Exam 2 Flashcards
FD&C
Federal Food, Drug, and Cosmetic Act
FDA
Food and Drug Administration
FTE
full-time equivalent
FY
fiscal year
GAO
General Accounting Office
GDP
gross domestic product
GP’s
general practitioners
HCFA
Health Care Financing Administration
HDHP
high-deductible health plan
HEDIS
Health Plan Employer Data and Information Set
HI
hospital insurance
HIPAA
Health Insurance Portability and Accountability Act
HIV
human immunodeficiency virus
HMO
Health maintenance organization
HPSAs
Health Professional Shortage Areas
HRSA
Health Resources and Services Administration
HSAs
Health savings accounts
IADL
instrumental activities of daily living
ICD-9
International Classification of Diseases, Version 9
ICF/MR
Immediate care facilities for the mentally retarded
IDS
integrated delivery systems
IDU
Injection use drug
IMGs
International medical graduates
IOM
Institute of Medicine
IPAD
independent practice association
IRB
Institutional Review Board
IT
Information technology
IUDs
Interuterine devices
IV
Intravenous
JCAHO
Joint Commission on Accreditation of Healthcare Organizations
LPN
Licensed practical nurse
LTC
long-term care
LTCH
long-term care hospital
LVN
Licensed vocational nurse
MBA
Master of business administration
MCO’s
Managed care organizations
MDs
doctor of medicine
MDS
minimum data set
MHSA
master of health service administration
MLR
medical loss ratio
MMR
Measles-mumps-rubella vaccine
MPA
Master of public administration/affairs
MRI
Magnetic resonance imaging
MSA
Medical savings account or metropolitan statistical area
MSO
Management services organization.
MUAs
Medically underserved areas
NCQA
National Committee for Quality Assurance
NF
Nursing facility
NHE
National health expenditures
NHI
National health insurance
NP
Nurse practitioner
NNP
nonphysician practitioner
Person professionally trained in the technical aspects of insurance And related fields. Math of insurance, calculation of premiums, reserves, and other values.
ACTUARY
Individuals who likely to use more health care services than others due to poor health enroll in health insurance plans in greater numbers, compared to people who are healthy.
ADVERSE SELECTION
Federal and state laws that make certain anticompetitive practices illegal. Price fixing, discrimination, exclusive contract arrangements, and mergers.
ANTITRUST
Billing of leftover sum by the provider to the patient after insurance has only partially paid the charge initially billed.
BALANCED BILL
Anyone covered under a particular health insurance plan
BENEFICIARY
Under Medicare rules, inpatient stay as based on benefit periods. Determined by a spell of illness beginning with hospitalization and ending when the beneficiary has not been an inpatient in a hospital or skilled nursing facility for 60 consecutive days.
Benefit period
Reimbursement mechanism under which the provider is paid a set monthly fee per enrollee (PMPM rate) regardless of whether or not an enrollee sees the provider and regardless of how often an enrollee sees the provider.
Capitation
Assignment through contractual arrangements of specialized services to an outside organization because these services are not included in the contracts MCO’S have with their providers or the MCO does not provide the services.
Carve out
Public health programs designed to benefit only a certain category of people.
Categorical programs
Control exercised by a government planning agency over expansion of medical facilities
Certificated of need (CON)
Phenomenon in which people gain and lose health insurance coverage multiple times.
Churning
Demand for payment of covered medical expenses sent to an insurance company.
Claim
Also called, closed network, in network, or closed access. Plan that pays for services only when provided by physicians and hospitals on the plan’s panel.
Closed panel
Same insurance rate for everyone, as opposed to experience rating.
Community rating
Process that determine, on a daily basis, the length of stay necessary in a hospital. Also monitors use of ancillary services to ensure proper use.
Concurrent utilization review
A range or spectrum of health care services from basic to complex.
Continuum
Health care charges that the insured has to pay under the terms of their insurance policy.
Copayment (coinsurance)(deductible)
Sharing in the cost of health insurance premiums by those enrolled and/or payment of certain medical costs out of pocket
Cost sharing
Shifting of costs from one entity to another as a way of making p losses in one area by charging more in other areas.
Cost shifting
Reimbursement to a provider based on cost plus a factor to cover the value of capital.
Cost-plus
People enrolled in a managed care plan
Covered lives (enrollees)
The portion of health care costs that the insured must first pay before insurance payments kick in. Insurance payments may be further subject to copayment.
