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UHI Chapter 2
Understanding Health Insurance 10th edition Gossary Definitions plus additional definitions from table 2-1
Terms in this set (72)
Ambulatory Payment Classifiacton
prospective payment system used to calculate reimbursement for outpatient 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 acquiaition of health information technology systems.
Balance budget ACT of 1977
address healthcare fraud and abuse issues, and provides for department of Health and Human Services (DHHS) office of inspector general (OIG) investigative and audit services in helathcare fraud cases
period of time that usually covers 12 months: and is divided in to four consecutive quarters
CHAMPUS Reform Initiative
conductedin 1988; resulted in a new health program called TRICARE wich includes three options; TRICARE Prime, TRICARE Extra, and TRICARE Standard
Civilian Health and Medical Program of the Department of Veterans Affairs
program that provides health benefits for dependents of veterans rated as 100 percent permanently and totally disabled as a result of service connected condtions, vererans who died 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
originally designed as a benefit for dependents of personnel serving in teh armed forces and uniformed branches of the Public Health Service and the National Oceanic and Atmospheric Administration; now called TRICARE
Clinical Laboratory Improvement ACT
established qualitiy standards for all laboratory testing: to ensure the accuracy, reliability, and timliness of patient test results regadless of where the test was performed
a form used to submit medical claims: previously called HCFA-1500
also called coinsurance payment; the percentage the patient pays for covered sercvices after the deductible has been met and the copayment has been paid
Consolidated Omnibus Budget
Reconciliation ACT of 1985
allows enployees to continue healthcare coverage beyond the benefit termination date
consumer driven health plan
also called Consumer-Directed Health Plan, a healthcare plan that encourages indiviuals to locate the best healthcare at the lowest possible price, with the goal of holding down cost; also called consumer-directed health plan
continuity of care
documenting patient care services so that others who treat teh patient have a source of information on which to base additional care and treatment
provision in an insurance policy that requires the policy holder or patient to pay a specified dollar amount to a healthcare provider for each visit or medical service received.
the amount for which the patient is financially reponsible before an insurance policy provides coverage
prospective payment system that reimburse hospitals for patient stays
electronic health record
Global concept that includes the collection of patient information documentation by a number of providers; at a different facilities regarding one patient
electronic medical record
considered part of the electronic health record, the EMR is created on a computer using a keyboard, a mouse, an optical pen device, a voice recognition system, a scanner, or a touch screen; records are created using vendor software, which assists in provider decision making; numerous vendors offer EMR software, mostly to physician office practices that require practice management solutions
Employee Retirement Income Security ACT of 1974 (ERISA)
mandated reporting and disclosure requirement for group life and health plans (including managed car plans), permitted large employers to self insure employee health care benefits, and exempted large employers from taxes on health insurance premiums
employer-based self-insurance plans
Note: not in glossary
Evaluation and Management
services that describe patient encounters with providers for evaluation and management of general health status
Federal Employee's Compensation Act
replaced the 1908 worker's compensation legislation; civilian employee of federal government are provided medical care, survivors' benefits, and compensation for lost wages
is a list of predetermined payments for healthcare services provided to patients (e.g: a fee is assigned to each CPT code) Alternate definition: payment fee for physicains
Financial Services Modernization Act
prohibits sharing of medical information among health financial institutions for use in making credit decisions; also allows banks to merge with the 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 the Gramm-Leach-Bliley Act
same as Financial Services Mordinization Act
group helath insurance
traditional healthcare coverage subsidized by employers and other organizations (e.g., labor unions, rural and consumer health cooperatives), whereby part or all the premium cost are paid for and/or discounted group rates are offered to eligible individuals
expands the definition of medical care to include preventative services.
a contract between the policyholder and a third-party payer or government program to reimburse the policyholder for all or portion of the cost of medically necessary treatment or preventative care provided by a healthcare professionals
Hill Burton Act
provided federal grants for modernizing hospitals after the Great Depression nad WWII (1929-1945); facilites were required to provide services free, or at reduced rates, to patients unable to pay for care
individual health insurance
private healthcare insurance policy purchased by individuals or families who do not have access to group health coverage; appplicants can be denied coverage, and they can also be required to pay higher premiums due to age, gender, and/or preexisting medical conditions
International Classification of Diseases
the classification system used to collect data for statistical purposes
lifetime maxium amount
maxium benefit payable to a health plan participant
major medical insurance
coverage for catastrophic or prolonged illness and injuries
a systematic method for documentation that consist of four components: database, problem list, initial plan, and progress notes
public health insurance
state and federal health programs (e.g.; Medicare, Medicaid, SCHIP, and TRICARE) available to eligible individuals
documents helathcare services provided to a patient; also called patient record
allows patient information to be created at different locations according to a unique patient identifier or identification number
self-insured (or self-funded) employer-sponsored group health plans
allows a large employer to assume the financial risk for providing healthcare benefits to employees; employer does not pay a fixed premium to a health insurence payer, but establishes a trust fund (of employer and employee contributions) out of which claims are paid
single-payer plan (system?)
