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AHS 330 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

FD&C

A

Federal Food, Drug, and Cosmetic Act

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2
Q

FDA

A

Food and Drug Administration

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3
Q

FTE

A

full-time equivalent

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4
Q

FY

A

fiscal year

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5
Q

GAO

A

General Accounting Office

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6
Q

GDP

A

gross domestic product

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7
Q

GP’s

A

general practitioners

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8
Q

HCFA

A

Health Care Financing Administration

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9
Q

HDHP

A

high-deductible health plan

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10
Q

HEDIS

A

Health Plan Employer Data and Information Set

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11
Q

HI

A

hospital insurance

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12
Q

HIPAA

A

Health Insurance Portability and Accountability Act

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13
Q

HIV

A

human immunodeficiency virus

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14
Q

HMO

A

Health maintenance organization

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15
Q

HPSAs

A

Health Professional Shortage Areas

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16
Q

HRSA

A

Health Resources and Services Administration

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17
Q

HSAs

A

Health savings accounts

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18
Q

IADL

A

instrumental activities of daily living

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19
Q

ICD-9

A

International Classification of Diseases, Version 9

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20
Q

ICF/MR

A

Immediate care facilities for the mentally retarded

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21
Q

IDS

A

integrated delivery systems

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22
Q

IDU

A

Injection use drug

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23
Q

IMGs

A

International medical graduates

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24
Q

IOM

A

Institute of Medicine

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25
Q

IPAD

A

independent practice association

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26
Q

IRB

A

Institutional Review Board

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27
Q

IT

A

Information technology

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28
Q

IUDs

A

Interuterine devices

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29
Q

IV

A

Intravenous

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30
Q

JCAHO

A

Joint Commission on Accreditation of Healthcare Organizations

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31
Q

LPN

A

Licensed practical nurse

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32
Q

LTC

A

long-term care

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33
Q

LTCH

A

long-term care hospital

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34
Q

LVN

A

Licensed vocational nurse

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35
Q

MBA

A

Master of business administration

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36
Q

MCO’s

A

Managed care organizations

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37
Q

MDs

A

doctor of medicine

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38
Q

MDS

A

minimum data set

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39
Q

MHSA

A

master of health service administration

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40
Q

MLR

A

medical loss ratio

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41
Q

MMR

A

Measles-mumps-rubella vaccine

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42
Q

MPA

A

Master of public administration/affairs

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43
Q

MRI

A

Magnetic resonance imaging

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44
Q

MSA

A

Medical savings account or metropolitan statistical area

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45
Q

MSO

A

Management services organization.

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46
Q

MUAs

A

Medically underserved areas

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47
Q

NCQA

A

National Committee for Quality Assurance

48
Q

NF

A

Nursing facility

49
Q

NHE

A

National health expenditures

50
Q

NHI

A

National health insurance

51
Q

NP

A

Nurse practitioner

52
Q

NNP

A

nonphysician practitioner

53
Q

Person professionally trained in the technical aspects of insurance And related fields. Math of insurance, calculation of premiums, reserves, and other values.

A

ACTUARY

54
Q

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.

A

ADVERSE SELECTION

55
Q

Federal and state laws that make certain anticompetitive practices illegal. Price fixing, discrimination, exclusive contract arrangements, and mergers.

A

ANTITRUST

56
Q

Billing of leftover sum by the provider to the patient after insurance has only partially paid the charge initially billed.

A

BALANCED BILL

57
Q

Anyone covered under a particular health insurance plan

A

BENEFICIARY

58
Q

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.

A

Benefit period

59
Q

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.

A

Capitation

60
Q

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.

A

Carve out

61
Q

Public health programs designed to benefit only a certain category of people.

A

Categorical programs

62
Q

Control exercised by a government planning agency over expansion of medical facilities

A

Certificated of need (CON)

63
Q

Phenomenon in which people gain and lose health insurance coverage multiple times.

A

Churning

64
Q

Demand for payment of covered medical expenses sent to an insurance company.

A

Claim

65
Q

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.

A

Closed panel

66
Q

Same insurance rate for everyone, as opposed to experience rating.

A

Community rating

67
Q

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.

A

Concurrent utilization review

68
Q

A range or spectrum of health care services from basic to complex.

A

Continuum

69
Q

Health care charges that the insured has to pay under the terms of their insurance policy.

A

Copayment (coinsurance)(deductible)

70
Q

Sharing in the cost of health insurance premiums by those enrolled and/or payment of certain medical costs out of pocket

A

Cost sharing

71
Q

Shifting of costs from one entity to another as a way of making p losses in one area by charging more in other areas.

A

Cost shifting

72
Q

Reimbursement to a provider based on cost plus a factor to cover the value of capital.

A

Cost-plus

73
Q

People enrolled in a managed care plan

A

Covered lives (enrollees)

74
Q

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.

