Ch. 2 Coding and Billing: Intro to Health Insurance Flashcards
medical care
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.
health care
expands teh defintion of medical care to include preventive services.
preventive serivces
designed to help individuals avoid problems with health and injuries.
express contract
provisions that are stated in a health insurance contract. For example physical examinations
implied contract
results from actions taken by the health care facility or provider, such as agreeing to provide treatment to a patient.
stop-loss insurance
AKA: excess insurance
provides protection against catastrophic or unpredictable losses and includes: aggregate stop-loss pans and specific stop-loss plans
aggregate stop-loss plans
provide a max dollar amount eligible exspenses during a contract period (e.g. numerous employers who incur inpatient hospitalization expenses during a pandemic); and
specific stop-loss plans
provide protection against a high claim on an individual (e.g. pT diagnosed with cancer that requires extensive treatment).
health insurance
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.
premium
the amount paid for a health insurance poloicy. This is paid by the employee or individual looking to purchase a health insurance policy.
schedule of benefits
AKA: covered services
outlines the services covered by that specific health insurance plan.
carve-out plan
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).
fee for service
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)
fee schedule
list of predetermined payments for health serivices provided to pTs (e.g. a fee assigned to each CPT code)
indemnity plan
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.
managed health care
AKA: managed care
health care delivery system organized to manage health care costs, utilization, and quality.
prepaid health plan
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.
policyholder
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.
enrollee
AKA: subscriber
an individual who joins a manged care plan; subscribers aslo purchase traditional health insurance plans as a policy holder.
third-party payer
a health insurance company that provides health insurance coverage to their policyholders.
EX: Blue Cross Blue Shield
CMS-1500 claim
claim submitted for reimbursement of ohyscian office procedures and services; electronic version is called ANSI ASC X12N 837P.
payer mix
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.
guranteed renewal
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.
deductible
is an amount for which the pT is financially responsible before an insurance policy provides payment.
lifetime maximum amount
is the maximum benefits payable to a health plan participant.
riders
special contract clause stipulating additional coverage above the standard contract.
dpendent continuation
provides continue health insuracne coverage for kids who meet certain conditions. attending college students and ppl under the age of 26.
special accidental injury riders
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.
copayment
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.
coinsurance
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)
state insurance regulators
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.
group health insurance
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.
individual health insurance
a private health insurance policy purchased by individuals or families who do not have access to group health insurance coverage.
public health insurance
federal and state govenment health programs (Medicaid, medicare, CHIP, TRICARE) available to eligable individuals.
single payer helath insurance
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.
socialized medicine
a type of single-payer health system in which the govt owns and operates health facilities and providers (physcians) receive salaries (Finlad, Great Britain).
universal health care
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.)
Legislation
federal, state, county, and municipal (city) laws, which are rules of conduct enforced by thereat of punishment if violated.
third party administrators (TPAs)
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.
major medical insurance
coverage for catostrophic or prolonged illness and injuries, which can include hospital, medical, and surgical benefits taht supplement basic coverage benefits.
The Medis
Medicare: health insurance coverage for elderly individuals 65+
Medicaid is health insurance coverage provided to low income individuals.
Civilians Health and Medical Program-Uniformed Services (CHAMPUS)
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.
self-insured (self-funded) employer-sponsored group health plans
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.
mandate
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.
risk contract
an arrangment among providers to provide capitated (fixed, prepaid basis) health care services to medicare beneficiaries
competitive medical plan (CMP)
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.
quality improvement organizations (QIOs)
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.
quality assessment and performance improvement (QAPI) program
program implemented so that quality assurance activities are performed to improve the functioning of Medicare Advantage organzations.
health insuracne market place
AKA health insurance exchange
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.
risk adjustment program
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.
managed care (AKA: managed health care)
a health delivery system organized to manage health care costs, utilization, and quality.
managed care orgnization (MCO)
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.
capitation
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).
