Chapter 2 Flashcards
Accountable Care Organization (ACO)
groups of physicians, hospitals, and other health care providers, all of whom come together voluntarily to provide coordinated high quality care to Medicare patients
advanced alternative payment models (advanced APMs)
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.
alternative payment models (APMs)
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.
ambulatory payment classifications (APCs)
prospective payment system used to calculate reimbursement for outpatient care according to similar clinical characteristics and in terms of resources required.
American Recovery and Reinvestment Act of 2009 (ARRA)
authorized an expenditure of $1.5 billion for grants for construction, renovation, and equipment, and for the acquisition of health information technology systems.
Balanced Budget Act of 1997 (BBA)
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.
benchmarking
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).
CHAMPUS Reform Initiative (CRI)
conducted in 1988; resulted in a new health program called TRICARE, which includes two options: TRICARE Prime and TRICARE Select (formerly called TRICARE Standard).
Children’s Health Insurance Program (CHIP)
provides health insurance coverage to uninsured children whose family income is up to 200 percent of the federal poverty level (monthly income limits for a family of four also apply).
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
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.
Civilian Health and Medical Program—Uniformed Services (CHAMPUS)
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.
Clinical Laboratory Improvement Act (CLIA)
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.
CMS-1500 claim
claim submitted for reimbursement of physician office procedures and services; electronic version is called ANSI ASC X12N 837P.
coinsurance
also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
allows employees to continue health care coverage beyond the benefit termination date.
consumer-driven health plans (CDHPs)
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.
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.
copayment (copay)
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.
deductible
amount for which the patient is financially responsible before an insurance policy provides coverage.
diagnosis-related groups (DRGs)
prospective payment system that reimburses hospitals for inpatient stays.
eHealth exchange
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.
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 delivered safely, effectively, equitably, and timely.
electronic health record (EHR)
global concept that includes the collection of patient information documented by a number of providers at different facilities regarding one patient.
electronic medical record (EMR)
considered part of the electronic health record (EHR), the EMR is created using vendor software, which assists in provider decision making.
electronic submission of medical documentation system (esMD)
implemented to (1) reduce provider and reviewer costs and cycle time by minimizing and eventually eliminating paper processing and mailing of medical documentation.
Employee Retirement Income Security Act of 1974 (ERISA)
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.
Evaluation and Management (E/M)
services that describe patient encounters with providers for evaluation and management of general health status.
Federal Employees’ Compensation Act (FECA)
provides civilian employees of the federal government with medical care, survivors’ benefits, and compensation for lost wages.
Federal Employers’ Liability Act (FELA)
legislation passed in 1908 by President Theodore Roosevelt that protects and compensates railroad workers who are injured on the job.
fee schedule
list of predetermined payments for health care services provided to patients (e.g., a fee is assigned to each CPT code).
Financial Services Modernization Act (FSMA)
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.
Gramm-Leach-Bliley Act
see Financial Services Modernization Act.
group health insurance
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.
health care
expands the definition of medical care to include preventive services.
Health Information Technology for Economic and Clinical Health Act (HITECH Act)
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.
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.
