HITT 1445- Exam5
Home > Flashcards > Print Preview
The flashcards below were created by user
on FreezingBlue Flashcards
. What would you like to do?
- Ancillary services providers , such as laboratory, radiolgy, and pharmacy.
- ie..specialty providers
Co-payment: A payment made by an individual who has health insurance, usually at the time a service is received, to offset some of the cost of care. Co-payments are a common feature of HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) health plans in the US. Co-payment size may vary depending on the service, generally with low copayments required for clinic visits and higher payments for other services such as those received in an emergency department. Also called co-insurance.
1.Staff Model HMO
A type of HMO wherein all premiums are paid directly to the HMO, which hires physicians. The physicians are then paid a salary and predetermined bonuses.
2.Group Model HMO
An HMO that contracts with certain provider groups, with whom rates for medical care are negotiated. The HMO then pays the negotiated rate for care provided to the policyholders. Contracts are also made with hospitals for care provided to the policyholders.
3.Individual Practice Association (IPA) Model HMO
An arrangement wherein an individual practice association provides medical services from physicians they have contracted with.
4.Network Model HMO
An HMO model that contracts with multiple physician groups. The physician groups are free to provide care for other individuals not covered by the HMO.
Incentive With Hold
A fiduciary relationship that is legally binding where a trustee will hold and manage assets that are contributed to a trust by a grantor. Incentive trusts can be considered to be conditional inheritance for heirs or other beneficiaries that are named in the trust as there are specific conditions that these beneficiaries must meet prior to receiving funds from the trust.
Preferred Provider Arrangement
preferred provider organization (PPO)
An alternative to an HMO network available under certain health insurance plans. A network of care providers who treat members of a health insurance plan for a pre-determined fee. The insured may be required to pay a small co-payment and the rest of the charge is usually covered by the plan. This type of network is less restrictive than an HMO, as the insured is free to choose a hospital and physician.
Primary Care Physician
Individual that serves as the primary care point of contact. This doctor has typically provided medical services to the patient for an extended period of time. Some primary care physicians have treated some of their patients since they were born. This individual also treats most medical issues for patients that do not require the assistance of a specialist.
Characteristic of a resource that is committable, operable, or usable upon demand to perform its designated or required function. It is the aggregate of the resource's accessibility, reliability, maintainability, serviceability, and securability.
1. Extent to which a consumer or user can obtain a good or service at the time it is needed.
2. Ease with which a facility or location can be reached from other locations.
3. Ease of contact with a person or organization.
4. Authorization, opportunity, or right to access records or retrieve information from an archive, computer system, or website.
Resource-Based Relative Value Scale
A scale used by Medicare to determine how doctors will be compensated.
Capitation System (Johns p291)
Capitation is a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.
Usual, Customary, and Reasonable Charges Plan
Denotes the base amount that is treated as the most typical charge for a medical service when provided in a specific geographic region. Third-party payers such as insurance carriers and employers implement these fees to conclude the amount to be paid on behalf of the enrollee, for services that are recompensed by a health insurance policy or plan.
DRG payment system
- Diagnosis-related group (DRG) is a system to classify hospital cases into one of originally 467 groups. The system is also referred to as "the DRGs", and its intent was to identify the "products" that a hospital provides.
- Mandated by TEFRA (Tax Equity and Fiscal Responsibility Act of 1982)
Financial institution (such as a bank, credit union, finance company, insurance company, stock exchange, brokerage company) which acts as the 'middleman' between those who want to lend and those who want to borrow.
Who manages the processing of Medicare Part B claims
The Multi Carrier System (MCS) is a critical component of the Fee For Service (FFS) program, processing millions of Medicare claims a year, supporting Medicare's mission to provide quality health care to beneficiaries. The MCS is one of the shared systems used to process Medicare Part B claims for physician care, durable medical equipment, and other outpatient services nationwide. MCS meets CMS' core requirements for processing Medicare Part B claims, to include: data collection and validation, claims control, pricing, adjudication, correspondence, on-line inquiry, file maintenance, reimbursement, and financial processing.
Whom Manages Medicare payment to providers
By 2011, new Medicare Administrative Contractors (MACs) will replace Medicare contractors. The Centers for Medicare & Medicaid Services (CMS) contract with insurance companies nationwide to evaluate, process and pay over 1 billion Medicare claims each year. Medicare contractors who operate under insurance companies use national and local coverage regulations and policies to determine what is "reasonable and medically necessary" for paying claims.
They can vary by region
They are not assigned by the state
In 1946, Congress passed a law that gave hospitals, nursing homes and other health facilities grants and loans for construction and modernization. In return, they agreed to provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area. The program stopped providing funds in 1997, but about 170 health care facilities nationwide are still obligated to provide free or reduced-cost care.
Access control refers to exerting control over who can interact with a resource. Often but not always, this involves an authority, who does the controlling. The resource can be a given building, group of buildings, or computer-based information system.
Accredited Standards Committee X12N
ASC X12, chartered by the American National Standards Institute(ANSI) provides stadards for hospitals, professional, and dental claims, eligibility inquireies, electronic remittance advice, and or standards (as mandated by HIPAA)
An audit trail (or audit log) is a security-relevant chronological record, set of records, or destination and source of records that provide documentary evidence of the sequence of activities that have affected at any time a specific operation, procedure, or event
is the act of confirming the truth of an attribute of a datum or entity.
Certification Commission for Health Information Technology (CCHIT)
The Certification Commission for Health Information Technology (CCHIT) is an independent, 501(c)3 nonprofit organization with the public mission of accelerating the adoption of robust, interoperable health information technology. The Commission has been certifying electronic health record technology since 2006 and is approved by the Office of the National Coordinator for Health Information Technology (ONC) of the U.S. Department of Health and Human Services (HHS) as an Authorized Testing and Certification Body (ONC-ATCB). The CCHIT Certified program is an independently developed certification that includes a rigorous inspection of an EHR’s integrated functionality, interoperability and security using criteria developed by CCHIT’s broadly representative, expert work groups. These products may also be certified in the ONC-ATCB certification program.
Health Level Seven (HL7), is a non-profit organization involved in the development of international healthcare informatics interoperability standards. "HL7" also refers to some of the specific standards created by the organization. HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information. The 2.x versions of the standards, which support clinical practice and the management, delivery, and evaluation of health services, are the most commonly used in the world.
What would you like to do?
Home > Flashcards > Print Preview