Ch. 2 Coding and Billing: Intro to Health Insurance

Question 1

medical care

Answer 1

includes the idetification 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 2

health care

Answer 2

expands teh defintion of medical care to include preventive services.

Question 3

preventive serivces

Answer 3

designed to help individuals avoid problems with health and injuries.

Question 4

express contract

Answer 4

provisions that are stated in a health insurance contract. For example physical examinations

Question 5

implied contract

Answer 5

results from actions taken by the health care facility or provider, such as agreeing to provide treatment to a patient.

Question 6

stop-loss insurance

AKA: excess insurance

Answer 6

provides protection against catastrophic or unpredictable losses and includes: aggregate stop-loss pans and specific stop-loss plans

Question 7

aggregate stop-loss plans

Answer 7

provide a max dollar amount eligible exspenses during a contract period (e.g. numerous employers who incur inpatient hospitalization expenses during a pandemic); and

Question 8

specific stop-loss plans

Answer 8

provide protection against a high claim on an individual (e.g. pT diagnosed with cancer that requires extensive treatment).

Question 9

health insurance

Answer 9

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

Question 10

premium

Answer 10

the amount paid for a health insurance poloicy. This is paid by the employee or individual looking to purchase a health insurance policy.

Question 11

schedule of benefits

AKA: covered services

Answer 11

outlines the services covered by that specific health insurance plan.

Question 12

carve-out plan

Answer 12

an arrangement provided by a health insurance company to offer a specfic health benefit that is managed seperately from the health insuracne plan (usually at an additional cost).

Question 13

fee for service

Answer 13

reimbursement method that increases payment if the health care service fees increase. If multiple units of service are provided, or if more expensive serivces are provided instead of less expensive services (e.g. brand name vs generic perscription medication)

Question 14

fee schedule

Answer 14

list of predetermined payments for health serivices provided to pTs (e.g. a fee assigned to each CPT code)

Question 15

indemnity plan

Answer 15

allows pTs to seek health care from any provider, and the provider receives reimbursement accoridng to a fee shcedule; indemnity plans are sometimes called fee-for-serive plans.

Question 16

managed health care

AKA: managed care

Answer 16

health care delivery system organized to manage health care costs, utilization, and quality.

Question 17

prepaid health plan

Answer 17

establishes a capitation contract between a manged health care plan and participating network providers (facilities, physcians, and other health care practitionaers w/in community). The community of providers provide service for a certain pT population and the providers are reimbursed eitehr monthly or annually.

Question 18

policyholder

Answer 18

a person who signs a contract with a health insurance company and therefore owns the health insurance policy as long as they provide monthly payment on health insurance plan.

Question 19

enrollee

AKA: subscriber

Answer 19

an individual who joins a manged care plan; subscribers aslo purchase traditional health insurance plans as a policy holder.

Question 20

third-party payer

Answer 20

a health insurance company that provides health insurance coverage to their policyholders.

EX: Blue Cross Blue Shield

Question 21

CMS-1500 claim

Answer 21

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

Question 22

payer mix

Answer 22

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

It is important that providers determine the % of reimbursement from each type of payer, as part of revenue management. Help ensure financial validity of the facility or place of practice.

Question 23

guranteed renewal

Answer 23

a provision included in health insurance contracts; that require a health insurance to be renewed as logn as policy premiums are being paid.

Depending on state this provision does not limit how much a person can be charged to renew or continue coverage.

Question 24

deductible

Answer 24

is an amount for which the pT is financially responsible before an insurance policy provides payment.

Question 25

lifetime maximum amount

Answer 25

is the maximum benefits payable to a health plan participant.

Question 26

riders

Answer 26

special contract clause stipulating additional coverage above the standard contract.

Question 27

dpendent continuation

Answer 27

provides continue health insuracne coverage for kids who meet certain conditions. attending college students and ppl under the age of 26.

Question 28

special accidental injury riders

Answer 28

covers 100% of non-surgical care sought and rendered within 24 to 72 hours of an accident/injury.

EX; get hurt at work you have a certian amount of time (2-3 days) to get your services in so it can be covered 100% by insurance. Cause its within an accident case window.

Question 29

copayment

Answer 29

a provision in a healthcare or managed care plan that states pTs must may pay a certain dollar amount out of pocket before receiving service.

Usually the Pt is charged per encounter or per medical service received.

