Ch. 02 Introduction to Health Insurance Flashcards
ACA
Affordable Care Act (Obamacare) 3/23/2010
CHIP
Children’s Health Insurance Program
CMS
Centers for Medicare and Medicaid Services
CMS-1500 claim
claim submitted for reimbursement of physician office procedures and services; electronic version is ANSI ASC X12N 837P.
COBRA
Consolidated Omnibus Budget Reconciliation Act of 1985
allows employees to continue health care coverage beyond the benefit termination date.
continuity of care
documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment.
CPT
Current Procedural Terminology
developed by the American Medical Association.
deductible
amount for which the patient is financially responsible before an insurance policy provides coverage.
DHHS
Department of Health and Human Services
EHR
electronic health record
global concept that includes the collection of patient information documented by a number of providers at different facilities regarding one patient.
EIN
Employer Identification Number
EMR
electronic medical record,
has a more narrow focus,
considered part of the electronic health record; is created for a single medical practice using vendor software, which assists in provider decision making.
group health insurance
traditional health care coverage subsidized by employers and other organizations (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.
health care
expands the definition of medical care to include preventive services.
health insurance
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.
Health Insurance Marketplace
Created by the ACA
allows Americans to purchase health coverage that fits their budget and meets their needs.
HIPAA
Health Insurance Portability and Accountability Act of 1996
governs privacy, security, and electronic transactions standards for health care information.
HMOs
Health Maintenance Organizations
ICD
International Classification of Diseases
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 (Aetna).
lifetime maximum amount
maximum benefit payable to a health plan participant.
Major medical insurance
coverage for catastrophic or prolonged illnesses and injuries.
Medicaid
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).
medical care
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.
medical necessity
the patient’s diagnosis must justify diagnostic and/or therapeutic procedures or services provided.
Medicare
reimburses health care services to American over the age of 65.
OSHA
Occupational Safety and Health Administration
patient record,
medical record
documents health care services provided to a patient;
serves as a medico-legal document and a business record.
payer mix
different types of health insurance payments made to providers for patient services.
PHR
personal health record
web-based application that allows individuals to maintain and manage their health info in a private, secure, and confidential environment.
policyholder
a person who signs a contract with a health insurance company and who, owns the health insurance policy; the policyholder is the insured or enrollee and the policy might include coverage for dependents.
preventive services
designed to help individuals avoid problems with health and injuries.
problem-oriented record
POR, a systematic method of documentation that consists of four components: database, problem list, initial plan, and progress notes.
Public health insurance
federal and state government health programs (Medicare, Medicaid, CHIP, TRICARE) available to eligible individuals.
record linkage
allows patient information to be created at different locations according to a unique patient identifier or identification number.
Single-payer system
Centralized health care plan adopted by some Western nations (Canada, Great Britain) and funded by taxes. The government pays for each resident’s health care, which is considered a basic social service.
SOAP
Subjective, Objective, Assessment, Plan.
Socialized medicine
type of single-payer system where the government owns and operates health care facilities and providers (physicians) receive salaries; the VA health care program is a form of socialized medicine.
third-party payer
a health insurance company that provides coverage, such as BlueCross BlueShield.
TPMS
total practice management software
used to generate the EMR, automating medical practice functions.
TRICARE
CHAMPUS Reform Initiative (CRI) resulted in a new health program which includes TRICARE Prime and TRICARE Select.
Universal health insurance
goal of providing every individual with access to health coverage, regardless of the system implemented to achieve that goal Obamacare).
Usual and Reasonable Payments
based on fees typically charged by providers in a particular region of the country.
WHO
World Health Organization
benchmarking
practice that allow an entity to measure and compare its own data against that of other agencies/organizations for the purpose of continuous improvement.
