Genetic Counselors in the Healthcare Ecosystem Flashcards

Flashcards covering health care systems, federal policies, US insurance logistics, professional regulation, billing, and clinical service models for genetic counseling.

Universal Healthcare Coverage (UHC)

A health care infrastructure where all people can go to the doctor for sick or preventive care, and the government ensures the ability to pay for that care.

Single-payer health system

A government-run and funded payer system, such as those found in Cuba and the United Kingdom, where health care is delivered through government-run hospitals and providers are often government employees.

Medicare

A public insurance program in the US provided to individuals aged $65$ or older, or to those with specific disabilities like ALS or End-Stage Renal Disease.

Medicaid

A joint federal and state insurance program for individuals below specific income thresholds, including children, pregnant women, and people with disabilities.

Accountable Care Organization (ACO)

An umbrella system, also called an Integrated Health System, where the same overall entity acts as both the insurer and the care provider (e.g., Kaiser Permanente).

Academic Medical Center

An institution typically having three goals: to provide patient care, to conduct research, and to train the health care workforce.

Federally Qualified Health Centers (FQHCs)

Centers designated to receive funds from the Health Services and Resource Administration to provide community-based primary care in underserved areas.

Genetic Information Nondiscrimination Act (GINA)

A $2008$ federal law preventing discrimination based on genetic information by health insurers (eligibility/premiums) and employers (hiring/firing/promotions).

Affordable Care Act (ACA)

A $2010$ law that expanded insurance access via subsidies, mandated coverage for pre-existing conditions, and required coverage for preventive measures like $BRCA1$ and $BRCA2$ testing.

21st Century Cures Act

A $2016$ law designed to accelerate rare disease treatments and promote communication between electronic health records while penalizing "information blocking."

Access to Genetic Counselor Services Act

Proposed federal legislation to add genetic counselors as recognized providers under the Social Security Act to permit reimbursement for services to Medicare beneficiaries.

Centers for Medicare and Medicaid Services (CMS)

The federal agency that administers the Medicare program and works with states to administer the national Medicaid program.

Medicare Administrative Contractors (MACs)

Private companies delegated by Medicare to process claims and establish regional policies known as Local Coverage Determinations (LCDs).

National Coverage Determinations (NCDs)

Medical policies issued by CMS that apply as a minimum standard for what should be covered for all Medicare beneficiaries nationwide.

Managed Care Organizations (MCOs)

Entities contracted by states to manage Medicaid plans per covered life while meeting specific quality standards.

Premium

The monthly amount paid by a member to enroll in a health insurance plan.

Co-pay

A portion of a service cost paid by the insured member at the time of service to create a disincentive for overutilization.

Deductible

Set amount an insured person must pay out of pocket before the insurance company begins to pay for care.

Coinsurance

The percentage of costs a patient is responsible for after meeting their deductible (e.g., $20\%$ for Medicare Part B).

Balance billing

The practice where a provider bills a patient for the difference between the provider’s charge and the allowed amount determined by the insurer.

Allowed amount

The maximum amount an insurer will pay for a particular medical service.

Current Procedural Terminology (CPT)

A code set created by the American Medical Association (AMA) used as the official standard for communicating medical procedures between providers and insurers.

ICD-10

The $10\text{th}$ edition of the International Classification of Diseases, used to communicate a patient's diagnosis and the reason for a service.

Prior authorization

An administrative process where a healthcare provider obtains approval from an insurance company before performing a service to ensure it is deemed medically necessary.

Certification (CGC)

A voluntary credential managed by the American Board of Genetic Counseling (ABGC) that measures competency to practice in the field.

Licensure

Legal authority granted by a state government to work in an occupation, intended to protect the public from unqualified practitioners.

Title protection

Legal definition within licensure laws specifying who is allowed to call themselves a "genetic counselor" in a particular state.

Credentialing

A process undertaken by institutions and third-party payers to verify a provider's qualifications to perform duties and receive reimbursement.

Evaluation and Management (E&M) codes

A category of CPT codes (ranges $99202$ to $99499$) used for billing outpatient office visits based on duration and complexity.

Incident-to billing

A billing method allowing services by non-physicians (like genetic counselors) to be billed under a supervising physician’s NPI number at the physician rate.

Relative Value Unit (RVU)

A unit of measure for the work and resources required to perform a service, used by CMS to determine payment rates.

Patient-Related Activities (PRAs)

Tasks handled outside face-to-face appointments, including note writing, medical record review, and coordination of care.

Service Delivery Models (SDMs)

Different modes or workflows for providing genetic counseling, such as telegenetics, group counseling, or using genetics extenders.

Genetic Counseling Assistants (GCAs)

Support staff who handle non-clinical tasks like pedigree drawing and records requests to allow genetic counselors to work at the top of their scope.

Downstream revenue

Revenue generated from additional consults, imaging, or surgeries that occur as a result of a patient's initial genetics visit or test results.

Institutional Review Board (IRB)

A board that evaluates research designs to protect the rights and welfare of human subjects, focusing on ethical treatment.

Assent

The agreement of a minor (typically age $7$ or older) to participate in research, which must be obtained alongside parental consent.

Section 504 Plan

A plan derived from civil rights law that provides accommodations for students with disabilities to ensure access to the learning environment (e.g., physical tools).

Individualized Education Program (IEP)

A plan for students (ages $3$ to $22$) with one of $13$ qualifying disabilities who require specially designed instruction with measurable goals.

Explanation of Benefits (EOB)

A document sent by an insurance company to a patient detailing services provided, amounts billed, covered amounts, and the patient's remaining responsibility.