Healthcare Structure and Organization Flashcards
Bobby was playing in the backyard and cut his foot on a piece of glass. His mother took him to their primary care physician’s office. The physician sutured the laceration and gave him a tetanus shot and then he was sent home.
Is he an Inpatient or an Outpatient?
Outpatient
Debbie delivered a baby via c-section. There were no complications during the c-section. She and the baby spent 3 days in the hospital and then they were both discharged to home. She was instructed to see her physician in 6 weeks. Is she an Inpatient or Outpatient?
Inpatient
Susan underwent an appendectomy at the same-day surgery unit at the hospital. The surgery went well and she was taken to the recovery room. While she was in the recovery room the nurse checked her temperature and she had a fever of 103 degrees. She was admitted to the hospital to determine the cause of the fever.
Is she an inpatient or outpatient?
Inpatient
Frank was painting his house and fell off the ladder and landed on his arm. He went to the emergency room because he was in extreme pain. The emergency room physician took an x-ray of his arm and determined that he fractured his radius. He was placed in a cast and sent home. Is he an inpatient or outpatient
outpatient
David had tubes placed in both of his ears due to chronic otitis media. Following the surgery he was taken to the recovery room. After a couple of hours in the recovery room he was discharged home. Is he an inpatient or outpatient?
Outpatient
Patients receive care on an inpatient or outpatient basis. This distinction is an important one for coding and billing services. T/F
True
A patient who comes to the hospital for an MRI is always considered an inpatient because Dr. Smith, the hospital radiologist, does the test at the hospital. T/F
False
Inpatients stay overnight and can access departments and services within the facility that are not accessed by ambulatory patients. T/F
True
Many inpatient facilities offer outpatient services. T/F
True
A patient who comes to the emergency room for treatment because of acute exacerbation of asthma who is observed for 12 hours and then discharged is considered an inpatient. T/F
False
Most large industries have trade associations of one kind or another.T/F
True
Trade associations allow individuals and companies to band together to influence regulations and share resources.
T/F
True
Trade associations are only effective when they organize on a national level. T/F
False
Trade associations provide services to their membership such as networking opportunities, professional tools, and trade publications. T/F
true
Healthcare vendors provide the healthcare industry with its tools of the trade. T/F
True
Kathy went shopping at a large discount store and slipped on the wet floor in the produce department, twisting her ankle. She made a report to the store manager. What type of third-party payer would likely cover Kathy’s healthcare expenses related to her ankle injury?_____
Liability Insurance
Kelly started her new job and signed up for healthcare insurance. Since she is the cardholder she will be the _____.
Subscriber
Bill went to an independent insurance agent to purchase health insurance for himself and his family. He was informed that his monthly payment would be $600.00. This monthly payment is known as _____.
Premium
Joe was working in a warehouse when a forklift hit him. He was taken to the local ER for his injuries. What type of third-party coverage is Joe’s employer required to have to cover this type of on-the-job injury?_____
Workers’ Compensation
Mary added her husband and two children onto her health insurance through work. Mary’s husband and two children are considered _____.
dependents
This federal agency is in charge of governing and regulating healthcare in the United States and has several agencies and offices under its umbrella.
DHHS
This law was passed to protect patient confidentiality and privacy.
HIPAA
This agency under DHHS occupies a central role in setting standards and regulations for healthcare documentation, coding classification and medical billing.
CMS
The mission of this office is to protect the integrity of DHHS programs, as well as the health and welfare of the beneficiaries of those programs. To accomplish this they perform audits.
OIG
This office helps protect consumers against discrimination by healthcare providers.
