Chapter 7 - Ethical Issues In Health Information Management

Question 1

Acute-care prospective payment system

Answer 1

The Medicare reimbursement methodology system referred to as the inpatient prospective payment system (IPPS). Hospital providers subject to the IPPS utilize the Medicare severity diagnosis-related groups (MSDRGs) classification system, which determines payment rates.

Question 2

Administrative service only (ASO) contract

Answer 2

An agreement between an employer and an insurance organization to administer the employer’s self-insured health plan.

Question 3

Ambulatory surgery center (ASC)

Answer 3

Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation

Question 4

Balanced Budget Refinement Act (BBRA) of 1999

Answer 4

Mandated the establishment of a per-discharge; DRG-based PPS for longer-term care hospitals beginning October 1, 2002

Question 5

Capitation

Answer 5

A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member’s healthcare services for a certain length of time

Question 6

Case-mix groups (CMGs)

Answer 6

The 97 function-related groups into which inpatient rehabilitation facility discharges are classified on the basis of the patient’s level of impairment, age, comorbidities, functional ability, and other factors

Question 7

Case-mix group (CMG) relative weight

Answer 7

Factors that account for the variance in cost per discharge and resource utilization among case-mix groups

Question 8

Case-mix index

Answer 8

The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system; calculated by dividing the sum of the weights of diagnosisrelated groups for patients discharged during a given period by the total number of patients discharged

Question 9

Categorically needy eligibility group

Answer 9

Categories of individuals to whom states must provide coverage under the federal Medicaid program

Question 10

Children’s Health Insurance Program (CHIP)

Answer 10

Title XXI of the Social Security Act) A program initiated by the BBA that allows states to expand existing insurance programs to cover children up to age 19; it provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children

Question 11

Civilian Health and Medical Program- Uniformed Services (CHAMPUS)

Answer 11

Run by the Department of Defense, provided medical care to active duty members of the military, military retirees, and their eligible dependents. This program is now called TRICARE

Question 12

Civilian Health and Medical Program- Veterans Administration (CHAMPVA)

Answer 12

The federal healthcare benefits program for dependents (spouse or widow[er] and children) of veterans rated by the Veterans Administration (VA) as having a total and permanent disability, for survivors of veterans who died from VA-related service-connected conditions or who were rated permanently and totally disabled at the t ime of death from a VA-related service-connected condition, and for survivors of persons who died in the line of duty

Question 13

Claim

Answer 13

A request for payment for services, benefits, or costs by a hospital, physician or other provider that is submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider

Question 14

Comorbidity

Answer 14

A medical condition that coexists with the primary cause for hospitalization and affects the patient’s treatment and length of stay 2. Pre-existing condition that, because of its presence with a specific diagnosis, causes an increase in length of stay by at least one day in approximately 75 percent of the cases

Question 15

Complication

Answer 15

A medical condition that arises during an inpatient hospitalization (for example, a postoperative wound infection) 2. Condition that arises during the hospital stay that prolongs the length of stay at least one day in approximately 75 percent of the cases

Question 16

Coordination of benefits (COB) transaction

Answer 16

Process for determining the respective responsibilities of two or more health plan that have some financial responsibility for a medical claim

Question 17

Cost outlier

Answer 17

Exceptionally high costs associated with inpatient care when compared with other cases in the same diagnosis-related group

Question 18

Cost outlier adjustment

Answer 18

Additional reimbursement for certain high-cost home care cases based on the loss-sharing ratio of costs in excess of a threshold amount for each home health resource group

Question 19

Diagnosis-related group (DRG)

Answer 19

A unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of costs; in the Medicare and Medicaid programs, one of more than 500 diagnostic classifications in which cases demonstrate similar resource consumption and length-of-stay patterns. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. 2. A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual

Question 20

Discounting

Answer 20

A reduction from the full rate of payment. This can be the result of a fee for service contract, multiple procedures, or due to third party payer guidelines

Question 21

Employer-based self-insurance

Answer 21

An umbrella term used to describe health plans that are funded directly by the employers to provide coverage for their employees exclusively in which employers establish accounts to cover their employees’ medical expenses and retain control over the funds but bear the risk of paying claims greater than their estimates

Question 22

Episode-of-care (EOC) reimbursement

Answer 22

Method that issues lump-sum payments to providers to compensate them for all the healthcare services delivered to a patient for a specific illness or over a specific period of time

Question 23

Exclusive provider organization (EPO)

Answer 23

Hybrid managed care organization that provides benefits to subscribers only when healthcare services are performed by network providers; sponsored by self-insured (self-funded) employers or associations and exhibits characteristics of both health maintenance organizations and preferred provider organizations

