Chpt 14 Flashcards
Accept assignment
When a physician agrees to accept the amount approved by the insurance company as payment in full for a given service
Advance beneficiary notice (ABN)
A form that patients need to sign agreeing to pay for services that may be denied by Medicare
Gives the patient the opportunity to refuse the service
Must be explained to the patient. If the patient doesn’t understand but signs the ABN they are not liable for charges
Copy to patient, original to patient file
Allowed amount
The dollar amount for a service that an insurance company considers acceptable and uses to determine benefit
payments.
Provider must write off the difference between this and their usual fee
Balance billing
Billing a patient for the dollar difference between the providers charge and the amount approved by the insurance agency
Violation of the preferred provider contract
Beneficiary
The person who is eligible to receive benefits and services under an insurance policy
Refers to an individual who qualifies for government policy programs
Birthday rule
According to this rule the parent with the birthday earlier in the year is the primary carrier for the children
Stepfamilies- custodial parent primary
Spouse of custodial secondary
Noncustodial parent third
Spouse of noncustodial fourth
Capitated plan
A healthcare plan in which providers are paid a set fee per month for each member patient
Per-patient per- month payment
Assigned physician-must see
Copay each time but no other payment required
If the patient is referred out that cost goes to the provider not the insurance carrier- incentive to use preventive care
Catastrophic
Large and usually unforeseen
Certificate of coverage
A letter from an insurance company that provides proof of type and time frame of coverage when a patient terminates a health insurance policy
Need a certificate to submit for any coverage during the 24 months
CHAMPVA
Civilian Health and Medical Program of the department of Veterans Affairs; health insurance for spouses and children of veterans
Children’s Health Insurance Program (CHIP)
A program created to cover children who do not have another form of health insurance coverage
Formerly SCHIP
Created by Balanced Budget Act of 1997
Federal/state joint program
3 categories chosen by state
1. Expand Medicaid eligibility to include more children
2. Design children health program completely separate from Medicaid
3. Combine Medicaid snd separate children health insurance fund
As od 2017, 8.3 million children covered
COBRA
1986
Consolidated Omnibus Budget Reconciliation Act
Employee can extend healthcare for 18 months at group rates
Enrolled while employed, still active to current employees
20 or more employees-full time and part time
Can be available to anyone covered the day before the event (dependents)
Qualify: termination, reduction in hours
For spouses- covered employees become entitled to Medicare; divorce or legal separation, death of employees
For children- loss of dependent child status, employee termination other than for gross misconduct; reduction in hours, reach Medicare, divorce, death
Notify plan administrator within 60 days of event. Employers must notify administrator within 30 days
Coinsurance
The percentage of medical charges patients are responsible for according to their insurance plan contracts
Consumer-directed healthcare plan
Health insurance plans that place patients in charge of how their healthcare dollars are spent
A certain amount from the paycheck is retained by the employer to fund premiums
Medical savings account, high deductible health insurance plan, gap between the two in which the individual pays out of pocket
Copayment
The set dollar fee per visit or service that patients are responsible for according to their insurance plan contracts
Deductible
Monetary amount patients must pay to a provider for healthcare services before their health insurance benefits begin to pay
Does not apply to all services
Dependent
A family member or other individual who qualifies for coverage on the basis insured’s policy
Inclusion is not automatic
E-billing
Electronic transmission of medical claims to insurers
Since 2005 must use with medicare if more than 10 full time employees
Elective procedure
A procedure that is generally considered not medically necessary
Eg. asthetic
Not covered by health insurance
Exclusions
Procedures or services not covered under an insurance plan
Ex. Experimental
Don’t require a prescription, vitamins or neck brace
Eye or hearing exams
Holistic healthcare
May be limited to a certain number rather than excluded
Exclusive provider organization (EPO)
A managed care contract with a small network of providers under which the employer agrees to not use any other networks in return for favorable pricing
Contracted hospitals as well
Don’t use network, pay total out of pocket
Experimental
A service or procedure that has not been approved by the U. S. Food and Drug Administration
Fee-for-service plan