Deductible
Designation used when a hospital, by virtue of its accreditation by Joint Commission or the American Osteopathic Association, does not require separate certification from DHHS to participate in Medicare and Medicaid programs.
Deemed status
Diagnostic category associated with a fixed payment to an acute care hospital under the prospective payment system
Diagnosis-related group (DRG)
Deployment of healthcare resources in a situation will become less effective in achieving desired outcome
Diminishing marginal returns
Process of determining whether a patient qualifies for benefits, based on such factors as age, income, and veteran status.
Eligibility
Legal requirement for employers to help pay for their employees health insurance
Employer mandate
Health care program to which certain people are entitled. Ex: Medicare
Entitlement
Health plan that is similar to those offered by preferred provider organizations, except that use is restricted to in-network providers
Exclusive provider plan
Setting of insurance rates based on a group’s actual health care expenses in a prior period. Allows healthier groups to pay less.
Experience rating
Phenomenon in which healthy people are disproportionately enrolled into a health plan.
Favorable risk selection
Payment of separate fees to physicians for each service performed. The physician sets the fees.
Fee for service
Term loosely denoting benefits provided by employer to employees.
Fringe benefits
Plan of total expenditures Ina health care system established in advance.
Global budget
Measure of all goods and services produced by a nation in a given year.
Gross domestic product (GDP)
Insurance plan that provides reimbursement to the insured regardless of the expenses actually incurred. The insured is responsible for paying the provider
Indemnity plan
System that integrates the functions of financing, insurance, delivery, and payment and uses mechanisms to control costs and utilization of services
Managed care
(Total revenues less Total costs) / Total revenue
Expressed as percentage
Margin
A program in which eligibility depends on income.
Means-tested ratio
Joint federal and state program of health insurance for the poor
Medicaid
The percentage of premium revenue spent on medical expenses.
Medical loss ratio
Federal program that provides health insurance for the elderly, certain disabled and people with ESRD.
Medicare
Commercial health insurance policies purchased by individuals to cover expenses not covered by Medicare.
Medigap
An assessment instrument used for determining the case mix for a skilled nursing facility.
Minimum data set(MDS)
Consumer behavior that leads to a higher utilization of health care services because people are covered by insurance.
Moral hazard
Costs of health care paid by the recipient of care.
Out-of-pocket-cost
Providers selected to render services to the members of a managed care plan constitutes its panel. Generally refers to preferred providers.
Panel
Reimbursement plan that links payment to quality and efficiency as an incentive to improve the quality of health care to reduce costs.
Pay for performance
Type of reimbursement mechanism for inpatient care in a health care institution. Flat rate for each day of inpatient stay.
Per diem
Employer mandate, must provide health insurance to employees or contribute to government-administered fund to provide health insurance for all who are not covered by employers.
Play or pay
The insurer’s charge for insurance coverage; the price for an insurance plan
Premium
Criteria for how much will be paid for a particular service is predetermined, as opposed to retrospective in which the amount of reimbursement is determined on the basis of costs actually incurred
Prospective payment system(PPS)
Acceptance by an insurer, of all or part of the risk underwritten by another company
Reinsurance
A system instituted by Medicare for determining fees. Based on time,skill, training required to treat the condition
Resource-based relative value scale (RBRVS)
Setting reimbursement rates based on costs actually incurred
Retrospective reimbursement
Any adjustment made for people who are likely high users of health care services
Risk adjustment
Pool of high risk individuals offered health insurance in some states at a subsidized premium
Risk pool
Requirement that individuals speed their assets down to predetermined level to be eligible for benefits
Spend-down
Planned rationing that is generally carried out by a government to limit the availability of health care services, particularly expensive technology
Supply-side rationing
Administrative organization, other than the employee benefit plan or health care program, that collects premiums, pays claims, and or provide administrative services
Third-party administrator (TPA)
The payers for covered services, they are neither the providers nor the recipients of medical services
Third-party payers
Systematic technique used by insurer for evaluating, selecting or rejecting, classifying, and rating risks.
Underwriting
Upcoding
A fraudulent practice in which a higher-priced service is billed when a lower-priced service is actually delivered
A process by which an insurer reviews decisions by physicians and other providers on how much care to provide
Utilization review (UR)
Employer-paid benefit that compensates workers for medical expenses and wages lost due to work-related injuries or illness
Worker’s compensation
