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Understanding Health Insurance; A Guide to Billing Reimbursement > Introduction to Health Insurance > Flashcards

Introduction to Health Insurance Flashcards

1
Q

accountable care organization (ACO)

A

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

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2
Q

advanced alternative payment models (Advanced APMs)

A

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.

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3
Q

alternative payment models (APMs)

A

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.

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4
Q

American Recovery and Reinvestment Act of 2009 (ARRA)

A

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

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5
Q

Balanced Budget Act of 1997 (BBA)

A

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.

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6
Q

benchmarking

A

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).

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7
Q

Children’s Health Insurance Program (CHIP)

A

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).

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8
Q

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

A

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.

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9
Q

Civilian Health and Medical Program-Uniformed Services (CHAMPUS)

A

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.

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10
Q

Clinical Laboratory Improvement Act (CLIA)

A

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.

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11
Q

CMS-1500 claim

A

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

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12
Q

coinsurance

A

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

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13
Q

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

A

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

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14
Q

consumer-driven health plan (CDHP)

A

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.

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15
Q

continuity of care

A

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

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16
Q

copayment (copay)

A

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.

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17
Q

deductible

A

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

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18
Q

diagnosis-related groups (DRGs)

A

prospective payment system that reimburses hospitals for inpatient stays.

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19
Q

eHealth Exchange

A

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.

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20
Q

electronic clinical quality measures (eCQMs)

A

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.

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21
Q

Electronic Funds Transfer Act

A

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

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22
Q

electronic medical record (EMR)

A

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

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23
Q

Electronic Submission of Medical Documentation System (esMD)

A

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

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24
Q

Employee Retirement Income Security Act of 1974 (ERISA)

A

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.

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25
Q

Evaluation and Management (E/M)

A

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

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26
Q

Federal Employees’ Compensation Act (FECA)

A

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

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27
Q

Federal Employers’ Liability Act (FELA)

A

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

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28
Q

fee schedule

A

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

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29
Q

Financial Services Modernization Act (FSMA)

A

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.

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30
Q

Gramm-Leach-BIlley Act

A

see Financial Services Modernization Act

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31
Q

group health insurance

A

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.

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32
Q

health care

A

expands the definition of medical care to include preventive services.

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33
Q

Health Care and Education Reconciliation Act (HCERA)

A

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.

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34
Q

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

A

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.

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35
Q

health insurance

A

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.

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36
Q

health insurance exchange

A

see health insurance marketplace

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37
Q

health insurance marketplace

A

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

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38
Q

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

A

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

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39
Q

Hill-Burton Act

A

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.

40
Q

Home Health Prospective Payment System (HH PPS)

A

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.

41
Q

individual health insurance

A

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.

42
Q

Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)

A

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.

43
Q

Inpatient Rehabilitation Facility Prospective Payment system (IRF PPS)

A

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.

44
Q

International Classification of Diseases (ICD)

A

classification system used to collect data for statistical purposes.

45
Q

Investing in Innovations (i2) Initiative

A

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

46
Q

lifetime maximum amount

A

maximum benefit payable to a health plan participant

47
Q

major medical insurance

A

coverage for catastrophic or prolonged illnesses and injuries.

48
Q

meaningful EHR user

A

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.

49
Q

meaningful use

A

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

50
Q

Medicaid

A

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).

51
Q

medical record

A

see patient record

52
Q

Medicare

A

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

53
Q

Medicare Access and CHIP Reauthorization Act (MACRA)

A

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.

54
Q

Medicare code editor (MCE)

A

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

55
Q

Medicare contracting reform (MCR) initiative

A

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.

56
Q

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

A

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

57
Q

Medicare Outpatient Observation Notice (MOON)

A

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).

58
Q

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

A

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

59
Q

Merit-Based Incentive Payment System (MIPS)

A

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.

60
Q

Minimum Data Set (MDS)

A

data elements collected by long-term care facilities.

61
Q

National Correct Coding Initiative (NCCI)

A

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

62
Q

Obamacare

A

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.

63
Q

Omnibus Budget Reconciliation Act of 1981 (OBRA)

A

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.

64
Q

Outcomes and Assessment Information Set (OASIS)

A

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.

65
Q

Outpatient Prospective Payment System (OPPS)

A

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

66
Q

Patient Protection and Affordable Care Act (PPACA)

A

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.

67
Q

patient record

A

documents health care services provided to a patient.

68
Q

payer mix

A

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

69
Q

per diem

A

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

70
Q

personal health record (PHR)

A

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.

71
Q

policyholder

A

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.

72
Q

preventative services

A

designed to help individuals avoid problems with health and injuries.

73
Q

problem-oriented record (POR)

A

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

74
Q

Promoting Interoperability (PI) Programs

A

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.

75
Q

prospective payment system (PPS)

A

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

76
Q

Protecting Access to Medicare Act (PAMA)

A

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

77
Q

public health insurance

A

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

78
Q

quality improvement organization (QIO)

A

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

79
Q

quality payment program (QPP)

A

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.

80
Q

record linkage

A

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

81
Q

Resource-Based Relative Value Scale (RBRVS) system

A

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.

82
Q

rural health information organizations (RHIO)

A

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.

83
Q

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

A

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.

84
Q

single-payer system

A

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.

85
Q

Skilled Nursing Facility Prospective Payment System (SNF PPS)

A

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.

86
Q

socialized medicine

A

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.

87
Q

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

A

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.

88
Q

third-party administrator

A

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.

89
Q

third-party payer

A

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

90
Q

total practice management software (TPMS)

A

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.

91
Q

universal health insurance

A

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

92
Q

usual and reasonable payments

A

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

93
Q

World Health Organization (WHO)

A

developed the International Classification of Diseases (ICD)

94
Q

CHAMPUS Reform Initiative (CRI)

A

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

95
Q

medical care

A

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.

96
Q

Medicare Catastrophic Coverage Act

A

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.

Understanding Health Insurance; A Guide to Billing Reimbursement (18 decks)

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