Chapter 7: Reimbursement for Health Care Services

Question 1

Medical Insurance

Answer 1

contract between a policyholder and an insurance company to reimburse a percentage of the cost of the policyholder’s medical bills

Question 2

Policy

Answer 2

contract between an insurance company and an individual or organization

Question 3

Health Insurance

Answer 3

type of policy designed to reimburse the cost of preventative as well as corrective medical care

Question 4

Athletic-Accident Insurance

Answer 4

type of insurance policy intended to reimburse medical vendors associated with acute athletic accidents

Question 5

Exclusions

Answer 5

situations or circumstances specifically not covered by an insurance policy

Question 6

Rider

Answer 6

additions to a standard insurance policy that provide coverage for conditions that are normally not covered

Question 7

Premium

Answer 7

the invoiced cost of an insurance policy

Question 8

Catastrophic Insurance

Answer 8

type of accident insurance designed to provide lifelong medical, rehabilitation, and disability benefits for the victims of devastating injury

Question 9

Disability Insurance

Answer 9

insurance designed to protect an athlete against future loss of earnings because of a disabling injury or sickness

Question 10

Experimental Treatments

Answer 10

therapies not proved effective

Question 11

Usual, Customary, and Reasonable Fee (UCR)

Answer 11

charge consistent with what other medical vendors would assess

Question 12

90th Percentile Fee

Answer 12

fee below which 90% of all other medical vendors in a particular geographic area charge for a specific service

Question 13

Primary Coverage

Answer 13

type of health, medical, or accident insurance that begins to pay for covered expenses immediately after a deductible has been paid

Question 14

Secondary Coverage

Answer 14

excess insurance; type of health, medical, or accident insurance that begins to pay for covered expenses only after all other sources of insurance coverage have been exhausted

Question 15

Third Party Reimbursement

Answer 15

process by which medical vendors receive reimbursement from insurance companies for services provided to policyholders

Question 16

Third Party

Answer 16

medical vendor with no binding interest in a particular insurance contract

Question 17

Fee-for-Service Plan

Answer 17

indemnity plan; type of traditional medical insurance whereby patients are free to seek medical services from any provider; plan covers a portion of the cost covered procedures, and patient is responsible for balance

Question 18

Health Maintenance Organization (HMO)

Answer 18

type of health insurance plan that requires policyholders to use only those medical vendors approved by the company; all medical services are coordinated by a primary care physician, who acts as a gatekeeper to specialty services

Question 19

Capitation

Answer 19

system whereby medical vendors receive a fixed amount per patient

Question 20

Individual Practice Association (IPA)

Answer 20

managed-care model whereby an HMO provides healthcare services through a network of individual medical practitioners; care is provided in a physician’s office as opposed to large, multifunctional medical center

Question 21

Preferred Provider Organization (PPO)

Answer 21

type of health insurance plan that provides financial incentives to encourage policyholders to use medical vendors approved by the company

Question 22

Exclusive Provider Organization (EPO)

Answer 22

type of PPO whereby medical services are reimbursed only if the patient uses contracted providers

Question 23

Point-of-Service Plan

Answer 23

managed-care plans similar to PPO, except that primary care physicians are assigned to patients to coordinate their care

Question 24

Fraud

Answer 24

criminal misrepresentation for the purpose of financial gain

Question 25

International Classification of Disease (ICD-9-CM)

Answer 25

a coding system applied to illnesses, injuries, and other medical conditions, to standardize the language associated with third-party reimbursement

Question 26

Current Procedural Terminology (CPT)

Answer 26

coding system applied to medical procedures to standardize the language associated with third-party reimbursement

Question 27

Insurance Claim Registry Form

Answer 27

worksheet that aids in tracking the progress of an insurance claim through the entire process

Question 28

Explanation of Benefits Form (EOB)

Answer 28

summary prepared by an insurance company, and sent to a policyholder, that documents how the insurance policy covered the charges associated with a particular claim

Question 29

Managed Care

Answer 29

growing concept in the insurance industry emphasizing cost control through coordination of medical services, such as with an HMO or PPO

Question 30

Primary Care Provider

Answer 30

physicians selected by an HMO provider, who acts as the first source of medical service for the patient; most HMOs require members to seek a referral from the primary care provider before seeking care from another medical vendor

Question 31

CM5 1500

Answer 31

form that private practice clinics should use when filing a claim with an insurance company; originally developed for Medicare claims

Question 32

UB-92

Answer 32

CMS 1450; insurance claim form that hospitals should use

Question 33

Electronic Data Interchange (EDI)

Answer 33

system whereby insurance claims can be submitted electronically; paperless claims system

Question 34

Insurance Agent

Answer 34

representation of an insurance company or an independent insurance agency who sells and services insurance policies

Question 35

Layered Coverage

Answer 35

method of using different insurance companies to write different levels of coverage in a common policy

Question 36

Co-payments

Answer 36

percentage of medical bill not paid for by the insurance company