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Ch. 2 Reimbursement

Introduction to Health Insurance

Prospective payment system used to calculate reimbursement for outpatient care according to similar clinical characteristics and in terms of resources required. Ambulatory Payment Classification (APC)
Authorized an expenditure of $1.5 billion for grants for construction, renovation and equipment, and for the acquisition of health information technology systems. American Recovery and Reinvestment Act of 2009 (ARRA)
Addresses healthcare fraud and abuse issues, and provides for Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) investigative and audit services in healthcare fraud cases. Balanced Budget Act of 1997 (BBA)
Conducted in 1988; resulted in a new health program called TRICARE, which includes 3 options: TRICARE Prime, TRICARE Extra, and TRICARE Standard. CHAMPUS Reform Initiative (CRI)
Program that provides health benefits for dependents of veterans rated as 100% permanently and totally disabled as a result of service-connected conditions, and veterans who died on duty with less than 30 days active service. Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
Originally designed as a benefit for dependents of personnel serving in the armed forces and uniformed branches of the Public Health Service and the National Oceanic and Atmospheric Administration; now called TRICARE. Civilian Health and Medical Program - Uniformed Services (CHAMPUS)
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. Clinical Laboratory Improvement Act (CLIA)
Form used to submit Medicare claims; previously called the HCFA-1500. CMS-1500
Also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid. Coinsurance
Allows employees to continue healthcare coverage beyond the benefit termination date. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
Healthcare 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. Consumer-driven health plan (CDHP)
Documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment. Continuity of Care
Provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a healthcare provider for each visit or medical service received. Copmayment (copay)
Amount for which the patient is financially responsible before an insurance policy provides coverage. Deductible
Global concept that includes the collection of patient information documented by a number of providers at different facilities regarding one patient. Electronic Health Record (EHR)
Considered part of the EHR, 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 Electronic Medical Record (EMR)
Mandated reporting and disclosure requirements for group life and health plans (including managed care plans), permitted large employers to self-insure employee healthcare benefits, and exempted large employers from taxes on health insurance permiums. Employee Retirement Income Security Act of 1974 (ERISA)
Services that describe patient encounters with providers for evaluation and management of general health status. Evaluation and Management (E/M)
Provers civilian employees of the federal government with medical care, survivors' benefits, and compensation for lost wages. Federal Employees' Compensation Act (FECA)
Legislation passed in 1908 by President Theodore Roosevelt that protects and compensates railroad workers who are injured on the job. Federal Employment Liability Act (FELA)
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 the economy Financial Services Modernization Act (FSMA) also called Gramm-Leach-Bliley Act
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 Gramm-Leach-Bliley Act also called Financial Services Modrenization Act (FSMA)
Traditional healthcare coverage subsidized by employers and other organizations whereby part or all of premium costs are paid for and/or discounted group rates are offered to eligible individuals. Group Health Insurance
Expands the definition of medical care to include preventive services. Health care
Includes healthcare reform initiatives that amend the Patient Protection and Affordable Care Act to increase tax credits to buy healthcare insurance, eliminate special deals provided to senators, close the Medicare "donut hole," delay taxing until 2018 Health Care and Education Reconciliation Act
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 healthcare quality, safety, and efficiency. Health Information Technology for Economic and Clinical Health Act (HITECH)
Mandates regulations that govern privacy, security, and electronic transactions standards for healthcare information. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Provided federal grants fro modernizing hospitals 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 Hill-Burton Act
Reimbursement methodology for home health agencies that uses a classification system called home health resource groups (HHRGs), which establishes a predetermined rate for healthcare services provided to patients for each 60-day episode of home health car Home Health Prospective Payment System (HH PPS)
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 pay higher premiums due to age, gender, and/or preexisting conditions. Individual Health Insurance
System in which Medicare reimburses inpatient psychiatric facilities according to a patient classification system that reflects differences in patient resources use and costs; it replaces the cost-based payment system with per diem IPF PPS. Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)
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. Inpatient Rehabilitation Facility Prospective Payment System(IRF PPS)
Classification system used to collect data for statistical purposes. International Classification of Diseases (ICD)
Designed to spur innovations in health IT by promoting research and development to enhance competitiveness in the US. Investing in Innovations Initiative (i2 Initiative)
Maximum benefit payable to a health plan participant Lifetime Maximum Amount
Coverage for catastrophic or prolonged illnesses and injuries. Major Medical Insurance
Physicians and hospitals who demonstrate that certified EHR technology is connected and used to exchange electronic health information on clinical quality measures to improve quality of care. Meaningful EHR User
Cost-sharing program between the federal and state governments to provide healthcare services to low-income Americans; originally administered by the Social and Rehabilitation Service (SRS). Medicaid
