Chapter 2 Flashcards
Medical care
Includes the identification of disease and the provision of care and treatment to persons who are sick, injured or concerned about their health status.
Health care
Expands definition of medical care to include preventative services. Help avoid health and injury problems.
Health Insurance
A contact between policy holder and a third party payer or government health program to reimburse policy holder for all or a portion of the cost of medically necessary treatment or preventative care.
Policy holder
Person who signs a contract with a health Insurance
Third-party payer
Is a health Insirance company that provides coverage such as blue cross blue shield.
Group health insurance
Insirance coverage subsidized by employers and other organizations
Individual health insurance
Prívate health Insurance policy purchased by Individuals or families who do not have access to group health INsurance coverage. (Aetna)
Public health insurance
Federal and state government health programs. Ex. Medicare, Medicaid, chip, tricare
Available to eligible ppl
Single payer system
Centralized health care system adopted by some western nations (Canada) and funded by taxes. The gov pays for your health care.
Socialized medicine
A type of single payer system in which the government owns and operates health care facilities and providers. (Physicians) receive salaries (Finland, Great Britain)
Universal health Insurance
The goal of providing every I do usual with access to health coverage, regardless of the system implemented to achieve the goal. (Obamacare)
Continuity of care
Involves documenting patient care services so that others who treat the patient have a source of I formation to assist with additional care and treatment
Problem-oriented récord (POR)
Is a systematic method of documentation that consists of four components
- data base
- problem list
- initial plan
- progess notes
Electronic health record (EHR)
Health information in a digital format that is created and shared by providers across more than one healthcare setting , such as hospitals , emergency departments, labs, ambulatory surgery centers and outpatient diagnostic facilities.
EHR contains info from all providers involved in patients care. All that are authorized Can access
Record linkage
Allows patient Info to be created at different locations according to a unique patient identifier or I identification number
Electronic medical record (EMR)
A digital versión of the patients chart in a medical office. The days that is contained in an EMR cannot be electronically shared with other physicians, specialist or Insititutions
Personal health record (PHR)
Web based application that allows individuals to maintain and manage their health information. In a private secure and confident environment
Total practice management software (TPMS)
Used to generate EMR automating the following medical practice functions.
- registering patients
- scheduling appt
- generating insurance claims and patient statements
- processing payments from patient to third party payers
- producing administrative and clinical reports
Electronic clinical quality measures (eCQMs)
Use data from electronic health record (EHR) and health Information technology systems to measure health care quality.
Promoting Interoperability (PI) programs
Previously called EHR incentive programs. Focus on improving patient access to Health Info. And reducing time and cost required of providers to comply with the programs requirements
Quality payment program (QPP)
Hemos providers focus on quality patient care and making patients healthier that includes advanced alternative payment models (advanced APMs) and a merit based incentive payment system (MIPS)
Alternative payment model (APM)
Payment approach that gives added incentive payments to provide high quality and cost efficient care
Advanced alternative payment models (advanced APMs)
A subset of APMs and include new ways for CMS to reimburse health care providers for care provided to Medicare beneficiaries
Merit based incentive payment system (MIPS)
Combines parts of the physician quality reporting system (PQRS), the value modified , and the Medicare electronic health record incentive program into one single program that allows providers to earn a performance based payment adjustment.
Self Pay patients
Not insured and covered by health insurance
Policy holder
A person in who’s name the insurance policy is issued to.
Dependents
Family members of the policy holder who are covered under the policy.
Legal spouse and dependent children.
Benefits
Amounts paid by the insurance company for covered health care items and services
Exclusions
Describe anything the insurance company will not cover. Varies from plan to plan. Ex. Pre existing medical conditions
Medical underwriting
Means that the Insurance company screens the applicants to find out about their health status and risk factors.
Guaranteed issue
Is a policy that is issued to an I dividí al regardless of age, pre existing conditions , or other factors that might predict the use of health services.
Deductible
The amount of money that the patient must pay for covered medical expenses before the insurance reimbursement begin. Deductibles are usually an annual amount.
Coinsurance
Is the percentage of costs a patient shares with their health insurance. Ex. 80/20 coverage where insurance pays 80% and patient pays 20%
Copayment or copay
A specified dollar amount that the patient must pay to a healthcare provider for each visit or medical service provided.
Health insurance marketplace
Individuals who don’t have health insurance through their work are eligible to use the marketplace to compare plans and purchase coverage
Medicare part A
Reimbursed facilities for inpatient care, skilled nursing care, hospice care and home healthcare
Medicare part b
Reimburses physicians for inpatient and out patient services
Medicare
Is a federal health insurance programs for people aged 65 and older. People under age 65 with certain disabilities and people of all ages wihh end stage renal disease.
Childrens health insurance program (CHIP)
Gives health Insurance and preventative care to 1 in 7 uninsured American children.
Worker compensation
A plan that is mandated by state governments requiring employers to cover employees who get sick or injured on the job.
TRICARE
A healthcare program for active duty and retired uninformed services members and their families
CHAMPVA
Healthcare coverage for souses, widows, and children of veterans with disabilities that are entirely service related
Indian Health Service (IHS)
An agency within the U.S. department of health and human services. Responsible for providing a comprehensive health service delivery system to native (north) American individuals and First Nations peopke who live in Alaska.
Cost control
Medical record control the cost of healthcare by eliminating unnecessary or redundant services
Legal document
Medical records help healthcare providers defend against malpractice or other inquiries concerning patient care
Financial document
Medical record provide documentation that a doctor saw a patient or performed a service and that ensures payment by third party payers
SOAP notes
- Subjective: reason patient is in office
- objective: vital signs, findings and results
- Assessment: diagnoses of condition
- Plan: what doctor will do to treat
Practice management software
Cloud based software that is designed to support many of the administrative and financial functions of a medical practice.
Automate a variety of office tasks such as
-scabbing of insurance cards
-verifying insurance eligibility
-processing Insurance claims
-scheduling appt
Etc
Payer mix
Different types of Health insurance payments that are part of the providers payer mix
Patient record or medical record
Documents Health care provided to a patient
