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.
federal employers liability act FELA
legislation passed in 1908 by t. Roosevelt that protects and compensates railroad workers who are injured on the job
financial services modernization act FSMA
prohibits sharing of medical information among health insurers and other financial institutions for use in making credit decisions; also allows banks to merge with investment and insurance houses which allows them to make a profit no matter what the status the economy because people usually house their money in one of the options aka Gramm leach billey act
gramm leach billey act
aka financial services modernization act
group health insurance
traditional health care coverage subsidized by employer and other organization whereby part or all of premium costs are paid for and or discounted group rates are offered to eligible individuals.
health care and education reconciliation act HCERA
includes health care reform initiatives that amend the patient protection and affordable care act to increase tax credits to buy health care insurance, eliminate special deals provided to senators, close the medicare donut hole delay taxing of “cadillac heatlh care plans”
Health information technology for economic and clinical health act-HITECH Act
included in the american recovery and reinvestment act of 2009 and amended the public health service act to establish an office of national coordinator for health information technology within HHS to improve health care quality, safety and efficiency.
health insurance exchange
aka health insurance marketplace method americans use to purchase health coverage that fits their budget and meet their needs, effective oct 1,2013
health insurance portability and accountability act of 1996 HIPPAA
mandates and regulations that govern privacy security and electronic transactions standards for health care information
hill burton act
provided federal rants for modernizing hospitals that had become obsolete because of a lack of capital investment during the great depression and WWII. In return for federals funds, facilities were required to provide services free, or at reduced rates, to patients unable to pay for care
home health prospective payment system HH PPS
reimbursement methodology for home health agencies that uses a classification system called home health resource groups HHRGs which establishes a predetermined rate for health care services provided to patients for each 60 day episode of home health care.
international classification of diseases ICD
classification system used to collect data for statistical purposes
investing in innovations (i2) initiative
designed to spur innovations in health information technology by promoting research and development to enhance competitiveness in the US
lifetime maximum amount
maximum benefit payable to a health plan participant
major medical insurance
coverage for catastrophic or prolonged illnesses and injuries
meaningful EHR user
providers who demonstrate that certified EHR technology is used for electronic prescribing, electronic exchange of health information in accordance with law and HIT standards and submission of information on clinical quality measure and hospitals that demonstrate that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve quality of care and that the technology is used to submit information on clinical quality measures.
meaningful use
objectives and measures that achieved goals of improved patient care outcomes and delivery through data capture and sharing, advance clinical processes, and improved patient outcomes; replaced by quality payment program QPM
medicaid
cost sharing program between the federal and state governments to provide health care services to low income americans originally administered by the social and rehabilitation service SRS
medicare
reimburses health care services to americans over the age o 65
medicare access and CHIP reauthorization act MACRA
ended the sustainable growth rate formula for determining medicare payments for health insurance
medicare beneficiary identifier MBI
replaces SSN as health insurance claim number on new Medicare cards for transactions such as billing, eligibility status and claim status.
medicare catastrophic coverage act
mandated the reporting of ICD9 diagnosis codes on Medicare claims; in subsequent years, private third party payers adopted similar requirements for claims submissions.
medicare contracting reform MCR initiatve
established to integrate the administration of medicae parts A and B fee-for-service benefits with new entities called medicare administrative contractors MAC. MACs replaced Medicare carriers DMERCs and fiscal intermediaries.
medicare, medicaid, and CHIP benefits improvement and protection act of 2000 BIPA
requires implementation of a $400 billion prescription drug benefit improved medicare advantage benefits faster medicare appeals decision and more.
medicare prescription drug, improvement and modernization act MMA
adds new prescription drug and preventive benefits and provides extra assistance to people with low income
merit based incentive payment system MIPS
eliminated PQRS value based payment modifier and the medicare EHR incentive program creating a single program based on quality, resource use, clinical practice improvement, and meaningful use of certified EHR tech
minimum data set MDS
data elements collected by long term care facilities
National correct coding initiative NCCI
developed by CMS to promote national national correct coding methodologies and to eliminate improper coding practices.
OBAMACARE
aka patient protection and affordable care act PPACA which was signed into federal law by obama on march 23 2010 and created the health care marketplace.
omnibus budget reconciliation act of 1981 OBRA
federal law that require providers to keep copies of any government insurance claims and copies of all attachments filled by the provider for a period of 5 yrs also expanded medicare and medicaid programs
outcomes and assessment information set OASIS
group of data elements that represent core items of a comprehensive assessment for an adult home care patient
outpatient prospective payment system
aka OPPS; uses ambulatory payment classifications APCs to calculate reimbursement was implemented for billing of hospital based medicare outpatient claims.
patient protection and affordable care act PPACA
focuses on private health insurance reform to provide better coverage for individuals with pre existing conditions improve prescription drug coverage under medicare, extend the life of the Medicare trust fund by at least 12 yrs and create the health insurance market place.
payer mix
different types of health insurance payments made to providers for patient services.
personal health record PHR
web based application that allows individuals to maintain and manage their health information in private ,secure, and confidential environment.
preventive services
designed to help individuals avoid problems with health and injuries
problem-oriented record POR
a systematic method of documentation that consists of four components; database, problem list, initial plan and progress notes.
promoting interoperability PI programs
focus on improving patient access to health information and reducing the time and cost required of providers to comply with the programs requirements previously called EHR incentives programs
prospective payment system
PPS issues predetermined payment for services, such as bundled payments, capitation, case rates, and global payments.
protecting access to medicare act PAMA
implemented skilled nursing facility value based purchasing program
