIS)

answer

A group of data elements that represents core items of the comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purpose of outcome-based quality improvement

question

Benefits improvement and Protection Act of 2000 (BIAP)

answer

Along with Medicare, Medicaid, and SCHIP, BIPA requires implementation of a $400 billion prescription drug benefit, improved Medicare Advantage formerly called Medicare plus choice benefits, required faster Medicare Appeals decisions, and more.

question

SOAP format

answer

The POR progress notes are documented for each problem assigned to the patient using this format: 1. Subjective (S) (patient statement about how he or she feels, including symptomatic information [e.g., I have a headache]). 2. Objective (O) (observations about the patience, such as physical findings, or lab or X ray results. [e.g., chest X ray negative]) 3. assessment (A) judgment, options, or valuations made by the healthcare provider e.g. accurate headache 4. Plan (P) (diagnostic, therapeutic, and education plans to resolve the problem [e.g., patient to take Tylenol as needed for pain])

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