Chapter 7 Definitions Flashcards
medical insurance
a contract between a policyholder and an insurance company to reimburse a percentage of the cost of the policyholder’s medical bills
policy
a contract between an insurance company and an individual or organization
health insurance
a type of policy designed to reimburse the cost of preventative as well as corrective medical care
athletic accident insurance
a type of insurance policy intended to reimburse medical cendors for hte expenses assoicated with acute athletic accidents
exclusions
situations or circumstances specifically not covered by an insurance policy
rider
additions to a standard insurance policy that provide coverage for conditions that are normally not covered
premium
the invoiced cost of an insurance policy
catastrophic insurance
a type of accident insurance designed to provide lifelong medical, rehabilitation, and disability benefits for the victims of devastating injury
disability insurance
insurance designed to protect an athlete agaiinst future loss of earnings because of a disabling injury or sickness
experimental treatments
therapies not proved effective
usual, customary, and reasonable fee (URC)
the charge consistent with what other medical vendors would assess
90th-percentile fee
the fee below which 90% of all other medical vendors in a particular geographic area charge for a speific service
primary coverage
a type of health, medical, or accident insurance that begins to pay for covered expenses immediately after a deductible has been pain
secondary coverage
a type of health, medical, or accident insurance that begins to pay for coverage expenses only after all other sources of insurance coverage have been exhausted. also known as excess insurance
third-party reimbursement
the process by which medical vendors receive reimbursement form insurance companies for services provided to policyholders
third-party
a medical vendor with no binding interest in a particular insurance contract
fee-for-service plan
also known as an indemnity plan. a type of traditional medical insurance wherby patients are free to seek medical services from any provider. The plan covers a portion of the cost of covered procedures, and the patient is responsible for the balance
health maintenance organization (HMO)
a type of health insurance plan that requires policyholders to use only those medical vendors approved by the compnay. all medical services are coordinated by a primary care physician, who acts as a gatekeeper to specialty services
capitation
a system wherby medical vendors receive a fixed amount per patient
individual practice association (IPA)
a managed-care model whereby a HMO provides helath care services through a network of individual medicla practitioners. care is provided in a physician’s office as opposed to a large, multifuntional medical center
preferred provider organization (PPO)
a type of health insurance plan that provides financial incentives to encourage policyholders to use medical vendors approved by the company
exclusive provider organizaiton (EPO)
a type of PPO wherby medical services are reimbursed only if the patient uses contracted providers
point-of-service plan (POS)
managed-care plans that are similar to PPOs, except that primary care physicians are assigned to patients to coordinate their care
fraud
criminal misrepresentation for the purpose of financial gain
international classification of diseases (ICD-9-CM)
a coding system applied to illnesses, injuries, and other medical conditions to standardize the language associated with third-party reimbursement
current procedural terminology (CPT)
a coding system applied to medical procedures to standardize the language associated with third-party reimbursement
managed care
a growing concept in the insurance industry emphasizing cost control through coordination of medical services, such as with an HMO or PPO
primary care provider
the physician, selected by an HMO member, who acts as the first source of medical service for the patient. most HMOs requrie members to seek a referral from the primary care provider before seekign care form another medical vendor
CMS 1500
the form that private-practice clinics should use when filing a claim with an insurance company. orginally developed by the health care financing administration (now known as the centers for medicare and medicaid services) for Medicare claims
UB-92 AKA CMS 1450
insurance claim form that hospitals should use
electronic data interchange (EDI)
a system wherby insurance claims can be submitted electronically. also known as paperless claims system
insurance agent
a repesentative of an insurance company or an independent insurance agency who sells and services insurance policies
layered coverage
a method of using different insurance companies to underwrite different levels of coverage in a common policy
copayments
the percentage of a medical bill not paid for by the insurance company