OCR
CHAMPVA
this plan is for non-retired veterans and is managed by the Department of Veterans’ Affairs
TRICARE
this plan is managed by the Department of Defense, is funded by federal tax dollars, and covers active military personnel and their families, as well as retired personnel and their families
Workers’ Compensation
insurance coverage mandated by law for employees wit work-related injuries or illness
Liability
Liability: insurance purchased by an entity or individual to cover costs of individuals injured on their property or using their product or service
Policy
binding contract, which includes the benefits and coverage as issued by an insurance company to an individual or group, that promises to pay for healthcare reasonably required by the policyholder to treat illness or injury
Deductible
he amount of covered expenses that must be paid by the insured/member before benefits become payable by the insurance carrier/plan
Pre-existing Condition
a medical condition that occurred before a program of health benefits went into effect
Premium
he cost of coverage for the insurance policy. This is typically paid on a monthly basis. Employees usually share in the cost of the healthcare insurance premium with their employers
Department of Justice
a branch of government tasked with prosecuting criminals who engage in fraudulent, abusive, discriminating, or other law-breaking activities
Reactive Audit
an inspection or audit carried out in response to a tip, complaint, or concern brought to the attention of the OIG
Proactive Audit
an audit where the OIG is routinely inspecting a healthcare provider to make sure documentation and treatment is appropriate
Centers for Medicare and Medicaid Services (CMS)
an agency of the Department of Health of Human Services that administers the Medicare and Medicaid programs and the State Children’s Health Insurance Program. CMS is the largest third-party payer of health benefits in the United States and occupies a central role in setting standards and regulations for healthcare documentation
Department of Health and Human Services (DHHS)
the federal agency tasked with governing and regulating healthcare in the United States
Medicare Part D
Medicare’s prescription plan. It is a fairly new addition to medicare as it only went into effect in 2006. This prescription drug plan offers insurance on medications. It is an optional plan that can be purchased
Medicare Part C
also known as Medicare Advantage plan. Part C is a plan that overrides plans A, B, and D. it is a more comprehensive program that is offered through many private insurance companies and works like a managed care plan
Medicare Part B
outpatient insurance. It will cover many services provided from physician care, including general exams, laboratory tests, counseling, therapy, and other outpatient care
Medicare Part A
Hospital insurance. It will cover most inpatient care up to 90 days and includes hospital, skill nursing facility, hospice, and espie care
Medicare
the government-sponsored healthcare program for qualified seniors over age 65 and qualified disabled people under the age of 65. It is a federal program administered by the federal government
Medicaid
A joint state and federal healthcare benefit program for qualified individuals administered by each state that individuals who qualify for Medicaid according to state guidelines. It is usually for disabled and low-income individuals who lack resources to private pay or have no access to another third-party payer
Ancillary Healthcare Services
goods and/or services provided to patients by healthcare providers to aid in the diagnosis or treatment of an illness or injury
Short-term Care
medical attention for patients who have diagnoses that healthcare professionals can resolve quickly
Consulting Physician
the physician collaborating and consulting with the attending physician to decide on diagnosis and/or course of treatment
Attending Physician
the physician assuming primary responsibility for the treatment of a patient at any given time
Outpatient
a patient who does not stay overnight in a healthcare facility
Inpatient
A patient who says overnight in a healthcare facility
Admitting Privileges
authorization for a physician to admit patients to an inpatient facility (hospital)
Acute Care
urgent care for patients who require immediate medical attention for recently developed symptoms
The healthcare vendor’s role is to provide healthcare professionals with updated goods and services. T/F
True
Services such as home healthcare, transcription, and coding also have vendors dedicated to providing them with tools of the trade. T/F
True
Healthcare industry tools of the trade include medications, surgical instruments, and durable medical equipment. T/F
True
This major trade association has both for profit and not-for-profit assisted living, nursing facilities as well as subacute care providers.
AHCA
Home healthcare, hospice, medical equipment, suppliers and home care aide organizations belong to this trade association.
NAHC
Members/ Mission:
National Association for Home Care (NAHC)
Members:
Home care agencies, hospices, home care aide organizations, and medical equipment suppliers.
Mission: NAHC’s mission can be summarized in one line: “We are bringing healthcare back home where it belongs.”
Members/ Mission:
American Medical Association (AMA)
Members:
Physicians
Mission: to promote the are and science of medicine and the betterment of public health
members/ Mission:
American Health Data Institute (AHDI)
Members:
Coalitions, Employers, Providers, Administrative Organizations (PPOs, TPAs), and Risk Takers
Mission:
Transform healthcare data into actionable intelligence so employers, coalitions, providers, payers, consumers and others can purchase high quality cost effective healthcare.
Members/ Mission:
American Academy of Professional Coders (AAPC)
Members:
Medical Coders
Mission:
Dedicated to providing the highest standard of professional coding and billing services to employers, clients, and patients.
Members/Mission:
American Health Information Management Association (AHIMA)
Members: Medical Coders
Mission:
To be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source for education, research, and professional credentialing.