A

Deductible

75
Q

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.

A

Deemed status

76
Q

Diagnostic category associated with a fixed payment to an acute care hospital under the prospective payment system

A

Diagnosis-related group (DRG)

77
Q

Deployment of healthcare resources in a situation will become less effective in achieving desired outcome

A

Diminishing marginal returns

78
Q

Process of determining whether a patient qualifies for benefits, based on such factors as age, income, and veteran status.

A

Eligibility

79
Q

Legal requirement for employers to help pay for their employees health insurance

A

Employer mandate

80
Q

Health care program to which certain people are entitled. Ex: Medicare

A

Entitlement

81
Q

Health plan that is similar to those offered by preferred provider organizations, except that use is restricted to in-network providers

A

Exclusive provider plan

82
Q

Setting of insurance rates based on a group’s actual health care expenses in a prior period. Allows healthier groups to pay less.

A

Experience rating

83
Q

Phenomenon in which healthy people are disproportionately enrolled into a health plan.

A

Favorable risk selection

84
Q

Payment of separate fees to physicians for each service performed. The physician sets the fees.

A

Fee for service

85
Q

Term loosely denoting benefits provided by employer to employees.

A

Fringe benefits

86
Q

Plan of total expenditures Ina health care system established in advance.

A

Global budget

87
Q

Measure of all goods and services produced by a nation in a given year.

A

Gross domestic product (GDP)

88
Q

Insurance plan that provides reimbursement to the insured regardless of the expenses actually incurred. The insured is responsible for paying the provider

A

Indemnity plan

89
Q

System that integrates the functions of financing, insurance, delivery, and payment and uses mechanisms to control costs and utilization of services

A

Managed care

90
Q

(Total revenues less Total costs) / Total revenue

Expressed as percentage

A

Margin

91
Q

A program in which eligibility depends on income.

A

Means-tested ratio

92
Q

Joint federal and state program of health insurance for the poor

A

Medicaid

93
Q

The percentage of premium revenue spent on medical expenses.

A

Medical loss ratio

94
Q

Federal program that provides health insurance for the elderly, certain disabled and people with ESRD.

A

Medicare

95
Q

Commercial health insurance policies purchased by individuals to cover expenses not covered by Medicare.

A

Medigap

96
Q

An assessment instrument used for determining the case mix for a skilled nursing facility.

A

Minimum data set(MDS)

97
Q

Consumer behavior that leads to a higher utilization of health care services because people are covered by insurance.

A

Moral hazard

98
Q

Costs of health care paid by the recipient of care.

A

Out-of-pocket-cost

99
Q

Providers selected to render services to the members of a managed care plan constitutes its panel. Generally refers to preferred providers.

A

Panel

100
Q

Reimbursement plan that links payment to quality and efficiency as an incentive to improve the quality of health care to reduce costs.

A

Pay for performance

101
Q

Type of reimbursement mechanism for inpatient care in a health care institution. Flat rate for each day of inpatient stay.

A

Per diem

102
Q

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.

A

Play or pay

103
Q

The insurer’s charge for insurance coverage; the price for an insurance plan

A

Premium

104
Q

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

A

Prospective payment system(PPS)

105
Q

Acceptance by an insurer, of all or part of the risk underwritten by another company

A

Reinsurance

106
Q

A system instituted by Medicare for determining fees. Based on time,skill, training required to treat the condition

A

Resource-based relative value scale (RBRVS)

107
Q

Setting reimbursement rates based on costs actually incurred

A

Retrospective reimbursement

108
Q

Any adjustment made for people who are likely high users of health care services

A

Risk adjustment

109
Q

Pool of high risk individuals offered health insurance in some states at a subsidized premium

A

Risk pool

110
Q

Requirement that individuals speed their assets down to predetermined level to be eligible for benefits

A

Spend-down

111
Q

Planned rationing that is generally carried out by a government to limit the availability of health care services, particularly expensive technology

A

Supply-side rationing

112
Q

Administrative organization, other than the employee benefit plan or health care program, that collects premiums, pays claims, and or provide administrative services

A

Third-party administrator (TPA)

113
Q

The payers for covered services, they are neither the providers nor the recipients of medical services

A

Third-party payers

114
Q

Systematic technique used by insurer for evaluating, selecting or rejecting, classifying, and rating risks.

A

Underwriting

115
Q

Upcoding

A

A fraudulent practice in which a higher-priced service is billed when a lower-priced service is actually delivered

116
Q

A process by which an insurer reviews decisions by physicians and other providers on how much care to provide

A

Utilization review (UR)

117
Q

Employer-paid benefit that compensates workers for medical expenses and wages lost due to work-related injuries or illness

A

Worker’s compensation

AHS 330 (9 decks)

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