Chapter 2 Insurance

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Question

Answer

Which is the abbreviation for the standardized notice that informs Medicare patients they are an outpatient receiving observation services and are not an inpatient of a hospital or a critical access hospital (CAH)?

MOON

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Which legislation provides civilian employees of the federal government with medical care, survivors' benefits, and compensation for lost wages?

Federal Employees' Compensation Act

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The first Blue Cross policy was introduced by

Baylor University in Dallas, Texas.

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The Blue Shield concept grew out of the lumber and mining camps of the _____ region at the turn of the century.

Pacific Northwest

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Health care coverage offered by _____ is called group health insurance.

employers

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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 and World War II (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.

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Third-party administrators (TPAs) administer health care plans and process claims, serving as a

system of checks and balances for labor and management.

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

catastrophic or prolonged

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

Medicare.

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The percentage of costs a patient shares with the health plan (e.g., plan pays 80 percent of costs and patient pays 20 percent) is called

coinsurance.

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The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) enacted the _____ prospective payment system (PPS).

diagnosis-related groups

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The 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.

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The National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and eliminates improper coding. NCCI edits are developed based on coding conventions defined in _____

CPT

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The intent of HIPAA legislation is to

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

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The Patient Protection and Affordable Care Act (PPACA) was signed into federal law by President Obama on March 23, 2010, and resulted in creation of a(n)_____.

Health insurance marketplace

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Which is a primary purpose of the patient record?

ensure continuity of care

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

database, problem list, initial plan, progress notes

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The electronic health record (EHR) allows patient information to be created at different locations according to a unique patient identifier or identification number, which is called

Record linkage.

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When a patient states, "I haven't been able to sleep for weeks," the provider who uses the SOAP format documents that statement in the _____ portion of the clinic note.

Subjective

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The provider who uses the SOAP format documents the physical examination in the _____ portion of the clinic note.

Objective

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Civilian health and medical care program of the Department of Veterans Affairs (CHAMPVA)

Program that provides health benefits for veterans who are disabled, died, or died on duty within 30 days of active duty

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CMS - 1500 claim

Claim submitted for reimbursement of physician office procedures and services

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Coinsurance

the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid

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Continuity of Care

Documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment

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Deductible

Amount for which the patient is financially responsible before an insurance policy provides coverage

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Copayment

provision in an insurance policy that requires the policyholder or the patient to pay a specified dollar amount to a healthcare provider for each visit or medical service received.

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Electronic Health Record (EHR)

Global concept that includes the collection of patient in formation documented by a number of providers at different facilities regarding one patient

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Fee Schedule

list of predetermined payments for health care services provided to patients

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Group Health insurance

Traditional health care coverage by employers and other organizations

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HIPAA

Mandates regulations that govern privacy, security, and electronic transactions standards for health care information

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Medicaid

Health insurance for low-income Americans

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National Correct Coding Initiative (NCCI)

Developed by CMS to promote national correct coding methodologies and to eliminate improper coding practices

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Personal Health Record (PHR)

web-based application that allows individuals to manage and maintain their health information, in private, secure, and confidential environment

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policyholder

person who signs contract with health insurance company and owns the health insurance policy

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public health insurance

federal and state government health programs (Medicare, Medicaid, TRICARE)

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Third party payer

health insurance company that provides coverage such as blue cross blue shield

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World Health Organization (WHO)

developed the international classification of diseases (ICD)

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