Understanding Health Insurance Chapter 2 Key Terms

Ambulatory payment classification (APC’s)
Used to calculate reimbursement, is implemented for billing of hospital-base Medicare outpatient claims.
American Recovery and Reinvestment Act of 2009 (ARRA)
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”.
Balanced Budgets Act of 1997 (BBA)
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.
CHAMPUS Reform Initiative (CRI)
In a new program, TRICARE, which includes options such as Tricare Prime, TRICARE extra, TRICARE Standard. (Chapter 16 covers TRICARE claim processing).
Civilian health and medical program of the Department of Veterans Affairs (CHAMPVA)
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.
Civilian Health and Medical Program- Uniformed Services
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
Clinical Laboratory Improvement Act (CRI)
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.)
CMS – 1500
Form used to submit Medicare claims; previously called the HCFA-1500.
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.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
Allow employees and/or their loved ones to continue health care coverage beyond the benefit termination date, out of pocket.
Customer Driven Health Plan (CDHP)
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.
Continuity of care
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.
Copayment (copay)
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.
The amount for which a patient is financially responsible before an insurance policy provides payment.
Diagnosis Related Group (DRG)
Reimburses hospital for inpatients days.
Electronic Health Record (EHR)
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.
Electronic medical records (EMR)
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.
Employee Retirement Income Security Act of 1974 (ERISA)
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.
Evolution and Management (E/M)
Which describes patient encounters with providers for the purpose of evaluation and management of general health status.
Federal Employee’s Compensation Act (FECA)
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
Financial Services Modernization Act (FSMA)
(Gramm-Leach-Bliley Act) prohibits sharing of medical information among health insurance and other financial institutions for the used in making credit decisions.
Federal Employees’ Liability Act (FELA)
President Theodore Roosevelt signs this act in 1908 legislation that processes and compensation railroad workers were injured on the job
Graham-Leash-Blilly Act
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]).
Health insurance
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.
Health care and Education reconsiliation Act (HCERA)
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.
Health Information Technology for Economic and Clinical Health Act (HITCH Act)
(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.
Health insurance
Health insurance exchange
Americans will purchase health coverage that fits the budget and meet their needs by accessing this also known as the health insurance marketplace.
Health insurance marketplace
Americans will purchase health coverage that fits their budget and meet their needs by accessing this also known as the health insurance exchange
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
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.
Hill-Burton Act
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.
Home Health Prospective Payment System (HH PPS)
Reimburses home health agencies at a predetermeant rate for health care services provided to patients. This was implemented in October 1st, 2000.
Individual health insurance
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
Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)
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.
Inpatient Rehabilitation Facility Prospective Payment System (IPF PPS)
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.
International Classification of Diseases (ICD)
In 1948 the World Health Organization (WHO) developed the International Classification of Disease a classification system used to collect data for statistical purposes.
Investing in Innovation (i2) Initiative
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.
Lifetime maximum amount
The maximum benefits payable to the health plan participants
Major medical insurance
Provided coverage for catastrophic and prolonged illness and injury starting in 1950. most of these programs incorporate large deductibles and lifetime maximum amount.
Meaningful EHR user
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
Meaningful user
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.
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
Medical care
The identification of disease and the provision of care and treatment to persons who are sick, injured, were concerned about their health status.
Medical record
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.
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
Medicare catastrophic coverage act
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.
Medicare Contracting Reform (MCR) initiative
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.
Medicare Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)
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.
Medicare Prescription Drug, Improvement, and Modernization Act (MMA)
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.)
Minimum data set (MDS)
Data collected from resident assessment using data elements and relative weights development from staff time data.
National Correct Coding Initiative (NCCI)
This was created to promote national correct coding methodologies answer eliminate improper coating.
Omnibus Budget Reconciliation Act of 1981 (OBRA)
Was a federal legislation that expanded the Medicare and Medicaid programs started in 1981.
Outpatient prospective payment system (OPPS)
Which uses Ambulatory Payment Classifications (APC’s) to calculate reimbursement, is implemented for billing of hospital-base Medicare outpatient claims.
Patient Protection and Affordable Care Act (PPACA)
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)
Patient record
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.
Per diem
Issue payment based on daily rates.
Personal health record (PHR)
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.
A person who signs a contract with a health insurance company and who, thus, owns the health insurance policy.
Preventive Services
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
Problem-oriented record (POR)
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
Prospective payment system (PPS)
PPS which issue a determined payment for inpatient services.
Public Health insurance
Federal and state government health programs (e.g., Medicare and Medicaid, SCHIP, TRICARE) available to eligible individuals.
Quality improvement organization (QIO)
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
Record linkage
Allows patient information to be created at a different location according to a Unique patient identifiers for identification number.
Resource utilization groups (RUGs)
Is based on data collected from resident assessments (using data elements called the Minimum Data Set (MDS)
Resource-Based Relative Value Scale (RBRVS) system
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.
Self insured (or self funded) employer-sponsored group help plans
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
Single-payer system
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.
Skilled nursing facility prospective payment system (SNF PPS)
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)
Socialized medicine
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
State Children’s Health Insurance Program (SCHIP)
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.
Tax Equity and Financial Responsibility Act of 1982 (TEFRA)
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.
Third party administrators (TPA)
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.
Third-party payer
Is a health insurance company that provides coverage, such as Blue Cross Blue Shield.
Total Practice Management Software (TPMS)
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.
Universal health insurance
The goal of providing every individual with access to health coverage, regardless of the system impediment to achieve the goals
Usual and reasonable payments
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).
World Health Organization (WHO)
This is the organization develop to the international classification of diseases ICD, a classification system used to collect data for statistical purposes
Health care
The definition of medical care to include preventive services, which are designed to help individuals avoid health and injury problems.
Group health insurance
Health insurance coverage subsidized by employers and other organizations e.g., labor union, rule and customer health cooperatives.
A fee schedule
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).
Outcomes and Assessment Information Set (OASIS)
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
Benefits improvement and Protection Act of 2000 (BIAP)
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.
SOAP format
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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