Exam 1 Terms Flashcards
Buying the insurance
Premium
An amount that the patient has to pay in a time period before benefits will be paid (typiclaly per calendar year)
Deductible
(Ex. After deductible is met, insurance will pay 80%)
The patient portion of the Medicare Allowed Amount after the deductible has been met
Co-insurance
-Ex: patient pays 20% of the cost each time.
A fixed amount the patient pays for a covered health care service, usually when they receive the service. The amount can vary by the type of covered health care service
Co-payment
Ex: The patient pays $20 for each time insurance is utilized
Means the doctor, provider, or supplier agrees to accept the medicare approved amount as full payment for covered services
Assignment
Statement from the payer sent to a provider and an insured explaining services provided, services denied, amount billed, amount owed by the insured, amount not paid, amound payed by the insurer, etc.
Explanation of Benefits (EOB)
-a.k.a. Explanation of Medical Benefits (EOMB)
Determining a patient coverage by contacting the insurance provider to determine what is covered and what is not covered
Verification
What is characteristic of a PAR Medicare provider?
-Signed agreement/contract with Medicare
-Accept assignment on all claims
-Payments are made directly to the provider
-Secondary insurance is automatically billed
-Payments are up to 15% higher that NON-PAR allowed amount for unassigned claims
-Provider listed in the Medicare provider directory
What is characteristic of Non-PAR Medicare providers?
- Enrolled in Medicare
- No signed agreement with Medicare
- May choose to accept or not accept assignment
- Non-assigned claim payments go to the patient
- Secondary insurance is billed by provider
- Charges can’t be more that the limiting charge
- Provider NOT listed in the Medicare provider directory
CMS
Center for Medicare and Medicaid Services
- Division of US department of health and human services
- Largest governmental health insurance plan in the U.S.
The federal agency responsible for protecting the integrity of HHS programs by eliminating waste and fraud in the health programs
Office of Inspector General (OIG)
A 10 digit number that is required for all electronic HIPAA transactions.
National Provider Identifier (NPI)
Related to activities which may be justified as reasonable treatment for a given condition
Medical Necessity
How to enroll in Medicare as a provider?
Need to go to PECOS government website to enroll and have an NPI
-Revalidation occurs every 5 years
What generally occurs on the first visit?
- Patient makes appointment
- Patient comes to office
- Doctor examines
-Makes diagnosis
-Provides services
-Above are changed into codes
