Introduction to Health Insurance

Question 1

accountable care organization (ACO)

Answer 1

groups of physicians, hospitals, and other health care providers, all of whom come together voluntarily to provide coordinated high-quality care to Medicare patients.

Question 2

advanced alternative payment models (Advanced APMs)

Answer 2

include new ways for CMS to reimburse health care providers for care provided to Medicare beneficiaries; providers who participate in an Advanced APM through Medicare Part B may earn an incentive payment for participating in the innovative payment model.

Question 3

alternative payment models (APMs)

Answer 3

payment approached that includes incentive payments for provide high-quality and cost-efficient care; APMs can apply to a specific clinical condition, a care episode, or a population.

Question 4

American Recovery and Reinvestment Act of 2009 (ARRA)

Answer 4

authorized an expenditure of $1.5 billion for grants for construction, renovation, and equipment, and for the acquisition of health information technology systems.

Question 5

Balanced Budget Act of 1997 (BBA)

Answer 5

addresses health care fraud and abuse issues, an provides for Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) investigative and audit services in health care fraud cases.

Question 6

benchmarking

Answer 6

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 (e.g. coding error rates).

Question 7

Children’s Health Insurance Program (CHIP)

Answer 7

provides health insurance coverage to uninsured children whose family income is up to 200 percent of the federal poverty level (monthly income limits for a family of four also apply).

Question 8

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

Answer 8

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.

Question 9

Civilian Health and Medical Program-Uniformed Services (CHAMPUS)

Answer 9

originally designed as a benefit for dependents of personal serving in the armed forces and uniformed branches of the Public Health Service and the National Oceanic and Atmospheric Administration; now called TRICARE.

Question 10

Clinical Laboratory Improvement Act (CLIA)

Answer 10

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.

Question 11

CMS-1500 claim

Answer 11

claim submitted for reimbursement of physician office procedures and services; electronic version is called ANSI ASC x12N 837P.

Question 12

coinsurance

Answer 12

also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.

Question 13

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

Answer 13

allows employees to continue health care coverage beyond the benefit termination date.

Question 14

consumer-driven health plan (CDHP)

Answer 14

health care plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of holding down costs; also called consumer-directed health plan.

Question 15

continuity of care

Answer 15

documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment.

Question 16

copayment (copay)

Answer 16

provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received.

Question 17

deductible

Answer 17

amount for which the patient is financially responsible before an insurance policy provides coverage.

Question 18

diagnosis-related groups (DRGs)

Answer 18

prospective payment system that reimburses hospitals for inpatient stays.

Question 19

eHealth Exchange

Answer 19

health information exchanged network for securely sharing clinical information over the internet nationwide that spans all 5o states and is the largest health information exchange infrastructure in the United States; participants include large provider networks, hospitals, pharmacies, regional health information exchanges, and many federal agencies.

Question 20

electronic clinical quality measures (eCQMs)

Answer 20

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 safely, effectively, equitably, and timely.

Question 21

Electronic Funds Transfer Act

Answer 21

established the rights, liabilities, and responsibilities of participants in electronic funds transfer systems.

Question 22

electronic medical record (EMR)

Answer 22

considered part of the electronic health record (EHR), the EMR is created using vendor software, which assists in provider decision making.

Question 23

Electronic Submission of Medical Documentation System (esMD)

Answer 23

implemented to reduce provider and reviewer costs and cycle time by minimizing and eventually eliminating paper processing and mailing of medical documentation.

Question 24

Employee Retirement Income Security Act of 1974 (ERISA)

Answer 24

mandated reporting and disclosure requirements for group life and health plans (including management care plans), permitted large employers to self-insure employee health care benefits, and exempted large employers from taxes on health insurance premiums.

Question 25

Evaluation and Management (E/M)

Answer 25

services that describe patient encounters with providers for evaluation and management of general health status.