Trade associations provide some or all of what types of services to their membership:
~education/educational resources, professional development
~advocacy/professional lobby
~Professional licensure/certification
~Member and industry networking opportunities
~Professional standards development
~Legal services
~Professional tools
~Employment registry
~Trade publications/professional journals
~Public relations/public education
Trade Association:
group of people or organizations that come together because they share a common interest, goal, or purpose
Cindy received a letter from her insurance company stating they had paid $250 on her $500 hospital bill. Because it was the beginning of the calendar year and this was Cindy’s first healthcare visit, the remaining $250 would be Cindy’s responsibility. The provision that patients must pay a certain amount each year before their third-party payer begins paying is a common practice. The portion the patient must pay before third-party payment begins is called the _____.
Deductible
Claudia went to Wal-Mart to do some shopping. While in the parking lot she twisted her ankle stepping in a pothole. She filed a report with the store manager. The manager agreed to pay for any claims related to this injury. What type of insurance will cover this claim? _____.
Liability Insurance
A person who purchases a healthcare policy directly from an insurance provider or agent for themselves and/or their family is buying what type of insurance?
Individual Healthcare Policy
Managed by CMS, it covers people over the age of 65 and some disabled people under 65.
Medicare
Places of business and sometimes homeowners have this type of insurance just in case an individual should fall or have some other type of accidental injury on their property.
Liability Insurance
Covers disabled veterans and/or families of deceased military.
CHAMPVA
Managed by CMS and each state, coverage is for low income families who meet state guidelines
Medicaid
This out-of-pocket expense must be met every calendar year before benefits are paid by the insurance carrier.
Deductible
Managed by DHHS, funded by federal income tax and federal grants. A group of individuals covered under this plan are Alaska natives.
Indian Health Services
The cost of coverage for an insurance policy (usually paid on a monthly basis.)
Premium
Managed by Department of Defense, it covers active military personnel and their families.
Tricare
Description:
Insurance purchased by an entity or individual to cover costs of individuals injured on their property or using their product or service
Beneficiaries:
Individuals injured or sickened where another is liable
Examples:
Geico, Progressive, AAA, State Farm, All State, Citizen, Kemper
What am I?
Liability Insurance
Description:
Insurance coverage for automobiles and drivers that protects against losses and liability that may result from an accident
Beneficiaries:
Automobile driver, passenger injured in auto accidents
Examples:
Geico, Progressive, AAA, State Farm, Allstate
What am I?
Automobile Insurance
Group/individual policies sell healthcare coverage plans to individual, employers, or other affiliated groups. T/F
True
Individuals injured or sickened where another is liable are covered under group/individual policies. T/F
False
Liability is to cover automobile drivers or passengers injured in auto accidents. T/F
False
An employee sick or injured on the job would be a beneficiary of an industrial/workers compensation plan. T/F
True
Description:
A company in the business of selling healthcare coverage plans to individuals, employers, or other affiliated groups
Beneficiaries:
Insured/Subscriber and dependents
Examples:
Kaiser Permanente, Cigna, Private Health Care Services (PHCS), UnitedHealthcare, Aetna, Beech Street
What am I?
Group/individual policies
This plan is for non-retiree veterans is managed by the Department of Veterans’ Affairs.
CHAMPVA
This plan is managed by the Department of Defense, is funded by federal tax dollars, and covers active military personnel and their families, as well as retired personnel and their families.
TRICARE
An insurance plan covered by federal income taxes and federal grants; managed by DHHS; one of the patient populations this plan covers is the Alaska natives.
Indian Health Services
Managed by:
DHHS — Indian Health Services
Beneficiaries:
American Indians and Alaska Natives
Founding Source:
Federal income taxes, some federal grant money
What am I?
Indian Health Services (IHS)
Managed by;
Department of Defense
Beneficiaries:
Active duty military; some benefit for families with military personnel overseas
Founding Source:
Federal income taxes
What am I?
TRICARE
Managed by:
Department of Veterans’ Affairs
Beneficiaries: Military veterans; spouses/families of disabled/deceased veterans
Founding Source:
Federal income taxes
What am I?
CHAMPVA
Managed by:
Center for Medicare and Medicaid; Designated agency within each state
Beneficiaries:
Qualified low income families; indigent (eligibility requirements vary by state)
Founding Source:
Federal and state income taxes
What am I?
