Test Bank For Understanding Health Insurance A Guide to Billing and Reimbursement - 2021 Edition - 26th - 2022 All Chapters - 9780357515587

Understanding Health Insurance h h




HealthhInsuranceh-h

Ahcontracthbetweenhahpolicyholderhandhahthird-
hhhhhhhhhhhhhh

partyhpayerhorhgovernmenthprogramhtohreimbursehthehpolicyholderhforhallhorhahportionhofhthehcosthofh
medicallyhnecessaryhtreatmenthorhpreventivehcarehprovidedhbyhhealthcarehprofessionals.



GrouphHealthhInsuranceh-h

Traditionalhhealthcarehcoveragehsubsidizedhbyhemployershandhotherhorganizationsh(e.g.,hlaborh
hhhhhhhhhhhhhh

unions,hruralhandhconsumerhhealthhcooperatives)hwherebyhparthorhallhofhpremiumhcostsharehpaidhforha
nd/orhdiscountedhgrouphratesharehofferedhtoheligiblehindividuals.



PersonalhHealthhRecordh(PHR)h-h

Ahweb-
hhhhhhhhhhhhhh

basedhapplicationhthathallowshindividualshtohmaintainhandhmanagehtheirhhealthhinformationh(andhthath
ofhothershforhwhomhtheyharehauthorized,hsuchhashfamilyhmembers)hinhahprivate,hsecure,handhconfidenti
alhenvironment.



TotalhPracticehManagementhSoftwareh(TPMS)h-h

UsedhtohgeneratehthehEMR,hautomatinghthehfollowinghmedicalhpracticehfuncitons;hregisteringh
hhhhhhhhhhhhhh

patientshschedulinghappointments,hgeneratinghinsurancehclaimshandhpatienthstatements,hprocessinghp
aymentshfromhpatientshandhthird-partyhpayers,handhproducinghadministrativehandhclinicalhreports.



ElectronichMedicalhRecordh(EMR)h-h

Hashahmorehnarrowhfocush(ashcomparedhwithhthehEHR).hThehpatienthrecordhcreatedhforhahsingl
hhhhhhhhhhhhhh

ehmedicalhpracticehandhishgeneratedhusinghtotalhpracticehmanagementhsoftwareh(TPMS).



FederalhEmployees'hCompensationhActh(FECA)h-h

Replacedhtheh1908hworkers'hcompensationhlegislation,handhcivilianhemployeeshofhthehfederalh
hhhhhhhhhhhhhh

governmenthwerehprovidedhmedicalhcare,hsurvivor'shbenefits,handhcompensationhforhlosthwages.hAdmi
nisteredhbyhthehOfficehofhWorker'shCompensationhProgramsh(OWCP).



Self-insuredh(orhself-funded)h-h

employer-
hhhhhhhhhhhhhh

sponsoredhgrouphhealthhplanshAllowshlargehemployershtohassumehthehfinancialhriskhforhprovidinghhealt

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,hcarehbenefitshtohemployees.hThehemployerhdoeshnothpayhahfixedhpremiumhtohahhealthhinsurancehpaye
r,hbuthestablisheshahtrusthfundh(ofhemployerhandhemployeehcontributions)houthofhwhichhclaimsharehpaid
.



CivilianhHealthhandhMedicalhProgramh-UniformedhServicesh(CHAMPUS)h-h

Designedhashahbenefithforhdependentshofhpersonnelhservinghinhtheharmedhforceshandhuniforme
hhhhhhhhhhhhhh

dhbrancheshofhthehPublichHealthhServicehandhthehNationalhOceanichandhAtmospherichAdministration.hT
hishprogramhishnowhcalledhTRICARE.



Medicaidh(TitlehXIXhofhthehSSAhofh1965)h-h

ishahcost-
hhhhhhhhhhhhhh

sharinghprogramhbetweenhthehfederalhandhstatehgovernmentshtohprovidehhealthcarehserviceshtohlow-
incomehAmericans.h(OriginallyhadministeredhbyhthehSocialhandhRehabilitationhServiceh[SRS]).



Medicareh(TitlehXVIIIhofhthehSSAhofh1965)h-h

provideshhealthcarehserviceshtohAmericanshoverhthehagehofh65.h(Originallyhadministeredhbyhth
hhhhhhhhhhhhhh

ehSocialhSecurityhAdministration).



LifetimehMaximumhAmounth-h

Thehmaximumhbenefitshpayablehtohahhealthhcarehparticipant.
hhhhhhhhhhhhhh




Deductibleh-h

Thehamounthforhwhichhthehpatienthishfinanciallyhresponsiblehbeforehanhinsurancehpolicyhprovid
hhhhhhhhhhhhhh

eshpayment.



MajorhMedicalhInsuranceh-h

Provideshcoveragehforhcatastrophichorhprolongedhillnesseshandhinjuries.hMosthofhthesehprogra
hhhhhhhhhhhhhh

mhincorporatehlargehdeductibleshandhlifetimehmaximumhamounts.



InternationalhClassificationhofhDiseasesh(ICD)h-h

Ahclassificationhsystemhusedhtohcollecthdatahforhstatisticalhpurposes.
hhhhhhhhhhhhhh




WorldhHealthhOrganizationh(WHO)h-h




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, DevelopedhthehInternationalhClassificationhofhDiseasesh(ICD),hahclassificationhsystemhusedhtohc
hhhhhhhhhhhhhh

ollecthdatahforhstatisticalhpurposes.



