Intro to Health Insurance Flashcards
accountable care organization (aco)
Groups of physician, hospitals, and other health care providers all of whom come together voluntarily to provide coordinated high quality care to medicare patients.
advanced altertinativve payment models (advanced APMs).
include new ways for cms to reimburse health care providers for care provided to Medicare beneficiaries; providers who participate in 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 incentives 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 outpatients care according to similar clinical characteristics and in terms of resources required.
American recovery and reinvestment act of 2009
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
addresses health care fraud and abuse issues, and provides for department of health and human services office of the inspector general 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
CHAMPUS reform Initiative (CRI)
Conducted in 1988; resulted in a new health program called TRICARE, which includes two options; TRICARE prime and TRICARE select
Children’s Health Insurance Program (CHIP)
Provides health insurance coverage to uninsured children whose family income is up to 2000 percent of the federals poverty level.
Civilain Health and medical pogram of the deparment Veterans affair 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 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 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 sevices, electronic version is called ANSI ASCX12N 837P
coinsurance
also called coinsurance payment; the percentage the patent 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 CDHP
health care plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of holding down costs aka 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
diagnosis related groups DRGs
prospective payment system that reimburses hospital for inpatient says
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, hospital, 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 safety 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. created using vendor software which assists in provider decision making
electronic submissions of medical documentation system esMD
implemented to, 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 programs
evaluation and management E/M
services that describe patient encounters with providers for evaluations 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.
