B&C Chapter 2: Health Insurance

Question 1

accountable care organization (ACO)

Answer 1

groups of physicians, hospitals, and other health care providers, all of whom come together voluntarily to provide coordinated high quality care to Medicare patients

Question 2

advanced alternative payment models (advanced APMs)

Answer 2

include new ways for CMS to reimburse health care providers for care provided to Medicare beneficiaries; providers who participate in an Advanced APM through Medicare Part B may earn an incentive payment for participating in the innovative payment model.

Question 3

alternative payment models (APMs)

Answer 3

payment approach that includes incentive payments to provide high-quality and cost-efficient care; APMs can apply to a specific clinical condition, a care episode, or a population.

Question 4

ambulatory payment classifications (APCs)

Answer 4

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

Question 5

American Recovery and Reinvestment Act of 2009 (ARRA)

Answer 5

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

Question 6

Balanced Budget Act of 1997 (BBA)

Answer 6

addresses health care fraud and abuse issues, and provides for Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) investigative and audit services in health care fraud cases.

Question 7

benchmarking

Answer 7

practice that allows an entity to measure and compare its own data against that of other agencies and organizations for the purpose of continuous improvement (e.g., coding error rates).

Question 8

CHAMPUS Reform Initiative (CRI)

Answer 8

conducted in 1988; resulted in a new health program called TRICARE, which includes two options: TRICARE Prime and TRICARE Select (formerly called TRICARE Standard).

Question 9

Children’s Health Insurance Program (CHIP)

Answer 9

provides health insurance coverage to uninsured children whose family income is up to 200 percent of the federal poverty level (monthly income limits of a family of four also apply).

Question 10

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

Answer 10

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

Question 11

Civilian Health and Medical Program - Uniformed Services (CHAMPUS)

Answer 11

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

Question 12

Clinical Laboratory Improvement Act (CLIA)

Answer 12

established quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test was performed.

Question 13

CMS-1500 claim

Answer 13

claim submitted for reimbursement of physician office procedures and services; electronic version is called ANSI ASC X12N 837P.

Question 14

coinsurance

Answer 14

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

Question 15

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

Answer 15

allows employees to continue health care coverage beyond the benefit termination date.

Question 16

consumer-driven health plans (CDHPs)

Answer 16

health care plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of holding down costs; also called consumer-directed health plan.

Question 17

continuity of care

Answer 17

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

Question 18

copayment (copay)

Answer 18

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

Question 19

deductible

Answer 19

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

Question 20

diagnosis-related groups (DRGs)

Answer 20

prospective payment system that reimburses hospitals for inpatient stays.

Question 21

eHealth exchange

Answer 21

health information exchange network for securely sharing clinical information over the Internet nationwide that spans all 50 states and is the largest health information exchange infrastructure in the United States; participants include large provider networks, hospitals, pharmacies, regional health information exchanges, and many federal agencies.

Question 22

electronic clinical quality measures (eCQMs)

Answer 22

processes, observations, treatments, and outcomes that quantify the quality of care provided by health care systems; measuring such data helps ensure that care is delivered safely, effectively equitably, and timely.

Question 23

electronic health record (EHR)

Answer 23

global concept that includes the collection of patient information documented by a number of providers at different facilities regarding one patient.

Question 24

electronic medical record (EMR)

Answer 24

considered part of the electronic health record (EHR), the EMR is created using vendor software, which assists in provider decision making.

Question 25

Electronic Submission of Medical Documentation System (esMD)

Answer 25

implemented to (1) reduce provider and reviewer costs and cycle time by minimizing and eventually eliminating paper processing and mailing of medical documentation.

Question 26

Employee Retirement Income Security Act of 1974 (ERISA)

Answer 26

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 exempted large employers from taxes on health insurance premiums.

Question 27

Evaluation and Management (E/M)

Answer 27

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

Question 28

Federal Employees’ Compensation Act (FECA)

Answer 28

provides civilian employees of the federal government with medical care, survivors’ benefits, and compensation for lost wages.

Question 29

Federal Employers’ Liability Act (FELA)

Answer 29

legislation passed in 1908 by President Theodore Roosevelt that protects and compensates railroad workers who are injured on the job.

Question 30

fee schedule

Answer 30

list of predetermined payments for health care services provided to patients (e.g., a fee is assigned to each CPT code).

Question 31

Financial Services Modernization Act (FSMA)

Answer 31

prohibits sharing of medical information among health insurers and other financial institutions for use in making credit decisions; also allows banks to merge with 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 Gramm-Leach-Bliley Act.

Question 32

Gramm-Leach-Bliley Act

Answer 32

see Financial Services Modernization Act.

Question 33

group health insurance

Answer 33

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

Question 34

health care

Answer 34

expands the definition of medical care to include preventive services.