Question 30

coinsurance

Answer 30

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

REFFERENCE EXAMPLE 1 IN NOTES

Example: a certain plan pays 80% of costs the pT pays 20%. pT pays a copayment or coinsurance amount for services which is there 20% before or after services. Insurance covers the provider based on fee schedule, adn the rest is a write off(loss)

Question 31

state insurance regulators

Answer 31

responsible for registering insurance companies, overseeing compliance/penalty provisions of state insc code, supervise insc Co formation w/in that state, and monitoring the reinsurance market. They work on a state level not a federal level.

Question 32

group health insurance

Answer 32

private health insurance model that provides coverage, which is subsidized by employers and other organizations. grp. hlth. insc. plans help distribute cost and provide voerage for a bigger group at more affordable rate.

The Patient Protection and Affordable Care Act include a tax credit to small business employers and tax-exmpt organizations afford the cost of coverign their employess.

Question 33

individual health insurance

Answer 33

a private health insurance policy purchased by individuals or families who do not have access to group health insurance coverage.

Question 34

public health insurance

Answer 34

federal and state govenment health programs (Medicaid, medicare, CHIP, TRICARE) available to eligable individuals.

Question 35

single payer helath insurance

Answer 35

national health serice model adopted by some weastern nations (e.g. Canada) and funded by taxes. The govt pays for each residents health care, which is considered a basic social service.

Question 36

socialized medicine

Answer 36

a type of single-payer health system in which the govt owns and operates health facilities and providers (physcians) receive salaries (Finlad, Great Britain).

Question 37

universal health care

Answer 37

social insurance model that has the goal of providing every individual w/ access to health coverage, regardless of they system implemented to acheive that goal, such as a combination of private and public health insurance.

In the U.S. most people are covered by multiple combined insuracne (Employer covers dental/vision insurance and I’m covered for Medicaid.)

Question 38

Legislation

Answer 38

federal, state, county, and municipal (city) laws, which are rules of conduct enforced by thereat of punishment if violated.

Question 39

third party administrators (TPAs)

Answer 39

company that provides claims administartation and other outsourcing services (e.g. emloyee benefits management) for self insured companies; provides administrative services to health care plans; specializes in mental health case managment; and process claims, seriving as a system of “checks and balances” for labor mangement.

Question 40

major medical insurance

Answer 40

coverage for catostrophic or prolonged illness and injuries, which can include hospital, medical, and surgical benefits taht supplement basic coverage benefits.

Question 41

The Medis

Answer 41

Medicare: health insurance coverage for elderly individuals 65+
Medicaid is health insurance coverage provided to low income individuals.

Question 42

Civilians Health and Medical Program-Uniformed Services (CHAMPUS)

Answer 42

OG designed as a benefit fro dependents of personel serivng in the armed forces/uniformed branches of public health service and the Nat. Oceanic and Atmosperic Admin. This program is now called Tricare.

Question 43

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

Answer 43

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

Question 44

mandate

Answer 44

offical directive, instruction, or order to take or perform a certain acion, such as regulations written by federal govt administrative agencies; they are also authoritative commands, such as by courts, governors, and legislatures.

Question 45

risk contract

Answer 45

an arrangment among providers to provide capitated (fixed, prepaid basis) health care services to medicare beneficiaries

Question 46

competitive medical plan (CMP)

Answer 46

an HMO that meets federal eleigibility requirements for a Medicare risk contract, but is not licsensed as a federally qualified plan.
SUMMARY: They provide federal eligibility requirments for the providers performing capitated services to medicare members.

It is not federal qualified plan.

Question 47

quality improvement organizations (QIOs)

Answer 47

a group of health quality experts and clinicians, and consumer organized to imporve and and oversee the quality of health care given to medicare beneficiaries.

Question 47

quality assessment and performance improvement (QAPI) program

Answer 47

program implemented so that quality assurance activities are performed to improve the functioning of Medicare Advantage organzations.

Question 48

health insuracne market place

AKA health insurance exchange

Answer 48

method Americans use to purchase health coverage taht fitstheir budget and meet their needs. This policy was effective Oct. 1, 2013 as a result of the passing of the Affordabel Care Act.

Question 48

risk adjustment program

Answer 48

implemnted by the PPACA (Affordabel Care Act) to lessen or elimate the influence of risk selection on premiums charged by health plans and includes the risk adjustment model and risk transfer formula.

Ensure a fair coverage and charging of services between healthy and sicker enrollees.

Question 49

managed care (AKA: managed health care)

Answer 49

a health delivery system organized to manage health care costs, utilization, and quality.