Question 26

Federal Employees' Compensation Act (FECA)

Answer 26

provides civilian employees of the federal government with medical care, survivors' benefits, and compensation for lost wages.

Question 27

Federal Employers' Liability Act (FELA)

Answer 27

legislation passed in2908, by President Theodore Roosevelt that protects and compensates railroad workers who are injured on the job.

Question 28

fee schedule

Answer 28

list of predetermined payments for health care services provided to patients (e.g., a fee is assigned to each CPT code).

Question 29

Financial Services Modernization Act (FSMA)

Answer 29

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 of the economy, because people usually house their money in one of the options; also called Gramm-Leach-Billey Act.

Question 30

Gramm-Leach-BIlley Act

Answer 30

see Financial Services Modernization Act

Question 31

group health insurance

Answer 31

traditional health care coverage subsidized by employers and other organizations (e.g., labor union, rural and consumer health cooperatives) whereby part or all of premium costs are paid for and/or discounted group rates are offered to eligible individuals.

Question 32

health care

Answer 32

expands the definition of medical care to include preventive services.

Question 33

Health Care and Education Reconciliation Act (HCERA)

Answer 33

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 health care plans" until 2018, and so on.

Question 34

Health Information Technology for Economic and Clinical Health Act (HITECH Act)

Answer 34

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.

Question 35

health insurance

Answer 35

contract between a policyholder and a third-party payer or government program to reimburse the policyholder for all or a portion of the cost of medically necessary treatment or preventive care by health care professionals.

Question 36

health insurance exchange

Answer 36

see health insurance marketplace

Question 37

health insurance marketplace

Answer 37

method Americans use to purchase health insurance coverage that fits their budget and meet their needs, effective October 1, 2013.

Question 38

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Answer 38

mandates regulations that govern privacy, security, and electronic transactions for health care information.

Question 39

Hill-Burton Act

Answer 39

provided federal grants for modernizing hospitals that had become obsolete because of a lack of capital investment during the Great Depression and WWII (1929-1945). In return for federal funds, facilities were required to provide services free, or at reduced rates, to patients unable to pay for care.

Question 40

Home Health Prospective Payment System (HH PPS)

Answer 40

reimbursement methodology for home health agencies that uses a classification system called home health patient-driven groupings model (PDGM), which established a predetermined rate for health care services provided to patients for each 60-day episode of home health care.

Question 41

individual health insurance

Answer 41

private health insurance policy purchased by individuals or families who do not have access to group health insurance coverage; applicants can be denied coverage, and they can also be required to pay higher premiums due to age, gender, and/or pre-existing medical conditions.

Question 42

Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)

Answer 42

system in which Medicare reimburses inpatient psychiatric facilities according to a patient classification system that reflects differences in patient resource use and costs; it replaces the cost-based payment system with a per diem IPF PPS.

Question 43

Inpatient Rehabilitation Facility Prospective Payment system (IRF PPS)

Answer 43

implemented as a result of the BBA of 1997; utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs.

Question 44

International Classification of Diseases (ICD)

Answer 44

classification system used to collect data for statistical purposes.

Question 45

Investing in Innovations (i2) Initiative

Answer 45

designed to spur innovations in health information technology (health IT) by promoting research and development to enhance competitiveness in the United States.

Question 46

lifetime maximum amount

Answer 46

maximum benefit payable to a health plan participant

Question 47

major medical insurance

Answer 47

coverage for catastrophic or prolonged illnesses and injuries.

Question 48

meaningful EHR user

Answer 48

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 measures; 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.

Question 49

meaningful use

Answer 49

objectives and measures that achieved goals of improved patient care outcomes (QPM)

Question 50

Medicaid

Answer 50

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).

Question 51

medical record

Answer 51

see patient record

Question 52

Medicare

Answer 52

reimburses health care services to Americans over the age of 65.