Question 24

Explanation of Benefits (EOB)

Answer 24

A statement issued to the insured and the healthcare provider by an insurer to explain the services provided, amounts billed, and payments made by the health plan

Question 25

Fee-for-service reimbursement

Answer 25

A method of reimbursement through which providers retrospectively receive payment based on either billed charges for services provided or on annually updated fee schedules

Question 26

Geographic practice cost index (GPCI)

Answer 26

An index developed by the Centers for Medicare and Medicaid Services to measure the differences in resource costs among fee schedule areas compared to the national average in the three components of the relative value unit (RVU): physician work, practice expenses, and malpractice coverage; separate GPCIs exist for each element of the RVU and are used to adjust the RVUs, which are national averages, to reflect local costs

Question 27

Global payment

Answer 27

A form of reimbursement used for radiological and other procedures that combines the professional and technical components of the procedures and disperse payments as lump sums to be distributed between the physician and the healthcare facility

Question 28

Global surgery payment

Answer 28

Covers all the healthcare services entailed in planning and completing a specific surgical procedure; every element of the procedure from the treatment decision through normal postoperative patient care is covered by a single bundle payment

Question 29

Group model HMO

Answer 29

A type of health plan in which an HMO contracts with an independent multispecialty physician group to provide medical services to members of the plan

Question 30

Group practice without walls (GPWW)

Answer 30

A type of managed care contract that allows physicians to maintain their own offices and share administrative services

Question 31

Health maintenance organization (HMO)

Answer 31

Entity that combines the provision of healthcare insurance and the delivery of healthcare services, characterized by: 1. An organized healthcare delivery system to a geographic area, 2. A set of basic and supplemental health maintenance and treatment services, 3. Voluntarily enrolled members, and 4. Predetermined fixed, periodic prepayments for members’ coverage

Question 32

Home Assessment Validation and Entry (HAVEN)

Answer 32

A type of data-entry software used to collect Outcome and Assessment Information Set (OASIS) data and then transmit them to state databases; imports and exports data in standard OASIS record format, maintains agency/patient/employee information, enforces data integrity through rigorous edit checks, and provides comprehensive online help. HAVEN is used in the home health prospective payment system (HHPPS)

Question 33

Home health agency (HHA)

Answer 33

A program or organization that provides a blend of home-based medical and social services to homebound patients and their families for the purpose of promoting, maintaining, or restoring health or of minimizing the effects of illness, injury, or disability; these services include skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides

Question 34

Home health resource group (HHRG)

Answer 34

A classification system for the home health prospective payment system (HHPPS) derived from the data elements in the Outcome and Assessment Information Set (OASIS) with 80 home health episode rates established to support the prospective reimbursement of covered home care and rehabilitation services provided to Medicare beneficiaries during 60-day episodes of care; a six-character alphanumeric code is used to represent a severity level in three domains

Question 35

Hospice

Answer 35

An interdisciplinary program of palliative care and supportive services that addresses the physical, spiritual, and economic needs of terminally ill patients and their families

Question 36

Hospital-acquired conditions (HAC)

Answer 36

CMS identified eight hospital-acquired conditions (not present on admission) as “responsibly presentable,” and hospitals will not receive additional payment for cases in which one of the eight selected conditions was not present on admission; the eight originally selected conditions include: foreign object retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, catheter-associated urinary tract infection, vascular catheter-associated infection, and surgical site infection- mediastinitis artery bypass graft; additional conditions were added in 2010 and remain in effect: surgical site infections following certain orthopedic procedures and bariatric surgery, manifestations of poor glycemic control, and deep vein thrombosis (DVT)/ pulmonary embolism (PE) following certain orthopedic procedures

Question 37

Independent practice association (IPA)

Answer 37

An open-panel health maintenance organization that provides contract healthcare services to subscribers through independent physicians who treat patients in their own offices; the HMO reimburses the IPA on a capitated basis; the IPA may reimburse the physicians on a fee-forservice or a capitated basis

Question 38

Indian Health Service (IHS)

Answer 38

The federal agency within the Department of Health and Human Services that is responsible for providing federal healthcare services to American Indians and Alaska natives

Question 39

Inpatient Rehabilitation Validation and Entry (IRVEN) system

Answer 39

A computerized data-entry system used by inpatient rehabilitation facilities (IRFs). Captures data for the IRF Patient Assessment Instrument (IRF PAI) and supports electronic submission of the IRF PAI. Also allows data import and export in the standard record format of the Centers for Medicare and Medicaid Services (CMS)

Question 40

Integrated delivery system (IDS)