Medicaid
Managed by:
Centers for Medicare & Medicaid (CMS)
Beneficiaries:
Qualified individuals over the age of 65; people with certain disabilities under the age of 65; people of all ages with permanent kidney failure
Founding Source:
Payroll taxes, federal income taxes, some beneficiary premiums
What am I?
Medicare
What are the five main categories third-party payers in the United States fall into?
~Government ~Commercial ~Industrial ~Liability ~automobile insurance
Bob designated several people as beneficiaries when he signed up for his health insurance. His wife, daughter, and two sons are all covered under his policy. Bob is covered as the subscriber; his family is covered as Bob’s _____
dependents
Marilyn was informed by her employer that she has an out-of-pocket expense of $250.00 each calendar year before her insurance plan will pay any benefits. This out-of-pocket expense before her insurance starts providing benefit is called the _____.
deductible
Waiting Period:
The period of time specified in a health insurance policy that must pass before some or all of the policyholder’s healthcare coverage begins.
Limits:
The maximum amount payable by the insurer for covered expenses. It may be a yearly or lifetime maximum
Exclusions
The types of health care services that a health insurance company won’t pay for. They may exclude a pre-existing condition or a service that is medically unnecessary.
Pre-existing Condition
A medical condition that occurred before a program of health benefits went into effect.
Copayment
also known as a copay) The amount an insurance company requires the policyholder or patient to pay to a healthcare provider for services rendered
Dependent
Refers to the individual(s) eligible to be designated as a beneficiary on a policy. Commonly these are restricted to those with a legal relationship to the subscriber.
Benefit
The amount payable by the insurance carrier toward the cost of the medical services for which the policyholder is eligible
Policy
The binding contract which includes the benefits and coverage as issued by an insurance company to an individual or group that promises to pay for healthcare reasonably required by the policyholder to treat illness or injury.
This agency falls under the umbrella of DHHS and is responsible for performing both proactive and reactive audits
OIG
This agency does not fall under the umbrella of DHHS
Department of Justice
Many healthcare providers work with this non-profit group to maintain accreditation to help reduce the possibility of investigation and punitive action by government agencies.
Joint Commission
This federal agency that is tasked with governing and regulating healthcare in the United States
DHHS
A joint federal-state program which provides coverage to 51.6 million low-income persons, including 25.1 million children.
Medicaid
This agency oversees two programs which provide healthcare to about one in every four Americans.
CMS
This agency not only protects individuals from discrimination in healthcare but also investigates violations to their privacy.
OCR
This agency has primary responsibility to investigate complaints due to HIPAA violations. _____
OCR
A patient receives a bill from the Brookdale Medical Group that includes charges for a chest x-ray and blood test. The patient calls the billing department to inform them they never had blood work or an x-ray performed. The billing specialist says nothing can be done at this point and the patient must pay the bill. The patient calls CMS with a complaint and the complaint is turned over to this agency for further investigation. _____
OIG
_____ is governed by a 29-members Board of Commissioners which includes, physicians, administrators, nurses, a labor representative, health plan leaders, quality experts, ethicists, a consumer advocate and educators.
Joint Commission
Participation in Joint Commission accreditation assists the healthcare provider in achieving compliance with industry and government standards.T/F
True
Healthcare providers are required to belong to and participate in audits by The Joint Commission.T/F
False
Administrative assistants could, during the course of their career, be directly involved in an audit by The Joint Commission. T/F
True
Healthcare providers voluntarily participate in Joint Commission accreditation for three reasons:
- assists the healthcare provider in achieving compliance with industry and government standards.
- demonstrates to consumers the healthcare providers’ commitment to quality patient care.
- reduces the possibility of investigation and punitive action by government agencies.
The joint commission’s corporate members are
~The american college of physicians ~The american college of surgeons ~The american dental association ~The american hospital association ~The american medical association
Governed by a 29-member Board of Commissioners that includes:
~Physicians ~Administrators ~Nurses ~Employers ~a labor representative ~Health plan leaders ~Quality experts ~Ethicists ~A consumer advocate ~Educators
Joint Commission
is an accrediting body that reviews healthcare providers to ensure they are meeting standards of care
CMS prosecutes criminals who engage in fraudulent or abusive billing activities.T/F
False
The OCR has primary responsibility for HIPAA enforcement. T/F
True
The Department of Justice works hand in hand with the OCR and OIG; all three departments fall under the DHHS. T/F
False
Department of Justice
separate branch of government tasked wth prosecuting criminals who engage in fraudulent, abusive, discriminating, or other law-breaking activities
CMS provides:
~Rules
~Regulations
~Standards
CMS provides reference and resource information with regard to coding and billing standards, HIPAA, _____, and other topics of importance tomedical office staff.