Question 53

Medicare Access and CHIP Reauthorization Act (MACRA)

Answer 53

ended the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers' services, the Merit-Based Incentive Payment System (MIPS) and requires CMS to remove Social Security numbers (SSNs) from all Medicare cards, replacing them with new randomly generated Medicare beneficiary identifiers (MBIs) that will be appear on new Medicare cards.

Question 54

Medicare code editor (MCE)

Answer 54

replaces SSN as health insurance claim number on new Medicare cards for transactions such as billing, eligibility status, and claim status.

Question 55

Medicare contracting reform (MCR) initiative

Answer 55

established to integrate the administration of Medicare Parts A and B fee-for-service benefits with new entities called Medicare administrative contractors (MACs); MACs replaced Medicare carriers, DMERCs, and fiscal intermediaries.

Question 56

Medicare, Medicaid, and CHIP Benefits Improvement and Protection Act of 2000 (BIPA)

Answer 56

requires implantation of a $400 billion prescription drug benefit, improved Medicare Advantage (formerly called Medicare=Choice) benefits, faster Medicare appeals decisions, and more.

Question 57

Medicare Outpatient Observation Notice (MOON)

Answer 57

standardized notice provided to Medicare beneficiaries that they are outpatients receiving observation services and are not inpatients of a hospital or a critical access hospital (CAH).

Question 58

Medicare Prescription Drug, Improvement, and Modernization Act (MMA)

Answer 58

adds new prescription drug and preventive benefits and provides extra assistance to people with low incomes.

Question 59

Merit-Based Incentive Payment System (MIPS)

Answer 59

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 technology.

Question 60

Minimum Data Set (MDS)

Answer 60

data elements collected by long-term care facilities.

Question 61

National Correct Coding Initiative (NCCI)

Answer 61

developed by CMS to promote national correct coding methodologies and to eliminate improper coding practices.

Question 62

Obamacare

Answer 62

nickname for the Patient Protection and Affordable Care Act (PPACA), which was signed into federal law by President Obama on March 23, 2010, and created the Health Care Marketplace.

Question 63

Omnibus Budget Reconciliation Act of 1981 (OBRA)

Answer 63

federal law that requires providers to keep copies of any government insurance claims and copies of all attachments filed by the provider for a period of five years; also expanded Medicare and Medicaid programs.

Question 64

Outcomes and Assessment Information Set (OASIS)

Answer 64

group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement.

Question 65

Outpatient Prospective Payment System (OPPS)

Answer 65

uses ambulatory payment classifications (APCs) to calculate reimbursement; was implemented for billing of hospital-based Medicare outpatient claims.

Question 66

Patient Protection and Affordable Care Act (PPACA)

Answer 66

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 Medicare Trust fund by at least 12 years, and create the health insurance marketplace.

Question 67

patient record

Answer 67

documents health care services provided to a patient.

Question 68

payer mix

Answer 68

different types if health insurance payments made to providers for patient services.

Question 69

per diem

Answer 69

Latin term meaning "for each day," which is how retrospective cost-based rates were determined; payments were issued based on daily rates.

Question 70

personal health record (PHR)

Answer 70

web-based application that allows individuals to maintain and manage their health information (and that of others whom they are authorized, such as family members) in a private, secure, and confidential environment.

Question 71

policyholder

Answer 71

a person who signs a contract with a health insurance company and who, thus, owns the health insurance policy; the policyholder is the insured (or enrollee), and the policy might include coverage for dependents.

Question 72

preventative services

Answer 72

designed to help individuals avoid problems with health and injuries.

Question 73

problem-oriented record (POR)

Answer 73

a systematic method of documentation that consists of four components: database, problem list, initial plan, and progress report.

Question 74

Promoting Interoperability (PI) Programs

Answer 74

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 incentive programs.

Question 75

prospective payment system (PPS)

Answer 75

issues predetermined payment for services, such as bundled payments, capitation, case rates, and global payments.

