Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Intro to Health Ins
Introduction to Health Insurance
| Term | Definition |
|---|---|
| medical care | the identification of disease and the provision of care and treatment such as that provided by members of the health care team to persons who are sick, injured or concerned about their health |
| health care | the maintenance and improvement of physical and mental health, especially through the provision of medical services. |
| preventative services | designed to help individuals avoid health and injury problems |
| insurance | a contract that protects the insured from loss |
| health insurance | 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 provided by health care professionals |
| automobile insurance policy | contract between an individual and an insurance company whereby the individual pays a premium and, in exchange, the insurance company agrees to pay for specific car-related financial losses during the term of the policy |
| personal injury protection (PIP) | reimburses medical expenses for covered individuals regardless of fault, for treatment due to an automobile accident; also pays for funeral expenses, lost earnings, rehabilitation, and replacement of services such as child care if a parent is disabled |
| disability insurance | reimbursement for income lost as a result of a temporary or permanent illness or injury |
| base period | usually covers a year and is divided into 4 consecutive quarters. Includes taxed wages paid approx. 6 to 18 months before the disability claim begins |
| liability insurance | policy that covers losses to a third party caused by the insured, by an object owned by the insured, or on premises owned by the insured |
| subrogation | the contractual right of a third-party payer to recover health care expenses from a liable party |
| Federal Employees' Compensation Act (FECA) | replaced the 1908 workers' compensation legislation, & civilian employees of the federal government were provided medical care, survivors' benefits, and compensation for lost wages. |
| prepaid health plans | participating hospitals & physicians performed specified medical services for a predetermined fee that was paid on either a monthly or yearly basis. |
| group health insurance | health coverage available through employers and other organizations; employers usually pay part or all of premium costs |
| group medical practices | consisted of three or more health care providers who shared equipment, supplies, & personnel, & who divided income by a prearranged formula |
| Hill-Burton Act | provided federal grants for modernizing hospitals that had become obsolete because of lack of capital investment during the Great depression and WWII. |
| Association of Medical Care Plans | with the Blue Shield symbol as an emblem, was created as a national coordinating agency for physician-sponsored health insurance palns |
| third-party administrators (TPAs) | administer health care plans and process claims, thus serving as a system of checks and balances for labor & management |
| World Health Organization (WHO) | developed the International Classification of Diseases (ICD) |
| International Classification of Diseases (ICD) | a classification system used to collect data for statistical purposes |
| inpatient | admitted to a hospital for treatment with the expectation that the patient will remain in the hospital for a period of 24 hours or more |
| National Association of Blue Shield Plans | The Blue Shield symbol was informally adopted in 1948 by a group of nine plans known as the Associated Medical Care Plans |
| major medical insurance | provided coverage for catastrophic or prolonged illnesses and injuries |
| deductible | the amount for which the patient is financially responsible before an insurance policy provided payment |
| lifetime maximum amount | maximum benefits payable to a health plan participant |
| Dependents' Medical Care Act of 1956 | signed into law and provided health care to dependents of active military personnel |
| Blue Cross Association (BCA) | replaced the American Hospital Association (AHA) |
| medicare | provides health care services to Americans over the age of 65. Originally administered by the Social security Administration |
| medicaid | cost-sharing program between the federal and state governments to provide health care services to low-income Americans. Originally administered by by the Social & Rehabilitation Service (SRS) |
| Civilian Health and Medical Program - Uniformed Services (CHAMPUS) | designed as a benefit for dependents of personnel serving in the armed forces and uniformed branches of the Public Helth Service & NOAA. Now called TRICARE |
| Occupational Safety and Health Administration Act of 1970 (OSHA) | designed to protect all employees against injuries from occupational hazards in the workplace |
| Professional Standards Review Organization (PSROs) | physician-controlled nonprofit organizations that contracted with HCFA(now CMS) to provide for the review of hospital inpatient resource utilization, quality of care, & medical necessity |
| End-stage renal disease (ESRD) | chronic kidney disorder that requires long-term hemodialysis or kidney transplantation because the patient's filtration system in the kidneys has been destroyed |
| Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) | provide health care benefits for dependents of vets rated as 100% permanently & totally disabled, or died as a result of service-connected conditions, & vets who died on duty w/ less than 30 days of active service |
| Health Maintenance Organization Assistance Act of 1973 | authorized federal grants and loans to private organizations that wished to develop HMOs |
| health maintenance organizations (HMOs) | responsible for providing health care services to subscribers in a given geographic area for fixed fee |
| Employee Retirement Income Security Act of 1974 (ERISA) | mandated reporting and disclosure requirements for group life & health plans (inc managed care plans), permitted large employers to self-insure employee health care benefits, & exempted large employers from taxes on health insurance premiums |