Answer 40

A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care

Question 41

Integrated provider organization (IPO)

Answer 41

An organization that manages the delivery of healthcare services provided by hospitals, physicians (employees of the IPO), and other healthcare organizations (for example, nursing facilities)

Question 42

Long-term care hospital (LTCH)

Answer 42

According to the Centers for Medicare and Medicaid Services (CMS), a hospital with an average length of stay for Medicare patients that is 25 days or longer, or a hospital excluded from the inpatient prospective payment system and that has an average length of stay for all patients that is 20 days or longer

Question 43

Low-utilization payment adjustment (LUPA)

Answer 43

An alternative (reduced) payment made to home health agencies instead of the home health resource group reimbursement rate when a patient receives fewer than four home care visits during a 60-day episode

Question 44

Major diagnostic category (MDC)

Answer 44

Under diagnosis related groups (DRGs), one of 25 categories based on single or multiple organ systems into which all diseases and disorders relating to that system are classified

Question 45

Managed care

Answer 45

Payment method in which the third-party payer has implemented some provisions to control the cost of healthcare while maintaining quality care. 2. Systematic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare

Question 46

Management service organization (MSO)

Answer 46

Under diagnosis-related groups (DRGs), one of 25 categories based on single or multiple organ systems into which all diseases and disorders relating to that system are classified

Question 47

Medicaid

Answer 47

A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most healthcare costs are covered if a patient qualifies for both Medicare and Medicaid

Question 48

Medical foundation

Answer 48

Multipurpose, nonprofit service organization for physicians and other healthcare providers at the local and county level; as managed care organizations, medical foundations have established preferred provider organizations, exclusive provider organizations, and management service organizations, with emphases on freedom of choice and preservation of the physician-patient relationship

Question 49

Medical home

Answer 49

A program to provide comprehensive primary care that partners physicians with the patient and their family to allow better access to healthcare and improved outcomes

Question 50

Medically needy option

Answer 50

An option in the Medicaid program that allows states to extend eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups but whose income and resources fall above the eligibility level set by their state

Question 51

Medicare

Answer 51

A federally funded health program established in 1965 to assist with the medical care costs of Americans 65 years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities

Question 52

Medicare administrative contractor (MAC)

Answer 52

Required by section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, CMS is completing the process of awarding Medicare claims processing contracts through competitive procedures resulting in replacing its current claims payments contractors, fiscal intermediaries and carriers, with new contract entities called MACs. Initially 19 MACS were expected through three procurement cycles. Currently there are 15 A/B MAC jurisdictions that have served as the foundation for CMS’s initial series of A/B MAC procurements. CMS will continue to consolidate to 10 A/B MAC jurisdictions

Question 53

Medicare Advantage plan

Answer 53

A type of Medicare health plan offered by a private company that contracts with Medicare to provide the beneficiary with all Part A and Part B benefits. These plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. Enrollees in Medicare Advantage Plans have their services are covered through the plan are not paid for under original Medicare

Question 54

Medicare fee schedule (MFS)

Answer 54

A feature of the resource-based relative value system that includes a complete list of the payments Medicare makes to physicians and other providers

Question 55

Medicare severity diagnosis-related groups (MS-DRGs)

Answer 55

The US government’s 2007 revision of the DRG system, the MS-DRG system better accounts for severity of illness and resource consumption

Question 56

Medicare summary notice (MSN)

Answer 56

A summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided

Question 57

Medigap

Answer 57

Private, supplemental health insurance that pays, within limits, most of the healthcare service charges not covered by Medicare Parts A or B

Question 58

Minimum Data Set 3.0 (MDS)

Answer 58

Document created when OBRA required CMS to develop an assessment instrument to standardize the collection of SNF patient data; the MDS is the minimum core of defined and categorized patient assessment data that serves as the basis for documentation and reimbursement in an SNF

Question 59

National conversion factor (CF)

Answer 59

A mathematical factor used to convert relative value units into monetary payments for services provided to Medicare beneficiaries

Question 60

Network model HMO

Answer 60

Program in which participating HMOs contract for services with one or more multispecialty group practices

Question 61

Network provider

Answer 61

A physician or another healthcare professional who is a member of a managed care network

Question 62

Omnibus Budget Reconciliation Act (OBRA)

Answer 62

Federal legislation passed in 1987 that required the Health Care Financing Administration (renamed the Centers for Medicare and Medicaid Services) to develop an assessment instrument (resident assessment instrument) to standardize the collection of patient data from skilled nursing facilities

Question 63

Outcome and Assessment Information Set (OASIS)

