FEDERAL & STATE GOV'T HEALTH PROGRAMS

ie. medicare, medicaid, SCHIP, TRICARE

centalized healthcare adopted by Western nations

ie. canada & UK

-funded by taxes

-gov't pays for each resident's health care

-considered basic social service

FELA

(FEDERAL EMPLOYERS' LIABILITY ACT)

1916, provides civilian employees of fed. gov't with 

• medical care
• survivors benefits
• compensation for lost wages

Administered by

• Office of workers compensation OWCP
• longshore & harbor workers comp act of 1927
• black lung benefits reform act 1977

BLUE CROSS

1929, justin ford kimball, baylor university dallas

• plan to guarantee school teachers 21 days of hospital care for $6.00 peer. yr.
• became the first blue cross plan

ICD 

(INTERNATIONAL CLASSIFICATRION OF DISEASES)

1948, developed by world health organizationv(WHO)

classification system used to collect data for statistical purposes 

1940, during world war II offered to full-time employees

• not subject to income or SS taxes
• healthcare coverage available through employers & other organizations (labor unions, rural & consumer health cooperatives)
• employers usually pay part or all of the premium cost

1939, 1st plan founded in CA, grew from the lumber & mining camps of Pacific northwest at turn of century

• employers wanted to provide medical care for their workers
• they paid monthly fees to medical service bureaus, which were composed of physicians

1946, provided fedral grants for modernizing hospitals (during great depression and WWII 1929-1945)

return for federal funds, facilites provide services free or at a reduced rate to patients unable to pay for care

1947, amended national labor relations act of 1932

restoring balanced relationship between labor and management

• direct result was the creation of third-party administrators (TPAs) to administer healthcare plans & processing claims
• serving as a check and balances for labor & management

1950, coverage for catastrophic or prolonged illnesses & injuries

• large deductables
• lifetime maximum amounts- maximum benefits payable to health plan participant
• deductable-amount patient financially responsible for before ins. policy makes a payment

created medicare risk programs

• allowed federally qualified HMOs & competitive medical plans that met specified medicare requirements to provide medicare-covered services under a risk contract

provides healthcare services to americans over the age of 65

cost-sharing program between federal & state gov'ts to provide healthcare services to low-income americans

amendment to the dependants medical care act 1956 

benefit for dependants of

• personnel serving in th armed forces
• uniformed branches of public health services 
• uniformed branches of national oceanic 
• uniformed branches of atmospheric administration

Now called TRICARE

1966, developed by american medical association

annual publications prepared including changes corresponding to significant updates of medical technology & practice

large employers assume the financial risk for providing healthcare benefits to employees

• employer doesn't pay fixed premium to health ins. payer
• establishes a trust fund out of which claims are paid

1973, CHAMPVA

(CIVILIAN HEALTH & MEDICAL PROGRAM OF THE DEPT. OF VETERANS AFFAIRS)

provide healthcare benefits for dependants of veterans

• rated 100% permanently & totally disabled as a result from service-connected conditions
• who died as a result of service-connected conditions
• died on duty with less than 30 days of active service

authorized federal grants & loans to private orgs. that wished to develop health maintenance organizations

• responsible for providing healthcare services to subscribers in geographic are for a fixed fee

mandated reporting & disclosure requirements for group life & health plans

• permitted lg. employers to self-insure employee healthcare benefits
• exempted lg. employers from taxes on health insurance premiums

COINSURANCE

to combine healthcare financing & quality assurance programs into a single agency

formed within the department of health & human services

Medicare & medicaid programs also transferred to agency

was created, which included CPT level II (national) and level III (local) codes

commercial payers also adopted HCPCS coding & use of the HCFA-1500 claim

1985,COBRA

(Consolidated Omnibus Budget Reconciliation Act)

Legislation established quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of pt. test results regardless of where test the test was performed.

1992 RBRVS

Resource- Based Relative Value Scale system

Reimburses physician practice expenses base on 

3 components of each physicians service

1. Physician work
2. Practice expense
3. Malpractice inexpenseexpense

• predetermined payments for services provided 
• co-pay or coinsurance
• Payer reimburses the provider based fee schedule
• Remainder is a write off

1996 NCCI

National Correct coding initiative

• Promote nationacorrect coding methodologies
• eliminate improper coding 
• edits are developed based on coding conventions defined in AMA current procedural terminology manual

1996 HIPAA

Health Insurance Portability & Accountability Act

Regulations that govern

• Privacy
• Security
• Electronic transaction standards for health info.
• Provide better access to health insurance, limit fraud & abuse
• Reduce Administrative costs

1997 SCHIP

state children's health insurance program

Established to provide health assistance to

• low income chiThrough through separate programs
• Through expanded eligibility understate Medicaid programs

■ Personally furnished by a physician who is not a 

resident;

■ Furnished by a resident when a teaching physician is 

physically present during the critical or key portions 

of the service; or

■ Furnished by residents under a primary care 

exception within an approved Graduate Medical 

Education (GME) Program

Graduate Medical 

Education (GME) Program

PAYS FOR Medical and surgical services furnished by an intern or 

resident within the scope of his or her training program 

are covered as provider services

resources are funded by medicare

 Indirect Medical Education 

(IME) 

payments, and the services of the intern or 

resident may not be billed or paid for using the MPFS. 

If a resident in an approved program is training in a nonprovider setting

If a resident in an approved program is training

in a nonprovider setting, the services provided by that 

resident are payable in one of two ways:

_{1. Through direct GME and IME payments to the} hospital if:

-the resident is providing patient care activities direct GME purposes

-The resident spends time in certain nonpatient care activities in certain nonhospital settings
-if the hospital incur the costs of the salaries and fringe benefits of the resident during the time the resident spends in the nonprovider setting

_{2.  MPFS if, regs.concerning the receipt of direct GME and IME} 

^{-the time spent by the resident in the nonprovider setting is not counted by the hospital for direct GME and IME payment purposes are not met.}

^{-time spent by res. in nonprovider setting is not counted by hosp. for direct GME & IME payment.}