exclusive provider organization (EPO)
managed care plan that provides benefits to subscribers if they receive services from netowrk providers.
network provider
a physcian or health care facility that is contracted under a speciifc manged cared plan
healthcare maintenance organization
responsible for providing health care services to subsribers in a given geopgraphical area for a fixed fee.
intergrated delivery system
organization of affiliated provider sites (e.g. hospitals, ambulatory surgical centers, or physcians groups) that offer joint health care services to subsribers
point of service (POS) plan
delivers health care services using both manged care network and traditional indemnity coverage so patients can seek outsdie the managed care network.
self-refferral
enrollee who sees a non-HMO panel specialist without refferral from the primary care physcian
preferred provider organization (PPO)
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.
triple option plan
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.
cafeteria plan (AKA: triple option plan)
provides different health benefit plans and extra helath benefits plans and extra coverage options through an insurer or third party administrator.
fee for service plans
reimburses providers according to a fee schedue after covered procedures and services have been provided to pTs
value sbased reimbursment methodology
compensates providers for the quality of care procided to patients as measured by patient outcomes
primary care provider
responsible for supervising and coordinating health care services for enrollee and preauthorizing referrals to specialities and inpatient hospital admissions (except in emergencies).
physcian refferal
written order by a primary care provider that facilitates patient evaluation and treatment by a physcian specialist
gatekeeper
primary care provider for essential health care services at the lwoest possible cost, avoiding nonessential care, and reffering patients to specialists.
gag clauses
prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursemnt for services.
physcian incentives
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.)
physican incentive plans
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
quality assurance programs (quality managment programs)
activities that assess the quality of care provided in ahealth care setting
performance meaurements
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.
external quality review organization (EQRO)
resonsible for reviewing health care provided by manged care organizations
accreditation
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.
NAtional Committe for Quality Assurance (NCQA)
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
Healthcare Affectiveness Data and Information
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
standards
requirements established by accreditation organizations
report card
contains data regarding a manged care plan’s quality utlization, customer satisfaction, administrative effectiveness, financial stability, and cost control.
quality improvemnt (QI)
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.
quality imporvement system for managed care (QISMC)
establishe by Medicare to ensure the accountability of manged care plans in terms of objective, measurable standards.
clinical practice guidelines
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.
utilization review organization
an entity that establishes utilization managment program and performs external etilization review services.
case manger
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.
second surgical opinion (SSO)
2nd physican is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perfrom the surgery.
perscription management
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
consumer directed health plans (CDHPs)
define employer contributions and ask empoyees to be more resonsible for health care descions and cost-sharing
flexible spending account
consumer directed health plan that allows tax-exempt accounts to be created by employees for the purpose of paying health care bills.
helathcare reimbursemnt account
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).
health reimbursement arrangment
tax-exmpt accounts funded by employers, which individuals use to pay health care bills.
health savings account
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.
continutiy of care
documenting patient care services so that others who treat that pT have a source of information on which to base additional care and treatment.
record linkage
allows pTs information to be created at different locations according to a unique patient identifier or identification number.
personal health record (PHR)
web-based application that allows individuals to maintian and mange their health information (and others authorized to view) a private, secure, and confidential environment.
Total practice managment software (TPMS)
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.
electronic clinical quality measures (eCQMs)
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.
promoting Interoperabilty (PI) programs
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.
quality payment program
implemented to help providers focus on quality of pT care and making patients healthier.
alternative payment model
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.
Advanced alternative paymetn models
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.
(MIPS) tradional merit-beased incentive payment system
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
(MIPS) value pathways
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.
benchmarking
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
medical underwriting
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.
guaranteed issue
a policy that is issued to an applicant regardless of age, scoeconomic status, pre-exsisting conditions, and other factors.
coinsurance
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%.
copay
the dollar amoutn a pT must pay before health services ar eprovided or pT can see the physcian
the joint commision
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.
