BASIC INSURANCE TERMINOLOGY Flashcards
Fraud
Providers, patients, or insurance companies may be found fraudulent if they are deliberately achieving their ends through misrepresentation, dishonesty, and general illegal activity
Open Enrollment
The yearly period when people can enroll in a health insurance plan or make changes to current health plans for the following year
Preferred Provider Organization (PPO)
Similar to an HMO
A patient can receive healthcare from providers within and established network set up by an insurance company, but is not restrictive to an HMO
Larger group of providers to choose from
Health Maintenance Organization (HMO)
Type of health insurance plan that usually limits coverage to care from a doctor or group of doctors who are contracted with the HMO
Generally will not cover out-of-network care except in an emergency
Have the most restricted coverage area (a very small group of providers to choose from)
Group Health Plan
Insurance plan provided by an employer to a group of employees
Group Name
Name given to the group of employees in the group health plan by the insurance carrier
Subscriber
Main individual covered under a group policy
i.e., an employee of a company with a group health policy would be one of many subscribers on that policy
Beneficiary
Person who is eligible and entitled to Medicare benefits
Any person or covered entity under an insurance policy who receives benefits
Network Provider
a.k.a. in-network
Providers within a health insurance company’s network that has contracted with the company to provide discounted services to a patient covered under the company’s plan
Using an in-network provider or participating provider will result in less financial responsibility for the patient
Out-of-Network (OON)
Providers outside of an established network of providers who contract with an insurance company to offer patients healthcare at a discounted rate
Using out-of-network providers typically costs the patient more
Patient is responsible for any amount the insurance does not reimburse
Pre-Authorization or Pre-Certification
Process of notifying and receiving approval from the insurance carrier prior to services or procedures being done
Some insurance plans require this be done or risk the charge being denied entirely or the reimbursement reduced
Preventive or Routine Services
Services intended to prevent illnesses and detect health concerns early, before symptoms are noticeable
Diagnostic Care
Provided to diagnose or treat symptoms the patient already has by monitoring the existing problem, checking out new symptoms, or following up on abnormal test results
Inpatient Admission
Status for a patient who is admitted to a hospital or facility on doctors orders for a severe medical condition (usually trauma or severe illness)
Outpatient Services
Patient who receives medical treatment without being admitted to a hospital
Observation Status
Hospital status indicating the patient is not sick enough to require an inpatient admission, but is too sick to be discharged without needing to be monitored for a period of time, sometimes overnight to determine if admission is eventually necessary
Non-Covered Charges
Procedures and services not covered or excluded by a patient’s health insurance plan
Self-Administered Drugs (SADs)
Medicare considers any drug a patient is able to take or consume themselves (oral, topical, injectable, or via eye drop) a SAD
Medicare does not cover any SAD charges for non-inpatient visits
Part D plans ‘may’ cover the SAD, but not always
The facility cannot bill Medicare for these charges because they are excluded from coverage, but must balance bill the patient
These charges generally are more expensive because they are being provided in the facility setting
Referral
Requiring a general practitioner to see a patient before a specialist will set up a visit
Secondary Insurance Coverage
Processes after primary insurance has finalized the claim
Tertiary Insurance Coverage
Processes after primary and secondary insurances have finalized the claim
Coordination of Benefits (COB)
Process of determining the order the insurance companies will process claims
i.e., primary vs. secondary insurance
Contractual Adjustment
Binding agreement between an in-network provider, patient, and insurance company where the provider agrees to write-off certain amounts
Patients are not responsible for the contractual adjustment amounts
Allowed Amount
Amount an insurance company will use to calculate the patient responsibility
Excludes contractual adjustments and non-covered charges