Answer 63

A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs

Question 64

Outpatient code editor (OCE)

Answer 64

A software program linked to the Correct Coding Initiative that applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent the services provided

Question 65

Outpatient prospective payment system (OPPS)

Answer 65

The Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications

Question 66

Packaging

Answer 66

A payment under the Medicare outpatient prospective payment system that includes items such as anesthesia, supplies, certain drugs, and the use of recovery and observation rooms

Question 67

Partial hospitalization

Answer 67

An alphabetic code assigned to CPT/HCPCS codes to indicate whether a service or procedure is to be reimbursed under the Medicare outpatient prospective payment system

Question 68

Physician-hospital organization (PHO)

Answer 68

An integrated delivery system formed by hospitals and physicians (usually through managed care contracts) that allows for cooperative activity but permits participants to retain some level of independence

Question 69

Point-of-service (POS) plan

Answer 69

A type of managed care plan in which enrollees are encouraged to select healthcare providers from a network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the cost

Question 70

Preferred provider organization (PPO)

Answer 70

A managed care contract coordinated care plan that: (a) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (b) provides for reimbursement for all covered benefits regardless of whether the benefits are provided with the network of providers; and (c) is offered by an organization that is not licenses or organized under state law as an HMO

Question 71

Premium

Answer 71

Amount of money that a policyholder or certificate holder must periodically pay an insurer in return for healthcare coverage

Question 72

Present on admission (POA)

Answer 72

A condition present at the time of inpatient admission

Question 73

Primary care physician (PCP)

Answer 73

Physician who provides, supervises, and coordinates the healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a managed care plan. Family and general practitioners, internists, pediatricians, and obstetricians and gynecologists are primary care physicians 2. The physician who makes the initial diagnosis of a patient’s medical condition

Question 74

Principal diagnosis

Answer 74

Disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit or the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

Question 75

Programs of AllInclusive Care for the Elderly (PACE)

Answer 75

Provides an alternative to institutional care for individuals 55 years old or older who require a level of care usually provided at nursing facilities; it offers and manages all of the health, medical, and social services needed by a beneficiary and mobilizes other services, as needed, to provide preventive, rehabilitative, curative, and supportive care

Question 76

Prospective payment system (PPS)

Answer 76

A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the services has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and linked to the anticipated intensity of services delivered as well as the beneficiary’s condition

Question 77

Relative value unit (RVU)

Answer 77

A number assigned to a procedure that describes its difficulty and expense in relationship to other procedures by assigning weights to such factors as personnel, time, and level of skill

Question 78

Remittance advice (RA)

Answer 78

An explanation of payments (for example, claim denials) made by thirdparty payers

Question 79

Resident Assessment Validation and Entry (RAVEN)

Answer 79

Data-entry software that imports and exports data in standard MDS record format; maintains facility, resident, and employee information; enforces data integrity via rigorous edit checks; and provides comprehensive online help

Question 80

Resource-based relative value scale (RBRVS)

Answer 80

A scale of national uniform relative values for all physicians’ services. The relative value of each service must be the sum of relative value units representing the physicians’ work, practice expenses net of malpractice insurance expenses, and the cost of professional liability insurance

Question 81

Resource Utilization Groups, Version IV (RUG-IV)

Answer 81

A case mix-adjusted resident classification system based on the MDS used in skilled nursing facilities for resident assessments; the RGU-IV classification system uses resident assessment data from the MDS collected by SNFs to assign resident to one of 66 groups

Question 82

Respite care

Answer 82

Temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program so that the usual caregiver can rest or take some time of

Question 83

Retrospective payment system

Answer 83

Type of fee-for-service reimbursement in which providers receive recompense after health services have been rendered

Question 84

Skilled nursing facility prospective payment system (SNF PPS)

Answer 84

A per-diem reimbursement system implemented in July 1998 for costs (routine, ancillary, and capital) associated with covered skilled nursing facility services furnished to Medicare Part A beneficiaries

Question 85

Staff model HMO

Answer 85

A type of health maintenance that employs physicians to provide healthcare services to subscriber

Question 86

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

Answer 86

The federal legislation that modified Medicare’s retrospective reimbursement system for inpatient hospital stays by requiring implementation of diagnosis-related groups and the acute care prospective payment system

Question 87

TRICARE

Answer 87

The federal healthcare program that provides coverage for the dependents of armed forces personnel and for the retirees receiving care outside military treatment facilities in which the federal government pays a percentage of the cost; formerly known as Civilian Health and Medical Program of the Uniformed Services

Question 88

Worker’s compensation

Answer 88

Insurance that employers are required to have to cover employees who get sick or injured on the job