Chp 13 Flashcards
Health Insurance and Reimbursement
group of physicians, hospitals, and other providers who have joined together to provide coordinated care to their patients.
Accountable care organizations
(ACO)
provides uninsured Americans with affordable health coverage. This law gave new rights, benefits, and protections regarding health insurance to all Americans. Some of the important features of the law include coverage for required preventative and wellness services.
Affordable Care Act
(ACA)
transfer of the patient’s legal right to collect third-party benefits for medical expenses to the provider of the services.
Assignment of benefits
billing the patient for the balance or difference between the physician’s charges and the Medicare-approved charges; prohibited by most managed care contracts.
Balance billing
commonly used by benefit plans and claims administratiors to coordinate the benefits of dependent children covered byh two plans.
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Birthday rule
managed care plan that pays a certain amount to a provider over a specific time for caring for the patients in the plan regardless of what or how many services are performed.
Capitation
a company that assumes the risk of an insurance company.
Carrier
requests to an insurance company for reimbursement of costs.
Claims
an individual who manages the thir-party reimbursement policies for a medical practice.
Claims administrator
the agreed-upon amount paid to the provider by a policyholder, also called “copayment.”
Coinsurance
the method of designating the order in which multiple carriers pay benefits to avoid duplication of payment.
Coordination of benefits
that part of an insured service the patient must pay (copay).
Copayments
claim that crosses over automatically from one coverage to another for payment.
Crossover claim
a specific amount paid by the policyholder before the carrier begins paying.
Deductible
spouse, children, and sometimes other individuals designated by the insured who are covered under a health care plan.
Dependent
categories used to determine hospital and physician reimbursement for Medicare patients’ inpatient services.
Diagnosis-related groups
(DRGs)
the determination of an insured’s right to receive benefits from a third-party payer based on such criteria as payment of premiums and date of start of coverage.
Eligibility
a person hired to perform given duties in return for financial compensation.
Employee
a statement that accompanies a payment from an insurance carrier and outlines which duties and services are being paid.
Explanation of Benefits
(EOB)
an established set of fees charged for specfic services and paid by the patient or insurance carrier.
Fee-for-service
a list of pre-established fee allowances set for specific sercvices and procedures performed by a provider.
Fee schedule
a policyholder who is a member of a group and covered by the group’s insurance carrier.
Group member
a benefit offered by some employers that allows employees to save money through payroll deduction to accouts that can only be used for medical care.
Health care savings account
(HSA)
a policy that promises to pay some or all of a customer’s medical bills.
Health insurance
several independently practicing physicians contracted with HMO to provide services to HMO members.
Independent practice association
(IPA)
an individual who owns a policy that promises to pay some or all of his or her medical bills.
Insured
the practice of third party payers to control costs by requiring physicians to adhere to specific rules as a condition of payment.
Managed care
social security-established health insurance for low-income or indigent persons of all ages.
Medicaid
social security - established health insurance for older adults.
Medicare
the 10-digit identification number assigned to all health care providers as part of the HIPAA Administration Simplification Standard.
National Provider Identifier
(NPI)
payment for health care services that are the responsibility of the patient or guarantor.
Out-of-pocket
a model of health care delivery in which the PCP coordinates the care for patients and refers patients to other providers for medical care as needed.
Patient-Centered Medical Homes
(PCMH)
organization of a group of physicians and specialists that conducts a review of a disputed case and makes a final recommendation.
Peer review organization
a coalition of physicians and a hospital contracting with large employers, insurance carriers, and other benefits groups to provide discounted health services.
Physician hospital organization
(PHO)
the highest amount paid by a third-party payer for any given service.
Plan maximum
a medical condition that existed before an individual’s health insurance policy became effecdtive.
Preexisting condition
an organization whose purpose is to contract with providers and then lease this network of contracted providers to health care plans.
Preferred provider organization
(PPO)
a notice from the Medicare Administrative Contractor showing payments and adjustments made on Medicare claims with explanations for reimbursement decisions. RAs submitted electronically are known as ERAs.
Remittance advice
(RA)
a value scaled designed to decrease Medicare Part B costs and establish national standards for coding and payment.
Resource-based relatvie value scale
(RBRVS)
administrator who processes claims for the sponsor of self-funded benefit planning.
Third-party administrator
(TPA)
the basis of a physician’s fee schedule, the usual and customary cost of the same service or procedure in a similar geographic area and under the same or similar circumstances.
Usual, customary, and reasonable
(UCR)
an analysis of individual cases by a committee to make sure services and procedures are being billed to a third-party payer, are medically necessary, and to ensure compliance with its rules and regulations regarding reimbursement.
Utilization review
(UR)
approved documentation prior to referrals to specialists and other facilities.
Precertification
