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Which was the first commercial insurance company in the US to provide private healthcare coverage for injuries not resulting in death?

Franklin Health Assurance Company

Which replaced the 1908 workers' compensation
legislation & provided civilian employees of the federal government w/medical car, survivors' benefits, & compensation for lost wages?

Federal Employees' Compensation Act

The first Blue Cross policy was introduced by?

Baylor University in Dallas, Texas

The Blue Shield concept grew out of the lumber & mining camps of the ___ region at the turn of the century?

Pacific Northwest

Healthcare coverage offered by ___ is called group health insurance.

employers

The Hill-Burton Act provided federal grants for modernizing hospitals that had become obsolete because of a lack of capital investment during the Great Depression & WWII (1929 to 1945). IN return for federal funds.

facilities were required to provide services free or at reduced rates to patients unable to pay for care

Third-party administrators (TPAs) administer healthcare plans & process claims, serving as a ___?

System of checks & balance for labor & management

Major medical insurance provides coverage for ___ illnesses & injuries, incorporating large deductibles & lifetime maximum amounts.

catastrophic or prolonged

The government health plan that provides healthcare services to Americans over the age of 65 is called ___?

Medicare

The percentage of costs a patient shares w/the health plan is called__?

Coinsurance

The Tax Equity & Fiscal Responsibility Act of 1982 enacted the ___ prospective payment system (PPS).

Diagnosis-related groups

Established quality standards for all laboratory testing to ensure the accuracy, reliability, & timelines of patient test results.

Regardless of where the test was performed

The primary intent of HIPPA legislation is to__

create better access to health insurance, limit fraud & abuse, and reduce administrative costs.

Which is a primary purpose of the patient record?

ensure continuity of care

The problem-oriented record (POR) includes the following four components:

database, problem list, initial plan, progress notes

The intent of managed health care was to:

replace fee-for-service plans with affordable, quality care to healthcare consumers

A nonprofit organization that contracts w/& acquires the clinical and business assets of phyician practices is called a:

medical foundation

A __ is responsible for supervising & coordinating healthcare services for enrollees:

primary care provider

Whick term best describes those who receive managed healthcare plan services?

enrollees

The term that describes requirements created by accreditation organizations is ___.

standards

HIPPA includes:

-improve the portability & continuity of health insurance coverage in the group & individual markets
-combat waste, fraud & abuse in health insurance & healthcare delivery
-improve access to long-term care services & coverage

HIPPA defines "fraud" as:

an intentional deception misrepresentation that someone makes, knowing it is false, that could result inan unauthorized payment

HIPPA defines "abuse" as:

involves actions that are inconsistent w/accepted, sound medical, costs to the program through improper payments

The difference between "fraud" & "abuse" is:

the individual's intent

The most common forms of "fraud" include:

-billing for services not furnished
-misrepresenting the diagnosis to justify payment
-soliciting, offering, or receiving a kickback
-unbunding codes
-falsifying certificates of medical necessity, plans of treatment, & medical records to justify payment

Examples of "abuse" include:

-excessive charges for services, equipment, or supplies
-submitting claims for items or services that are not medically necessary to treat the patient's stated condition
-improper billing practices that result in a payment by a government program when that claim is the legal responsibility of another third-party payer
-voilations of participating provider agreements w/insurance companies

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