Includes the identification of disease and the provision of care and treatment as provided by members of the healthcare team to persons who are sick, injured, or concerned about their health status. Medical Care
Documents healthcare services provided to a patient. Medical Record - see also Patient Record
Reimburses healthcare services to Americans over the age of 65. Medicare
Mandated the reporting of ICD-9-CM diagnosis codes on Medicare claims; in subsequent years, private third-party payers adopted similar requirements for claims submission. Medicare Catastrophic Coverage Act
Established to integrate the administration of Medicare Part A and B fee-for-service benefits with new entities called Medicare administrative contractors (MACs) Medicare Contracting Reform Initiative (MCR)
Requires implementation of a $400 billion prescription drug benefit, improved Medicare Advantage (formerly called Medicare+Choice) benefits, faster Medicare appeals decisions, and more. Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2003 (BIPA)
Adds new prescription drug and preventive benefits and provides extra assistance to people with low incomes. Medicare Prescription Drug, Improvement, and Modernization Act (MMA)
Data elements collected by long-term care facilities. Minimum Data Set (MDS)
Developed by CMS to promote national correct coding methodologies and to eliminate improper coding practices National Correct Coding Initiative (NCCI)
Federal law that requires physicians to keep copies of any government insurance claims and copies of all attachments filed by the provider for a period of 5 years; also expanded Medicare and Medicaid programs. Omnibus Budget Reconciliation Act of 1981 (OBRA)
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. Outcomes and Assessment Information Set (OASIS)
Uses ambulatory payment classifications (APCs) to calculate reimbursement; was implemented for billing of hospital-based Medicare outpatient claims. Outpatient Prospective Payment System (OPPS)
Focuses on private health insurance reform to provide better coverage for individuals with pre-existing conditions, improve prescription drug coverage under Medicare, and extend the life of the Medicare Trust fund by at least 12 years. Patient Protection and Affordable Care Act
Documents healthcare services provided to a patient. Patient Record
Latin term meaning "for each day," which is how retrospective cost-based rates were determined; payments were issued based on daily rates. Per Diem
Web-based application that allows individuals to maintain and manage their health information (and that of others for whom they are authorized, such as family members) in a private, secure, and confidential environment Personal Health Record
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. Policyholder
Designed to help individuals avoid health and injury problems. Preventive Services
A systematic method of documentation that consists of 4 components: database, problem list, initial plan, and progress notes. Problem-oriented Record
Issues predetermined payment for services. Prospective Payment System
Federal and state government health programs (Medicare, Medicaid, SCHIP, TRICARE) available to eligible individuals. Public Health Insurance
Performs utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries. Quality Improvement Organization (QIO)
Allows patient information to be created at different locations according to a unique patient identifier or identification number. Record Linkage
Based on data collected from resident assessments (using data elements called the Minimum Data Set, or MDS) and relative weights developed from staff time data. Payment system that reimburses physicians' practice expenses based on relative values for 3 components of each physician's services: physician work, practice expense, and malpractice insurance expense
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 insurance payer, but establishes a trust fund (of employer and employee contributions) to pay claims. Self-insured (or self-funded) Employer-sponsored Group Health Plan
Centralized healthcare system adopted by some Western nations and funded by taxes. The government pays for each resident's health care, which is considered a basic social service. Single-payer System
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 Skill Nursing Facility Prospective Payment System (SNF PPS)
Type of single-payer system in which the government owns and operates healthcare facilities and providers receive salaries; the VA healthcare program is a form of socialized medicine. Socialized Medicine
Also abbreviated as CHIP; provides health insurance coverage to uninsured children whose family income is up to 200% of the federal poverty level (monthly income limits for a family of 4 also apply). State Children's Health Insurance Program (SCHIP)
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. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
Company that provides health benefits claims administration and other outsourcing services for self-insured companies; provides administrative services to healthcare plans; specializes in mental health case management; and processes claims as checks and Third-party Administrator (TPA)
A health insurance company that provides coverage, such as Blue Cross Blue Shield. Third-party Payer
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 reports Total Practice Management Software (TPMS)
Goal of providing every individual with access to health coverage, regardless of the system implemented to achieve that goal. Universal Health Insurance
Based on fees typically charged by providers in a particular region of the country. Usual and Reasonable Payments
Developed the International Classification of Diseases (ICD) World Health Organization (WHO)
List of predetermined payments for healthcare services provided to patients (fee is assigned to each CPT code). Fee Schedule
Contract that protects the insured from loss. Insurance
Legislation designed to protect all employees against injuries from occupational hazards in the workplace. Occupational Safety and Health Administration Act of 1970 (OSHA)
An association of independent Blue Cross Blue Shield plans. BlueCross BlueShield Association (BCBSA)
Prospective payment system that reimburses hospitals for inpatient stays. Diagnosis-related Group (DRG)
Services that describe patient encounters with providers for evaluation and management of general health status; see also evaluation and management E/M Codes
Created by: adale3171