Question 35

Health Care and Education Reconciliation Act (HCERA)

Answer 35

includes health care reform initiatives that amend the Patient Protection and Affordable Care Act to increase tax credits to buy health care insurance, eliminate special deals provided to senators, close the Medicare “donut hole,” delay taxing of “Cadillac-health care plans” until 2018, and so on.

Question 36

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

Answer 36

included in the American Recovery and Reinvestment Act of 2009 and amended the Public Health Service Act to establish an Office of National Coordinator for Health Information Technology within HHS to improve health care quality, safety, and efficiency

Question 37

health insurance

Answer 37

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

Question 38

health insurance exchange

Answer 38

see health insurance marketplace

Question 39

health insurance marketplace

Answer 39

method Americans use to purchase health coverage that fits their budget and meet their needs, effective October 1, 2013.

Question 40

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Answer 40

mandates regulations that govern privacy, security, and electronic transactions standards for health care information.

Question 41

Hill-Burton Act

Answer 41

provided federal grants for modernizing hospitals that had become obsolete because of a lack of capital investment during the Great Depression and WWII (1929-1945). In return for federal funds, facilities were required to provide services free, or at reduced rates, to patients unable to pay for care.

Question 42

Home Health Prospective Payment System (HH PPS)

Answer 42

reimbursement methodology for home health agencies that uses a classification system called home health patient-driven groupings model (PDGM), which establishes a predetermined rate for health care services provided to patients for each 60-day episode of home health care.

Question 43

individual health insurance

Answer 43

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

Question 44

Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)

Answer 44

system in which Medicare reimburses inpatient psychiatric facilities according to a patient classification system that reflects differences in patient resource use and costs; it replaces the cost-based payment system with a per diem IPF PPS.

Question 45

Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)

Answer 45

implemented as a result of the BBA of 1997; utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs.

Question 46

International Classification of Diseases (ICD)

Answer 46

classification system used to collect data for statistical purposes.

Question 47

Investing in Innovations (i2) Initiative

Answer 47

designed to spur innovations in health information technology (health IT) by promoting research and development to enhance competitiveness in the United States.

Question 48

lifetime maximum amount

Answer 48

maximum benefit payable to a health plan participant.

Question 49

major medical insurance

Answer 49

coverage for catastrophic or prolonged illnesses and injuries.

Question 50

meaningful EHR user

Answer 50

providers who demonstrate that certified EHR technology is used for electronic prescribing, electronic exchange of health information in accordance with law and HIT standards, and submission of information on clinical quality measures; and hospitals that demonstrate that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve quality of care and that the technology is used to submit information on clinical quality measures.

Question 51

meaningful use

Answer 51

objectives and measures that achieved goals of improved patient care outcomes and delivery through data capture and sharing, advance clinical processes, and improved patient outcomes; replaced by quality payment program (QPM).

Question 52

Medicaid

Answer 52

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 53

medical care

Answer 53

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

Question 54

medical record

Answer 54

see patient record.

Question 55

Medicare

Answer 55

reimburses health care services to Americans over the age of 65.

Question 56

Medicare Access and CHIP Reauthorization Act (MACRA)

Answer 56

ended the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services, the Merit-Based Incentive Payment System (MIPS), and required CMS to remove Social Security Numbers (SSNs) from all Medicare cards, replacing them with new randomly generated Medicare beneficiary identifiers (MBIs) that will be appearing on new Medicare cards.

Question 57

Medicare beneficiary identifier (MBI)

Answer 57

replaces SSN as health insurance claim number on new Medicare cards for transactions such as billing, eligibility status, and claim status.

Question 58

Medicare Catastrophic Coverage Act

Answer 58

mandated the reporting of ICD-9-CM diagnosis codes on Medicare claims; in subsequent years, private third-party payers adopted similar requirements for claims submission. Effective October 1, 2015, ICD-10-CM (diagnosis) codes are reported.

Question 59

Medicare contracting reform (MCR) initiative

Answer 59

established to integrate the administration of Medicare Parts A and B fee-for-service benefits with new entities called Medicare administrative contractors (MACs); MACs replaced Medicare carriers, DMERCs, and fiscal intermediaries.

Question 60

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

Answer 60

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

Question 61

Medicare Outpatient Observation Notice (MOON)

Answer 61

standardized notice provided to Medicare beneficiaries that they are outpatients receiving observation services and are not inpatients of a hospital or a critical access hospital (CAH).

Question 62

Merit-Based Incentive Payment System (MIPS)

Answer 62

eliminated PQRS, value-based payment modifier, and the Medicare EHR incentive program, creating a single program based on quality, resource use, clinical practice improvement, and meaningful use of certified EHR technology.

