Understandng Health Insurance (Chapter 2)

Health Insurance
A 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 healthcare professionals.
Group Health Insurance
Traditional healthcare coverage subsidized by employers and other organizations (e.g., labor unions, rural and consumer health cooperatives) whereby part or all of premium costs are paid for and/or discounted group rates are offered to eligible individuals.
Federal Employees’ Compensation Act (FECA)
Replaced the 1908 workers’ compensation legislation, and civilian employees of the federal government were provided medical care, survivor’s benefits, and compensation for lost wages. Administered by the Office of Worker’s Compensation Programs (OWCP).
Third-party Administrators
An indirect result of the Taft-Hartly Act of 1947. Administers healthcare plans and process claims, thus serving as a system of checks and balances for labor and management.
World Health Organization (WHO)
Developed the International Classification of Diseases (ICD), a classification system used to collect data for statistical purposes.
International Classification of Diseases (ICD)
A classification system used to collect data for statistical purposes.
Major Medical Insurance
Provides coverage for catastrophic or prolonged illnesses and injuries. Most of these program incorporate large deductibles and lifetime maximum amounts.
The amount for which the patient is financially responsible before an insurance policy provides payment.
Self-insured (or self-funded) employer-sponsored group health plans
Allows large employers to assume the financial risk for providing healthcare benefits to employees. The employer does not pay a fixed premium to a health insurance payer, but establishes a trust fund (of employer and employee contributions) out of which claims are paid.
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 Health Service and the National Oceanic and Atmospheric Administration. This program is now called TRICARE.
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
Provides healthcare benefits for dependents of veterans rated as 100 percent permanently and totally disabled as a result of service-connected conditions, veterans who died as a result of service-connected conditions, and veterans who dies on duty with less and 30 days of active service.
Health Maintenance Organizations (HMOs
Responsible for providing healthcare services to subscribers in a given geographic area for a fixed free.
Copayment (Copay
A 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.
The percentage of costs a patient shares with the heath plan. (Example: Plan pays 80%, patient pays 20%)
Prospective Payment System (PPS)
Issues a predetermined payment for services.
Per Diem Basis
The method by which issued payments are calculated based on daily rates.
Diagnosis-related Groups (DRGs)
PPS implemented in 1983 that reimburses hospitals for inpatient stays.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
Allows employees to continue healthcare coverage beyond the benefit termination date.
CHAMPUS Reform Initiative (CRI)
Resulted in new program..TRICARE..which includes options such as 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.
Usual and reasonable payments
Based on fees typically charged by providers by specialty within a particular region of the country.
Fee schedule
A list of predetermined payments for healthcare services provided to patients (e.g., a fee is assigned to each CPT code)
National Correct Coding Initiative (NCCI)
Created to 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 healthcare information. The primary intent for ______ is to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs
Balanced Budget Act of 1997 (BBA)
Addresses healthcare fraud and abuse issues.
State Children’s Health Insurance Program (SCHIP)
Established to provide health assistance to uninsured, low-income children, either through separate programs or through expanded eligibility under state Medicaid programs.
Skilled Nursing Facility Prospective Payment System (SNF PPS)
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.
Home Health Prospective Payment System (HH PPS)
Implemented October 1, 2000. Reimburses home health agencies at a predetermined rate for healthcare services provided to patients.
Outcomes and Assessment Information Set (OASIS)
A 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.
Outpatient Prospective Payment System (OPPS)
Implemented for billing of hospital-based Medicare outpatient claims. Uses Ambulatory Payment Classifications to calculate reimbursements.
Base period
Usually covers 12 months and is divided into 4 consecutive quarters.
Disability Insurance
Reimbursement for income lost as a result of a temporary or permanent illness or injury.
Liability Insurance
a policy that covers losses to a third party caused by the insured, by an object owned by the insured, or on the premises owned by the insured.
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 status.
The contractual right of a third-party payer to recover health care expenses from a liable party
Individual Health Insurance
Private health insurance policy purchased by individuals or families who do not have access to group health insurance coverage. Applicants can be denied coverage, they can also be required to pay higher premiums due to age, gender, and/or pre-existing conditions.
Public Health Insurance
Federal and state government health programs (e.g., Medicare, Medicaid, SCHIP, TRICARE) available to eligible individuals.
Single-payer Plan
Centralized healthcare system adopted by some Western nations (e.g., Canada, Great Britain) and funded by taxed. The government pays for each resident’s health care, which is considered a basic social service.
Patient record
(Medical record) documents healthcare services provided to a patient, and healthcare providers are responsible for documenting and authenticating legible, complete, and timely entries, according to federal regulations and accreditation standards. Serves as a communication tool for physicians and other patient care professionals, and assists in planning individual patient care and documenting a patients illness and treatment.
Continuity of Care
Involves documenting patient care services so that others who treat the patient have a source of information to assist with additional care and treatment.
Problem-oriented Record (POR)
A systematic method of documentation that serves as the table of contents for the patient record. It consists of four components: Database, Problem List, Initial Plan, & Progress Notes (documented using the SOAP format). It includes the chief complaint, present conditions and diagnosis, social data; past, personal, medical, and social history, review of systems, physical examination, & baseline laboratory data.
Electronic Health Record (EHR)
A global concept that includes the collection of patient information documented by a number of providers at different facilities regarding one patient.
Record Linkage
Allows patient information to be created at different locations according to a unique patient identifier or identification number.
Electronic Medical Record (EMR)
Has a more narrow focus (as compared with the EHR). The patient record created for a single medical practice and is generated using total practice management software (TPMS).
Total Practice Management Software (TPMS)
Used to generate the EMR, automating the following medical practice functions; registering patients scheduling appointments, generating insurance claims and patient statements, processing payments from patients and third-party payers, and producing administrative and clinical reports.
Personal Health Record (PHR)
A 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.