Insurance Flashcards
Access to Care
The ability and ease of patients to obtain healthcare when they need it.
Actionable Tort
A legal duty, imposed by statute or otherwise, owing by defendant to the one
injured.
Actuarial Study
Statistical analysis of a population based on its utilization of healthcare services
and demographic trends of the population. Results used to estimate healthcare plan premiums or
costs.
Acuity
Complexity and severity of the patient’s health/medical condition.
Actuary
A trained insurance professional who specializes in determining policy rates, calculating
premiums, and conducting statistical studies.
Administrative Services Only (ASO)
An insurance company or third party administrator (TPA) that
delivers administrative services to an employer group. This usually requires the employer to be at
risk for the cost of health care services provided, which the this company/administrator processes and manages claims.
Adjuster
A person who handles claims (also referred to as Claims Service Representative)
Admission Certification
A form of utilization review in which an assessment is made of the medical
necessity of a patient’s admission to a hospital or other inpatient facility.
This
ensures that patients requiring a hospital-based level of care and length of stay appropriate for the
admission diagnosis are usually assigned and certified and payment for the services are approved.
Ambulatory Payment Classification (APC) System
An encounter-based classification system for
outpatient reimbursement, including hospital-based clinics, emergency departments, observation, and
ambulatory surgery. Payment rates are based on categories of services that are similar in cost and
resource utilization.
Appeal
The formal process or request to reconsider a decision made not to approve an admission
or healthcare services, reimbursement for services rendered, or a patient’s request for postponing the
discharge date and extending the length of stay.
Approved Charge
The amount Medicare pays a physician based on the Medicare fee schedule.
Physicians may bill the beneficiaries for an additional amount, subject to the limiting charge allowed.
Assignment of Benefits
Paying medical benefits directly to a provider of care rather than to a
member. This system generally requires either a contractual agreement between the health plan and
provider or written permission from the subscriber for the provider to bill the health plan.
Assumption of Risk
A doctrine based upon voluntary exposure to a known risk. It is distinguished
from contributory negligence, which is based on carelessness, in that it involves a comprehension
that a peril is to be encountered and a willingness to encounter it.
Assurance/Insurance
The term “assurance” is used more commonly in Canada and Great Britain.
The term “insurance” is the spreading of risk among many, among whom few are likely to suffer loss.
The terms are generally accepted as synonymous.
Beneficiary
An individual eligible for benefits under a particular plan. In managed care
organizations they may also be known as members in HMO plans or enrollees in PPO plans.
Benefit Package
The sum of services for which a health plan, government agency, or employer
contracts to provide. In addition to basic physician and hospital services, some plans also cover
prescriptions, dental, and vision care.
Benefits
The amount payable by an insurance company to a claimant or beneficiary under the
claimant’s specific coverage.
Capitation
A fixed amount of money per-member-per-month (PMPM) paid to a care provider for
covered services rather than based on specific services provided. The typical reimbursement method
used by HMOs. Whether a member uses the health service once or more than once, a provider who
is capitated receives the same payment.
Captive
An insurance company formed by an employer to assume its workers’ compensation and
other risks, and provide services.
Carrier
The insurance company or the one who agrees to pay the losses. It may be
organized as a company, either stock, mutual, or reciprocal, or as an Association or Underwriters.
Carve out
Services excluded from a provider contract that may be covered through arrangements
with other providers. Providers are not financially responsible for these services of their contract.
Case Rates
Rate of reimbursement that packages pricing for a certain category of services.
Typically combines facility and professional practitioner fees for care and services.
Case Reserve
The dollar amount stated in a claim file which represents the estimate of the amount
unpaid.
Casualty Insurance
A general class of insurance and workers’ compensation insurance.
Certification or Authorization
The approval of patient care services, admission, or length of stay by a health benefit
plan (e.g., HMO, PPO) based on information provided by the healthcare provider.
Claim
A request for payment of reparation for a loss covered by an insurance contract.
Claimant
One who seeks a claim or one who asserts a right or demand in a legal proceeding.
Claims Service Representative
A person who investigates losses and settles claims for an
insurance carrier or the insured. A term preferred to adjuster.
Clinical Review Criteria
The written screens, decision rules, medical protocols, or guidelines used
to evaluate medical necessity, appropriateness, and level of care.
Coinsurance
A type of cost sharing in which the insured person pays or shares part of the medical
bill, usually according to a fixed percentage.
Continued Stay Review
A type of review used to determine that each day of the hospital stay is
necessary and that care is being rendered at the appropriate level. It takes place during a patient’s
hospitalization for care.
Contractor
A business entity that performs delegated functions on behalf of the organization.
Coordination of Benefits (COB)
An agreement that uses language developed by the National
Association of Insurance Commissioners and prevents double payment for services when a
subscriber has coverage from two or more sources.
Copayment
A supplemental cost-sharing arrangement between the member and the insurer in
which the member pays a specific charge for a specified service. May be flat or variable
amounts per unit of service and may be for such things as physician office visits, prescriptions, or
hospital services. The payment is incurred at the time of service.
Current Procedural Terminology (CPT)
A listing of descriptive terms and identifying codes for
reporting medical services and procedures performed by health care providers and usually used for
billing purposes.
Days per Thousand
A standard unit of measurement of utilization. Refers to an annualized use of
the hospital or other institutional care. It is the number of hospital days that are used in a year for
each thousand covered lives.
Deductible
A specific amount of money the insured person must pay before the insurer’s payments
for covered healthcare services begin under a medical insurance plan.
Delegation
The process whereby an organization permits another entity to perform functions and
assume responsibilities on behalf of the organization, while the organization retains final authority to
provide oversight to the delegate.
Demand Management
Telephone triage and online health advice services to reduce members’
avoidable visits to health providers. This helps reduce unnecessary costs and contributes to better
outcomes by helping members become more involved in their own care.
Denial
No authorization or certification is given for healthcare services because of the inability to
provide justification of medical necessity or appropriateness of treatment or length of stay. This can
occur before, during, or after care provision.
Diagnosis-Related Group (DRG)
A patient classification scheme that provides a means of relating
the type of patient a hospital treats to the costs incurred by the hospital.
Demonstrate groups of patients using similar resource consumption and length of stay.
It also is known as a statistical
system of classifying any inpatient stay into groups for the purposes of payment.
May be primary or secondary; an outlier classification also exists. This is the form of reimbursement that the CMS uses to pay hospitals for Medicare and Medicaid recipients.
Also used by a few states for all
payers and by many private health plans (usually non-HMO) for contracting purposes.
Disengagement
The closing of a case is a process of gradual or sudden withdrawal of services, as
the situation indicates, on a planned basis.
Disenrollment
The process of terminating healthcare insurance coverage for an enrollee/insured.
Domestic Carrier
An insurance company organized and headquartered in a given state.
Eligibility
The determination that an individual has met requirements to obtain benefits under a
specific health plan contract.
Encounter
An outpatient or ambulatory visit by a health plan member to a provider. It applies mainly
to physician’s office but may also apply to other types of encounters.
Enrollee
An individual who subscribes for a health benefit plan provided by a public or private
healthcare insurance organization.
Enrollment
The number of members in an HMO. The process by which a health plan signs up
individuals or groups of subscribers.
