Mid-Term Flashcards
Define Contractual Allowance
Difference between what an insurance company approves according to its contract and what the health care provider charges for the procedure.
Types of Organizations that make up Acute Care segment of the industry
Primary, Secondary, Tertiary.
Ex: Hospitals, Ambulatory Surgery Centers, radiation therapy, mammography, shock wave therapy, air ambulance, etc.
Organizations that make up Long Term Care segment of industry
Assisted Living
Nursing
Skilled Nursing
What are the 6 Healthcare legislative initiatives that pertain to the healthcare industry?
HIPPA EMTLA Obamacare Stark II Anti-kickback False Claims Act (as amended in 1986)
What is the purpose of the Health Insurance Portability and Accountability Act (HIPAA)?
to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public’s health and well being
What is the purpose of the Emergency Medical Treatment and Active Labor Act (EMTALA)?
Federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay
What is the purpose of the Anti-kickback legislation?
Prohibits pharmaceutical companies and equipment manufacturers of paying physicians and other decision makers to use their products.
Purpose of Patient Protection and Affordable Care Act 2010 (Obamacare)…?
Requires all Americans have health insurance or be fined
Purpose of Stark II..?
Prohibits Physician Self Referall
Purpose of False Claims Act…?
knowingly attempt to get payment from CMS (centers of Medicaid/Medicare services) under false or fraudulent circumstances.
What is HFMA? Is it professional or Advocacy and who can become members?
HFMA: Healthcare Financial Management Association-
Any person that pays their dues and is in a healthcare administrative roll.
What is ACHE?
ACHE: American College of Healthcare Executives-Professional Organization. American College of Healthcare Executives-Those who have a Bachelor degree and a commitment to the improvement of
the healthcare industry.
What is AMA?
AMA: American Medical Association-Professional. All physicians are eligible to become members if they choose so.
What is AHA?
AHA: American Hospital Association-“Advocacy”. Represents Not-for-profit hospitals and member organizations pay dues.
What is FAH?
FAH: Federation of American Hospitals- Represents for-profit hospitals and member organizations pay dues. “Advocacy”
What is ASCA?
ASCA: Ambulatory Surgery Center Association-This gives all ASCs the advocacy support and any resources they need to provide high quality care.
What is AUPHA?
AUPHA: Association of University Programs in Healthcare-Graduate level students with a program accreditation, and bachelor degree type students with an undergraduate certification. This program ensures it has the best members in the world.
What is ANA?
ANA: American Nursing Association- professional and advocacy organization with any nurse wanting to join and be a member.
What is HSCA?
HSCA: Healthcare Supply Chain Association - “Advocacy Organization” healthcare member who pays dues.
What is accreditation?
healthcare organizations demonstrate the ability to meet predetermined criteria and standards of accreditation
Who does accreditation apply to and is it mandatory or voluntary?
Healthcare organizations and voluntary
What are the components of Medicare Part A?
Medicare A is inpatient services only. The patient doesn’t pay for the premiums. Most people will enroll in this one if they have other benefits or are complete idiots.
What are the components of Medicare Part B?
B is for inpatient or outpatient services. The enrollee pays premiums. more like traditional insurance.
What is certification?
Non-governmental agency recognizes an individual/organization for meeting specific set of standards which was voluntary.
What is licensure?
Non-voluntary by which a governmental agency regulates a profession and grants permission to an individual to practice a specific profession after showing mastery of required skills/knowledge.
Difference between certification and licensure?
Certification is by private whereas licensure is government.
Certification is voluntary whereas licensure is not.