Question 76

Protecting Access to Medicare Act (PAMA)

Answer 76

implemented skilled nursing facility (SNF) value-based purchasing (VBP) program.

Question 77

public health insurance

Answer 77

federal and state government health programs (e.g., Medicare, Medicaid, CHIP, TRICARE) available to eligible individuals.

Question 78

quality improvement organization (QIO)

Answer 78

performs utilization and quality control review of health care furnishing, or to be furnished, to Medicare beneficiaries.

Question 79

quality payment program (QPP)

Answer 79

helps providers focus on quality of patient care making patients healthier; includes advanced alternatives payment models (Advanced APMs) and merit-based incentive payment system (MIPS); replaced the EHR Incentive Program (or Meaningful Use), Physician Quality Reporting System, and Value-Based Payment Modifier program.

Question 80

record linkage

Answer 80

allows patient information to be created at different locations according to a unique patient identifier of identification number.

Question 81

Resource-Based Relative Value Scale (RBRVS) system

Answer 81

payment system that reimburses physicians' practice expenses based on relative values for three components of each physician's services: physician work, practice expense, and malpractice insurance expense.

Question 82

rural health information organizations (RHIO)

Answer 82

type of health information exchange organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in the community.

Question 83

self-insured (or self-funded) employer-sponsored group health plan

Answer 83

allows a large employer to assure the financial risk for providing health care benefits to employees; employer does not pay a fixed premium to a health insurance payer but establishes a trust fund (of employer and employee contributions) out of which claims are paid.

Question 84

single-payer system

Answer 84

centralized health care plan adopted by some Western nations (e.g., Canada, Great Britain) and funded by taxes. The government pays for each resident's health care, which is considered a basic social service.

Question 85

Skilled Nursing Facility Prospective Payment System (SNF PPS)

Answer 85

implemented (as a result of the BBA of 1997) to cover all costs (routine, ancillary, and capital) related to services furnished to Medicare Part A beneficiaries.

Question 86

socialized medicine

Answer 86

type of single-payer system in which the government owns and operates health care facilities and providers (e.g., physicians) received salaries; the VA health care program is a form of socialized medicine.

Question 87

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

Answer 87

created Medicare risk programs, which allowed federally qualified HMOs and competitive medical plans that met specified Medicare requirements to provide Medicare-covered services under a risk contract.

Question 88

third-party administrator

Answer 88

company that provides health benefits claims administration and other outsourcing services (e.g., employee benefits management) for self-insured companies; provides administrative services to health care plans; specializes in mental health case management; and processes claims, serving as a system of "check and balances" for labor-management.

Question 89

third-party payer

Answer 89

a health insurance company that provides coverage, such as BlueCross BlueShield.

Question 90

total practice management software (TPMS)

Answer 90

used to generate the EMR, automating medical practice functions of registering patients, scheduling appointments, generating insurance claims and patient statements, processing payments from patient and third-party payers, and producing administrative and clinical reports.

Question 91

universal health insurance

Answer 91

goal of providing every individual with access to health coverage, regardless of the system implemented to achieve that goal.

Question 92

usual and reasonable payments

Answer 92

based on fees typically charged by providers in a particular region of the country.

Question 93

World Health Organization (WHO)

Answer 93

developed the International Classification of Diseases (ICD)

Question 94

CHAMPUS Reform Initiative (CRI)

Answer 94

conducted in 1988; resulted in a new health program called TRICARE, which included two options: TRICARE Prime and TRICARE Select (formerly called TRICARE Standard).

Question 95

medical care

Answer 95

includes the identification of disease and the provision of care and treatment as provided by members of the health care team to persons who are sick, injured, or concerned about their health status.

Question 96

Medicare Catastrophic Coverage Act

Answer 96

mandated the reporting of ICD-10-CM diagnosis codes on Medicare claims; in subsequent years, private third-party payers adopted similar requirements for claims submission. Effective October 1, 2015, ICD-10-CM (diagnosis) codes are reported.