| managed care | allows patients to receive care from a group of participating providers to who a co-payment is paid for each service |
| co-payment (copay) | provision in an insurance policy that requries the policy |
| Health Care Financing Administration (HCFA) | formed within the Department of Health & Human Services (DHHS) to combine health care financing & QA programs into a single agency. Medicare and Medicaid programs were also transferred to this newly created agency |
| Omnibus Budget Reconciliation Act of 1981 (OBRA) | federal legislation that expanded the Medicare & Medicaid programs |
| Blue Cross Blue Shield Association (BCBSA) | an association of independent Blue Cross and Blue Shield plans |
| Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) | created Medicare risk programs, which allowed federally qualified HMOs & competitive medical plans that met specified Medicare requirements to provide Medicare-covered services under a risk contract |
| prospective payment system (PPS) | issues a predetermined payment for services |
| per diem | issued payment based on daily rates |
| diagnosis-related groups (DRGs) | reimburses hospitals for inpatient stays |
| peer review organizations (PROs) | review medical necessity issues, determine appropriateness of care provided through retrospective analysis of medical records, assess specific aspects of care to determine whether variations in practice patterns exist, conduct Dr. office site reviews |
| CMS-1500 (HCFA-1500) | form providers are required to use to submit Medicare claims |
| Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) | allows employees to continue health care coverage beyond the benefit termination date |
| CHAMPUS Reform Initiative (CRI) | resulted in a new program, TRICARE, which includes 3 options: TRICARE Prime, TRICARE Extra and TRICARE Standard |
| Clinical Laboratory Improvement Act (CLIA) | 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 |
| Health Plan Employer Data and Information Set (HEDIS) | created standards to assess managed care systems using data elements that are collected, evaluated, and published to compare the performance of managed health care plans |
| Evaluation and Management (E/M) | describes patient encounters with health care professionals for the purpose of evaluation & management of general health status |
| Resource-Based Relative Value Scale (RBRVS) | a payment system that reimburses physicians' practice expenses based on relative values for physician work, practice expense, and malpractice insurance expense |
| Usual and reasonable payments | based on fees typically charged by providers by specialty within a particular region of the country |
| fee schedule | list of predetermined payments for health care services provided to patients |
| National Correct Coding Initiative (NCCI) | promote national correct coding methodologies and to eliminate improper coding |
| Health Insurance Portability and Accountability Act of 1996 (HIPAA) | mandates regulations that govern privacy, security, and electronic transactions standards for health care information. |
| Balanced Budget Act of 1997 (BBA) | addresses health caer fraud and abuse issues. The DHHS Office of Inspector General (OIG) provides investigative & audit services in health care fraud cases. |
| State Children's Health Insurance Program (SCHIP) | established to provide health assistance to uninsured, low-income children, wither through separate programs or through expanded eligibility under state Medicaid programs |
| Skilled Nursing Facility Prospective Payment System (SNFPPS) | to cover all costs related to services furnished to Medicare Part A beneficiaries. |
| Resource Utilization Groups (RUGs) | resident classification system based on data collected from resident assessments and relative weights developed from staff time data |
| Minimum Data Set (MDS) | U.S. federally mandated process for clinical assessment of all residents in Medicare/Medicaid certified nursing homes. Provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. |
| Home Health Prospective Payment System (HHPPS) | reimburses home health agencies at a predetermined rate for health care service provided to patients |
| Outcomes and Assessment Information (OASIS) | 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 and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement |
| Financial Services Modernization Act (or Gramm-Leach-Bliley Act) | prohibits sharing of medical information among health insurers and other financial institutions for use in making credit decisions |
| Outpatient Prospective Payment System (OPPS) | uses Ambulatory Payment Classifications (APCs) to calculate reimbursement, is implemented for billing of hospital-based Medicare outpatient claims |
| Ambulatory Payment Classifications (APCs) | the United States government's method of paying for facility outpatient services for the Medicare (United States) program |
| Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) | requires implementation of $400 billion prescription drug benefit, improved Medicare Advantage benefits, faster Medicare appeals decisions, and more |
| Consumer-driven health plans | introduced as a way to encourage individuals to locate the best health care at the lowest possible price with the goal of holding down health care costs |
| Administrative Simplification Compliance Act (ASCA) | establishes the compliance date for modifications to the Electronic Transactions Standards and code Sets as required by HIPAA |
| Inpatient Rehabilitation Facilities Prospective Payment System (IRF PPS) | utilized information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs |
| quality improvement organizations (QIOs) | formerly known as peer review organizations |
| Medicare Prescription Drug, Improvement and Modernization Act (MMA) | adds new prescription drug and preventive benefits and provides extra assistance to people with low incomes |
| Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) | implemented as a requirement of Medicare, Medicaid, and SCHIP Balanced Budget refinement Ace of 1999. Includes a pt classification system that reflects differences in pt resource use & costs |
Created by:
amc538