Question 50

managed care orgnization (MCO)

Answer 50

responsible for the health of a group of enrollees, can be a health pln, hospital, physcian group, or health system.

usually contract their healht provond srvices to big employers and Cos.

Question 51

capitation

Answer 51

prospective payment per patient for a presribed period of time; provider accepts preestablished payments for providing health care services to enrollee over a specified period of time (usually annually or monthly).

Question 52

exclusive provider organization (EPO)

Answer 52

managed care plan that provides benefits to subscribers if they receive services from netowrk providers.

Question 53

network provider

Answer 53

a physcian or health care facility that is contracted under a speciifc manged cared plan

Question 54

healthcare maintenance organization

Answer 54

responsible for providing health care services to subsribers in a given geopgraphical area for a fixed fee.

Question 55

intergrated delivery system

Answer 55

organization of affiliated provider sites (e.g. hospitals, ambulatory surgical centers, or physcians groups) that offer joint health care services to subsribers

Question 56

point of service (POS) plan

Answer 56

delivers health care services using both manged care network and traditional indemnity coverage so patients can seek outsdie the managed care network.

Question 57

self-refferral

Answer 57

enrollee who sees a non-HMO panel specialist without refferral from the primary care physcian

Question 58

preferred provider organization (PPO)

Answer 58

network of physicans, other helath care practioners, adn hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subsribers for discounted fee.

Question 59

triple option plan

Answer 59

usually offered by either a single insurance plan or as a joint venture among two ormore third party payers. and provides subscribers or employees with a choice of HMO, PPO, or traditional helath insurance plans; also called caeteria plan or felxible benefit plan.

Question 60

cafeteria plan (AKA: triple option plan)

Answer 60

provides different health benefit plans and extra helath benefits plans and extra coverage options through an insurer or third party administrator.

Question 61

fee for service plans

Answer 61

reimburses providers according to a fee schedue after covered procedures and services have been provided to pTs

Question 62

value sbased reimbursment methodology

Answer 62

compensates providers for the quality of care procided to patients as measured by patient outcomes

Question 63

primary care provider

Answer 63

responsible for supervising and coordinating health care services for enrollee and preauthorizing referrals to specialities and inpatient hospital admissions (except in emergencies).

Question 64

physcian refferal

Answer 64

written order by a primary care provider that facilitates patient evaluation and treatment by a physcian specialist

Question 65

gatekeeper

Answer 65

primary care provider for essential health care services at the lwoest possible cost, avoiding nonessential care, and reffering patients to specialists.

Question 66

gag clauses

Answer 66

prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursemnt for services.

Question 67

physcian incentives

Answer 67

include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services (e.g. discharge an inpatient form the hospital more quickly) to save money for the managment care plan.)

Question 68

physican incentive plans

Answer 68

requires Medicare and Medicaid managed care plans to disclose physican incentives to CMS or state Medicaid agencies before a new or renewwed contract recieves final approval

Question 69

quality assurance programs (quality managment programs)

Answer 69

activities that assess the quality of care provided in ahealth care setting

Question 70

performance meaurements

Answer 70

strengthen organization accountability and support performance improvement initiatives by assessing the degree to which evidence-based treatment guidelines are followed and include an evaluation of results of care.

Question 71

external quality review organization (EQRO)

Answer 71

resonsible for reviewing health care provided by manged care organizations

Question 72

accreditation

Answer 72

volutary process that a health care facility/prganization hospital or manged care plan) undergos to demonstrate that is has met stndards beyond tose rquired by law.

Question 73

NAtional Committe for Quality Assurance (NCQA)

Answer 73

a private non-profit organization that assess that quality of manged care plans in the U.S and releases the date to the public for its benefit when selecting a mnaged care plan

Question 74

Healthcare Affectiveness Data and Information

Answer 74

created standards to assess maaged-care systems using data elements that are collected, evaluated, adn published to compare the performace of managed hleath care plans

Question 75

standards

Answer 75

requirements established by accreditation organizations

Question 76

report card

Answer 76

contains data regarding a manged care plan’s quality utlization, customer satisfaction, administrative effectiveness, financial stability, and cost control.

Question 77

quality improvemnt (QI)

Answer 77

involves continuous and ststematic actions that result in measurable imporvement in the provisions of health care services and the health status of targeted patient groups.

Question 78

quality imporvement system for managed care (QISMC)

Answer 78

establishe by Medicare to ensure the accountability of manged care plans in terms of objective, measurable standards.