Fraud reporting and prevention
CMS works jointly with private and public organizations to provide _____ to apply in the handling and transmission of medical records.
Regulations and standards
This agency governs and regulates Medicare and works with individual states to govern and regulate Medicaid programs in the United States.
CMS
Private organizations work with this U.S. government agency to set standards for the handling of medical records.
CMS
Guidelines for billing Medicare and Medicaid fall under CMS. CMS falls under _____.
Department of Health and Human Services
CMS administers the Children’s Health Insurance Program (CHIP) in each state. T/F
True
An agency of the Department of Health and Human Services, the Centers for Medicare and Medicaid Services (CMS) administers the federal Medicare program. T/F
True
Walter Jones was admitted to TriCare Community Hospital for treatment of a bleeding ulcer. Because of the severity of the bleed he is admitted to the ICU for intensive skilled nursing care. The nursing care is considered _____.
Inpatient services
Ancillary Healthcare Services
goods and/or services provided to patients by healthcare providers to aid in the diagnosis or treatment of an illness or injury
~My be either diagnostic or therapeutic in nature
The physician who has the primary responsibility for directing care and treatment of a patient.
Attending physician
Individuals who support patient care but do not actually provide the patient care.
Healthcare support professionals
The physician who is asked by the attending physician to collaborate in diagnosis and/or treatment of the patient.
Consulting physician
Healthcare workers who take an active role in the diagnosis and treatment of patient care.
Healthcare provider
A physician who turns over the care of a patient to another physician.
Referring physician
Sarah was admitted to the hospital for congestive heart failure. She spent 5 days in the hospital, improved and was ready for discharge. Sarah received her care on an _____ basis.
Inpatient
Lynn left her physician’s office with a prescription for an antibiotic. She went to the pharmacy to have the pharmacist fill her prescription. What role does Lynn have in the healthcare delivery system?
Healthcare consumer
Mary is seen by her family physician in his office for a cough, which she has had for 1 month. After the exam, the physician orders a chest x-ray to be taken immediately at the nearby hospital. Mary leaves the office and goes to the hospital with the order for the chest x-ray in hand. What type of service will the chest x-ray be?
outpatient
Sally (a neighbor) is going to a durable medical equipment store for Laura (the patient) who needs crutches. Laura has a broken leg. Since Sally purchased the crutches, she is considered the healthcare provider. T/F
False
A female patient goes to a free-standing radiology clinic to have a mammography performed; this would be considered outpatient care. T/F
True
A patient goes to the emergency room for treatment of a possible fracture of the radius and ulna. After arriving at the ER it was decided that he needed to be admitted for surgery. Because the patient came through the ER, his entire stay is considered outpatient.
T/F
False
When a patient is admitted to the hospital, no treatment can be provided to a patient without a physician first evaluating the patient and deciding on the appropriate course of treatment. T/F
True
Healthcare support professionals take an active part in direct patient care—treating and assessing patients. T/F
False
administrative assistants provide a key role in helping healthcare providers provide quality healthcare to their patients. T/F
True
Healthcare consumers include a group of people referred to as patients. T/F
True
A consulting physician collaborates with the attending physician to decide on a diagnosis and/or course of treatment. T/F
True
The attending physician has the primary responsibility for the care and treatment of a patient. The attending physician never changes throughout a patient’s course of treatment. T/F
False
The Commission on Consumer Protection and Quality in Healthcare Industry took 2 major elements “consumer protection” and “ensuring quality care” and they drafted the “Patients’ Bill of Rights.”
T/F
True
First Party Payer
the person who receives the healthcare goods or services
Third-party payer
the person who receives the services does not pay a portion of the bill
some patients don’t pay any of the bill
part of all of the payment comes from another party or organization
Primary Payer
The first-party or third-partty payer is responsible for paying most of the bill