Question 63

Minimum Data Set (MDS)

Answer 63

data elements collected by long-term care facilities

Question 64

National Correct Coding Initiative (NCCI)

Answer 64

developed by CMS to promote national correct coding methodologies and to eliminate improper coding practices.

Question 65

Obamacare

Answer 65

nickname for the Patient Protection and Affordable Care Act (PPACA), which was signed into federal law by President Obama on March 23, 2010, and created the Health Care Marketplace.

Question 66

Omnibus Budget Reconciliation Act of 1981 (OBRA)

Answer 66

federal law that requires providers to keep copies of any government insurance claims and copies of all attachments filed by the provider for a period of five years; also expanded Medicare and Medicaid programs.

Question 67

Outcomes and Assessment Information Set (OASIS)

Answer 67

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

Question 68

Outpatient Prospective Payment System (OPPS)

Answer 68

uses ambulatory payment classifications (APCs) to calculate reimbursement; was implemented for billing of hospital-based Medicare outpatient claims.

Question 69

Patient Protection and Affordable Care Act (PPACA)

Answer 69

focuses on private health insurance reform to provide better coverage for individuals with pre-existing conditions, improve prescription drug coverage under Medicare, extend the life of the Medicare Trust fund by at least 12 years, and create the health insurance marketplace.

Question 70

patient record

Answer 70

documents health care services provided to a patient.

Question 71

payer mix

Answer 71

different types of health insurance payments made to providers for patient services.

Question 72

per diem

Answer 72

Latin term meaning “for each day,” which is how retrospective cost-based rates were determined; payments were issued based on daily rates.

Question 73

personal health record (PHR)

Answer 73

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 74

policyholder

Answer 74

a person who signs a contract with a health insurance company and who, thus, owns the health insurance policy; the policyholder is the insured (or enrollee), and the policy might include coverage for dependents.

Question 75

preventive services

Answer 75

designed to help individuals avoid problems with health and injuries.

Question 76

problem-oriented record (POR)

Answer 76

a systematic method of documentation that consists of four components; database, problem list, initial plan, and progress notes.

Question 77

Promoting Interoperability (PI) Programs

Answer 77

focus on improving patient access to health information and reducing the time and cost required of providers to comply with the programs’ requirements; previously called EHR incentive programs.

Question 78

prospective payment system (PPS)

Answer 78

issues predetermined payment for services, such as bundled payments, capitation, case rates, and global payments.

Question 79

Protecting Access to Medicare Act (PAMA)

Answer 79

implemented skilled nursing facility (SNF) value-based purchasing (VBP) program.

Question 80

public health insurance

Answer 80

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

Question 81

quality improvement organization (QIO)

Answer 81

performs utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries.

Question 82

quality payment program (QPP)

Answer 82

helps providers focus on quality of patient care and making patients healthier; includes advanced alternative payment models (Advanced APMs) and merit-based incentive payment system (MIPS); replaced the EHR Incentive Program (or Meaningful Use), Physician Quality Reporting System, and Value-Based Payment Modifier program.

Question 83

record linkage

Answer 83

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

Question 84

Resource-Based Relative Value Scale (RBRVS) system

Answer 84

payment system that reimburses physicians’ practice expenses based on relative values for three components of each physician’s services: physician work, practice expense, and malpractice insurance expense.

Question 85

rural health information organization (RHIO)

Answer 85

type of health information exchange organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.

Question 86

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

Answer 86

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

Question 87

single-payer system

Answer 87

centralized health care plan adopted by some Western nations (e.g., Canada, Great Britain) and funded by taxes. The government pays for each resident’s health care, which is considered a basic social service.

Question 88

Skilled Nursing Facility Prospective Payment System (SNF PPS)

Answer 88

implemented (as a result of the BBA of 1997) to cover all costs (routine, ancillary, and capital) related to services furnished to Medicare Part A beneficiaries.

Question 89

socialized medicine

Answer 89

type of single-payer system in which the government owns and operates health care facilities and provider (e.g., physicians) receive salaries; the VA health care program is a form of socialized medicine.

Question 90

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

Answer 90

created Medicare risk programs, which allowed federally qualified HMOs and competitive medical plans that met specified Medicare requirements to provide Medicare-covered services under a risk contract.

Question 91

third-party administrators (TPAs)

Answer 91

company that provides health benefits claims administration and other outsourcing services (e.g., employee benefits management) for self-insured companies; provides administrative services to health care plans; specializes in mental health case management; and processes claims, serving as a system of “checks and balances” for labor-management.

Question 92

third-party payer

Answer 92

a health insurance company that provides coverage, such as BlueCross BlueShield.

Question 93

total practice management software (TPMS)

Answer 93

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

Question 94

universal health insurance

Answer 94

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

Question 95

usual and reasonable payments

Answer 95

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

Question 96

World Health Organization (WHO)

Answer 96

developed the International Classification of Diseases (ICD).