A plan in which insurance companies pay providers fees for each service provided to covered patients
Also known as indemnity plan
1980s
Yearly deductible then coinsurance - 80/20 or 70/30
Flexible spending account (FSA)
An account into which employees place pretax earnings for projected medical expenses
Also called healthcare savings accounts
Use for: deductibles, copay
Eyes, teeth , chiropractic, psychiatric, gym fees
Must be spent by a certain date or money is forfeited- usually March 15 of following year
Form locators
The boxes on the CMS-1500 insurance claim form
Formulary
The tiered list of drugs covered by an insurance company
Usually 2 or more tiers with different coverage for each tier
Gatekeeper
The physician responsible for determining when and if a patient needs specific types of healthcare
Group health insurance
A commercial insurance policy with rates based on a group of people, usually offered by an employer
Health insurance
Insurance purchased to cover medical expenses
A contract between the insurance carrier and the owner of the policy
Health maintenance organization (HMO)
A group of physicians or medical centers that provide comprehensive services to members
Only covers in network providers
PCP required
Must have referrals
Push preventive healthcare
Mist restrictive, lower cost
Healthcare and Education Reconciliation Act of 2010
Healthcare legislation produced to amend the Patient Protection and Affordable Care Act
Holistic healthcare
Natural, drug-free healthcare services
Hospice
Indemnity plan
Plan in which insurance companies pay providers fees for each service provided to covered patients
1980s
Individual health insurance
A commercial insurance policy with rates based on individual health criteria
Most expensive, benefits not as good
Minimum level of benefit package determined by the state-only some companies offer individual policies
General done through insurance exchange system since ACA - online marketplace- varies by state
Insured
The person who owns the insurance policy
Liability insurance
The type of insurance that covers injuries that occur on, in, or because of the insured’s property.
Lifetime maximum benefits
The monetary amount allowed by an insurance carrier for a member’s covered expenses over the member’s lifetime
Maintenance medications
Medications patients take on a long-term basis to create a chronic condition such as high blood pressure , arthritis or a heart condition
May have a mail-order option, 3 months for 2 copayments
90 day prescriptions with 3 refills for the remainder of the year.
Managed care
Most patients have this
A system of healthcare delivery focused on reducing costs by limiting the type and frequency of care members may receive
Medicaid
A joint federal and state program that helps with medical costs for eligible people with low incomes and limited resources
Medicare
A federal program that covers expenses for those ages 65 and over, those with end stage kidney disease, and those with long-term disabilities
55 million people in 2015
As of 2014 accounted for 14% of U. S. Federal budget
2015-2030-rise from 52 to 78 million
By 2019 part part A will have insufficient funds
Administered by CMS (formerly HCFA- health care financing administration)
Uptodate on website
Submit claims within 365 days of service, later subject to 10% penalty unless you can prove it was beyond the provider’s control
Services 1-1 through 9-30: bill by end of next calendar year
10-1 through 12-31: bill by end of 2 calendar years
Member
The person who owns the insurance policy
National provider identifier (NPI)
A unique, 10-digit number assigned to healthcare providers by CMS
Replaces UPIN (unique provider identification number)
NPI required since 2007, on patient billing forms
Nonparticipating provider
The healthcare provider who has not contacted with a particular health insurance carrier
Participating provider
The healthcare provider who has contracted with a particular health insurance carrier
Patient Protection and Affordable Care Act
Healthcare legislation passed in 2010
Payer number
The number that medical offices must include on an electronic claim to identity the insurance company to whom the claim is directed
Point-of-service option
(POS)
An insurance offering in which a patient has access to multiple plans, such as an HMO and PPO
Not stuck with network doctors but pay more
Choose an option each time you use healthcare
Contracted network of providers and facilities
Policyholder
The person who owns the insurance policy
Pre authorization
The process of obtaining approval from an insurance company for a patient’s procedure
Pre certification
The process of obtaining approval from an insurance company for a patient’s procedure
Preexisting condition
A condition for which a patient received treatment in a certain period before beginning coverage with a new insurance plan
Must be insured for 24 months before joining a new plan to be covered without a waiting period