centeralized healthcare system adopted by some Western nations (e.g.; Canada, Great Britain) and funded by taxes; the government pays for each residient's health care, which is considered a basic social service.
a type of single-payer system in which the government owns and operates the healthcare facility and providers (e.g.; physicans) recieve saleries. The VA helathcare plan is a form of socialized medicine
company that provides health benefits claims administration and other outsourcing service for self-insured companies; provides administrative services to healthcare plans; specializes in mental health case management; and processes claims, serving as a system of "checks and balances" for labor-management
total practice management software
used to generate EMR, automating medical practice functions of registered patients, scheduling appointments, generating insurance claims and patient statements, processing payments from patient and third-party payers, and producing administrative and clinical records
universal healthcare insurance
the goal of providing every individual with access to health coverage, regardless of the system implemented to acheive that goal
World Health Organization
United Nations health agency established in 1984 to develop the International Classification of Diseases (ICD), a classification system health care providers use to code and report inpatient/outpatient diseases and inpatient procedures for reimbursement purposes.
the fee schedule for Medicare physican office fees
an arrangement among providers to provide capitated (fixed, prepaid basis) heatlhcare service to Medicare beneficiaries
Health Insurance Portability and Accountability
Act of 1996
Law that mandates regulations governing privacy, security, and electronic transaction standards for health care information.
Home Health Prospective Payment System
Reimbursement method for home health agencies that uses a classification system called home health resource groups (HHRGs). Establishes a predetermined rate for health care services provided to patients for each 60-day episode of home health care.
Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)
Patient classification system implemented January 1, 2005, that reflects differences in patient resource use and costs. Replaces the cost-based payment system with a per diem cost.
Inpatient Rehabilitation Facilities Prospective Payment System (IRF PPS)
System implemented as a result of the Balanced Budget Act (BBA) of 1997, which uses information from patient assessment instruments to classify patients based on clinical characteristics and expected resource needs.
Contract that protects the insured from loss.
Care that includes the identification of disease and the provision of care and treatment as that provided by members of the health care team to people who are sick, injured, or concerned about their health statuses.
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, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2003 (BIPA)
Law that requires implementation of a $400 billion prescription drug benefit, improved Medicare Advantage (formerly called Medicare+Choice) benefits, faster Medicare appeals decisions, and more.
Medicare Prescription Drug Improvement and Modernization Act
Law that adds new prescription drug benefits and provides extra assistance to people with low incomes. Established the Medicare contracting reform (MCR) initiative to replace current Medicare carriers and fiscal intermediaries with Medicare administrative contractors (MACs).
minimum data set
Data elements collected by long-term care facilities.
National Correct Coding Initiative
Effort undertaken by the Health Care Financing Administration (HCFA), now called the Centers for Medicare & Medicaid Services (CMS), to promote national correct coding methods and eliminate improper coding.
Occupational Safety and Health Administration Act of 1970 (OSHA)
Legislation designed to protect all employees against injuries from hazards in the workplace.
Omnibus Budget Reconciliation Act of 1981 (OBRA)
Federal law that requires physicians to keep, for 5 years, copies of any government insurance claim forms and copies of all attachments filed by a provider. Also expands Medicare and Medicaid programs.
Outcomes and Assessment Information Set (OASIS)
Group of data elements that represent the core items of a comprehensive assessment for an adult home care patient. These form the basis for measuring patient outcomes for the purpose of outcome-based quality improvement.
Outpatient Prospective Payment System (OPPS)
System that uses ambulatory payment classifications (APCs) to calculate reimbursement. Implemented to bill hospital-based Medicare outpatient claims.
Latin term meaning "for each day," which is how retrospective cost-based rates were determined: Payments were issued based on daily rates.
prepaid health plan
Contract between an employer and a health care facility or physician whereby specified medical services are performed for a predetermined fee that was paid monthly or yearly.
Services designed to help individuals avoid health and injury problems.
prospective payment system
System that issues a predetermined payment for services.
quality improvement organizations
Groups that perform utilization and quality control reviews of health care furnished, or to be furnished, to Medicare beneficiaries. Previously called peer review organizations (PROs).
resource utilization groups
Groups based on data collected from resident assessments using data elements called the minimum data set (MDS) (see preceding entry) and relative weights developed from staff time data.
Resource-Based Relative Value Scale
Payment system that reimburses physicians' practice expenses based on relative values for three components of each physician's services: (1) physician work, (2) practice expense, and (3) malpractice insurance expense.
Skilled Nursing Facility Prospective Payment System (SNF PPS)
System mandated by the Balanced Budget Act (BBA) of 1997 to cover all costs (routine, ancillary, and capital) for services rendered to Medicare Part A beneficiaries.
State Children's Health Insurance Program
Program that provides health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
Law that creates Medicare risk programs which allow federally qualified HMOs and competitive medical plans meeting specified Medicare requirements to provide Medicare-covered services under a risk contract.
usual and reasonable payments
Payments based on fees typically charged by providers in a particular region of the country.
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