Question 79

clinical practice guidelines

Answer 79

define modialates for diagnosis, management, and treatment of patients, and they include recommendations based ona methodical and meticulous evaluation and synthsis of published medical literature; the guidlines are not protocols that must be followed, and instead are considered.

Question 80

utilization review organization

Answer 80

an entity that establishes utilization managment program and performs external etilization review services.

Question 81

case manger

Answer 81

submits written confirmation authorization treatment, to the provider; include nurses and social workers who help complex health care and support systems; also coodinate health care services to improve patient outcomes while considering financial implications as part of severity of illness and intensity of services to address the balance of medical necessity, procedures/serivces provided, and level of care needed.

Question 82

second surgical opinion (SSO)

Answer 82

2nd physican is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perfrom the surgery.

Question 83

perscription management

Answer 83

control medication costs using different stratergies etc. (pharmacy benefit manger, cast sharing copayments, disease managment programs, electronic prescribing, drug formularies, drug utilization review, generic sub, manufacturer rebates, neogtioned prices, and Rx mail service

Question 84

consumer directed health plans (CDHPs)

Answer 84

define employer contributions and ask empoyees to be more resonsible for health care descions and cost-sharing

Question 85

flexible spending account

Answer 85

consumer directed health plan that allows tax-exempt accounts to be created by employees for the purpose of paying health care bills.

Question 86

helathcare reimbursemnt account

Answer 86

tx exmpt account used to pay for health care expesnes; individual decides, in advance, how much money to deposit in an HCRA (and unused funds are lost).

Question 87

health reimbursement arrangment

Answer 87

tax-exmpt accounts funded by employers, which individuals use to pay health care bills.

Question 88

health savings account

Answer 88

participants enroll in a relatively inexspensive high deductable health plan (HDHP), and a tax deductable savings account is opened to cover current and future medical expenses.

Question 89

continutiy of care

Answer 89

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

Question 90

record linkage

Answer 90

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

Question 91

personal health record (PHR)

Answer 91

web-based application that allows individuals to maintian and mange their health information (and others authorized to view) a private, secure, and confidential environment.

Question 92

Total practice managment software (TPMS)

Answer 92

used to generate the EMR automating medical practice functions of registering pTs sceduling appoitnments, generating insc. claims and pTs statements, processing payments from pT and 3rd paty payer adn administrative and clinical reports.

Question 93

electronic clinical quality measures (eCQMs)

Answer 93

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

Question 94

promoting Interoperabilty (PI) programs

Answer 94

focus on imporivng patient access to health information and reducing the time and costrequired of providers to comply with the progrmas’ requirements; prviously called EHR incentive programs.

Question 95

quality payment program

Answer 95

implemented to help providers focus on quality of pT care and making patients healthier.

Question 96

alternative payment model

Answer 96

paymetn approach that includes ncentive payments to provide high-qulaity adn cost efficent care; APMs can apply to a specific clinical condition, care epsidoe, or population.

Question 97

Advanced alternative paymetn models

Answer 97

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

Question 98

(MIPS) tradional merit-beased incentive payment system

Answer 98

allows providers to earn a performace-based payment adjustment that consdiers quality resource use, clinical practice improvemnt, and promoting interoperability. Helps provide amore cohesive provier-participation experince

Question 99

(MIPS) value pathways

Answer 99

allow for more cohesive participation experince. They connect activitie and measures from four merit-based incentive payment systems. The categories activities and measures are applied to are based on the category of speciality, med condition, or epsiode of care. Also include quality, performace imporvment, and cost.

Question 100

benchmarking

Answer 100

practice that allows an entity to measure and compare its own data against that or other agencies and organizations for the purpose of continuous imporvemnt

Question 101

medical underwriting

Answer 101

the insc. Co. screens the applicants to find out about their health status ansd risk factors. BAsed on the info a decision is made as to whether the Co. wants to ensure the applicant and under whatterms. if a applicant seems to risky then the Co. can deny the applicant for coverage.

Question 102

guaranteed issue

Answer 102

a policy that is issued to an applicant regardless of age, scoeconomic status, pre-exsisting conditions, and other factors.

Question 103

coinsurance

Answer 103

the % of costs a pT shares with their health insurance. Example 80/20 where the insc. Co pays 80% of the med bill cost and the policyholder/pT is responsible for the remaining 20%.

Question 104

copay

Answer 104

the dollar amoutn a pT must pay before health services ar eprovided or pT can see the physcian

Question 105

the joint commision

Answer 105

the nation’s oldest adn largest standard setting accrediting body in health care. Their goal is to alwasy establish qaulity improvement adb pT safety in health care.