Third-partyhAdministratorshAnhindirecthresulthofhthehTaft-HartlyhActhofh1947.h-h

Administershhealthcarehplanshandhprocesshclaims,hthushservinghashahsystemhofhcheckshandhbal
hhhhhhhhhhhhhh

anceshforhlaborhandhmanagement.



Hill-BurtonhActh-h

Thishprovidedhfederalhgrantshforhmodernizinghhospitalshthathhadhbecomehobsoletehbecausehof
hhhhhhhhhhhhhh

hahlackhofhcapitalhinvestmenthduringhthehGreathDepressionhandhWWIIh(1929-

1945).hInhreturnhforhfederalhfunds,hfacilitieshwerehrequiredhtohprovidehserviceshfreehorhathreducedhrates
htohpatientshunalblehtohpayhforhcare.




OccupationalhSafetyhandhHealthhAdministrationhActhofh1970h(OSHA)h-h

Designedhtohprotecthallhemployeeshagainsthinjurieshfromhoccupationalhhazardshinhthehworkpla
hhhhhhhhhhhhhh

ce.



HealthhCarehFinancinghAdministrationh(HCFA)h-h

TohcombinehhealthcarehfinancinghandhqualityhassurancehprogramshintohahsinglehagencyhthehHC
hhhhhhhhhhhhhh

FAhwashformedhwithinhthehDepartmenthofhHealthhandhHumanhServicesh(DHHS).hThehMedicarehandhMe
dicaidhprogramshwerehalsohtransferredhtohthehnewlyhcreatedhagency.h(HCFAhishnowhcalledhthehCentershf
orhMedicarehandhMedicaidhServiceshorhCMS.)



CivilianhHealthhandhMedicalhProgramhofhthehDepartmenthofhVeteranshAffairsh(CHAMPVA)h-h

Provideshhealthcarehbenefitshforhdependentshofhveteranshratedhash100hpercenthpermanentlyha
hhhhhhhhhhhhhh

ndhtotallyhdisabledhashahresulthofhservice-
connectedhconditions,hveteranshwhohdiedhashahresulthofhservice-
connectedhconditions,handhveteranshwhohdieshonhdutyhwithhlesshandh30hdayshofhactivehservice.



MedicarehContractinghReformhinitiativeh(MCR)h-h

EstablishedhtohintegratehthehadministrationhofhMedicarehPartshAhandhBhfee-for-
hhhhhhhhhhhhhh

serviceshbenefitshwithhnewhentitieshcalledhMedicarehadministrativehcontractorsh(MACs)



RecordhLinkagehAllowsh-h

patienthinformationhtohbehcreatedhathdiffernethlocationshaccourdinghtohahuniquehpatienthidenti
hhhhhhhhhhhhhh

fierhorhidentificatonhnumber.

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, AmericanhRecoveryhandhReinvestmenthActhofh2009h(ARRA)h-h

Authorizedhanhexpenditurehofh$1.5hillionhforhgrantshforhconstruction,hrenovation,handhequipm
hhhhhhhhhhhhhh

ent,handhforhthehacquisitionhofhhealthhinformationhtechnologyhsystems.



ElectronichHealthhRecordh(EHR)h-h

Ahglobalhconcepththathincludeshthehcollectionhofhpatienthinformationhdocumentedhbyhahnumb
hhhhhhhhhhhhhh

erhofhprovidershathdifferenthfacilitieshregardinghonehpatient.



HealthhInformationhTechnologyhforhEconomichandhClinicalhHealthhActh(HITECH)h-h

IncludedhinhthehARRA,hthishacthammendedhthehPublichHealthhServiceshActhtohestablishhanhOffic
hhhhhhhhhhhhhh

ehofhNationalhCoordinatorhforhHealthhInformationhTechnologyhwithinhHHShtohimprovehhealthcarehquali
ty,hsafety,handhefficiency.



Problem-orientedhRecordh(POR)h-h

Ahsystematichmethodhofhdocumentationhthathserveshashthehtablehofhcontentshforhthehpatienthr
hhhhhhhhhhhhhh

ecord.hIthconsistshofhfourhcomponents:hDatabase,hProblemhList,hInitialhPlan,h&hProgresshNotesh(docume
ntedhusinghthehSOAPhformat).hIthincludeshthehchiefhcomplaint,hpresenthconditionshandhdiagnosis,hsocial
hdata;hpast,hpersonal,hmedical,handhsocialhhistory,hreviewhofhsystems,hphysicalhexamination,h&hbaseline

hlaboratoryhdata.




Patienthrecordh(Medicalhrecord)h-h

documentshhealthcarehserviceshprovidedhtohahpatient,handhhealthcarehprovidersharehresponsi
hhhhhhhhhhhhhh

blehforhdocumentinghandhauthenticatinghlegible,hcomplete,handhtimelyhentries,haccordinghtohfederalhre
gulationshandhaccreditationhstandards.hServeshashahcomunicationhtoolhforhphysicianshandhotherhpatient
hcarehprofessionals,handhassistshinhplanninghindividualhpatienthcarehandhdocumentinghahpatientshillnessh

andhtreatment.



ContinuityhofhCareh-h

Involveshdocumentinghpatienthcarehserviceshsohthathothershwhohtreaththehpatienthhavehahsourc
hhhhhhhhhhhhhh

ehofhinformationhtohassisthwithhadditionalhcarehandhtreatment.



HealthhMaintenancehOrganizationhAssistancehActhofh1973h-h

Authorizedhfederalhgrantshandhloanshtohprivatehorganizationshthathwishedhtohdevelophhealthh
hhhhhhhhhhhhhh

maintenancehorganizationsh(HMOs).



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