Insurance and Reimbursement Key Terms Flashcards
Advance beneficiary notice (ABN)
medicare may not cover certain services, pt responsible for bill
assignment of benefits
transfer pt legal rights to the provider to collect insurance $ / insurance payment for services will go straight to the provider instead of the patient
balance of billing
billing patient for total, or total after insurance
capitation
managed care plan that pays certain amount to provider over time for caring for pt
coinsurance
agreed amount paid to provider by policy holder
coordination of benefits
order in which multiple insurance companies pay (prevents double payments)
copayment/copay
part of insurance that patient pays
crossover claim
crosses over automatically from 1 coverage to another payment
current procedural terminology (CPT codes)
codes used by physicians to define services provided to the patient
deductible
amount pt pays before insurance begins paying
dependent
spouse or children under insurance plan
diagnosis related groups (DRGs)
categories used to determine reimbursements for medicare pt inpatient services
eligibility
pt meets the qualifications to be covered by the insurance
explanation of benefits (EOB)
statement that accompanies payment, includes date and services paid for
health care savings account (HSA)
offered by employer, takes some money out of paycheck and puts into a savings account for medical use
independent practice association (IPA)
independent physicians contracted with health maintenance organization to provide services to members
Health Maintenance Organization (HMO)
wide range of services through contract with specific group at predetermined rates
healthcare common procedure coding
assigns alphabetic and numeric code to services and items
medicare
federally funded insurance for people 65+ or disabled
medicare A
Portion of Medicare that deals with hospital expenses
medicare B
physician fees, test, some immunization
medicaid
Federal and State funded for people with low incomes.
medi-medi claim
beneficiary with Medicare primary and medicaid as secondary payment. AKA crossover claim
medicare administrative contractors (MACs)
process claims from providers for services rendered for medicare beneficiary
pre-existing condition
medical problems existing before insurance plan’s effective date
primary and secondary coverage
primary- file 1st secondary-bill remainder of charges
centers for medicare and medicaid services (CMS)
mandate use of panels defined by AMA for national standardization of testing
plan maximum
highest amount paid by insurance
preferred provider organization (PPO)
contract with preferred healthcare provider
remittance advice (RA)
medicare administration contract showing payments/ explaining reimbursment
usual, customary, reasonable (UCR)
usual cost of similar services in area
utilization review (UR)
checks cases to make sure bill were medically necessary
coding
assignment of a number to verbal statement or description
international classification of diseases (IDC)
transforming verbal description to numeric code
nonsufficient funds (NSF)
no money, hot checks
collections
acquiring funds that are due
credit
record of a payment recieved; balance in one’s favor on an account.
debit
a charge owed on an account
day sheet/ daily journal
a daily record listing all financial transactions and/or patients seen
denial
insurance company says they will not pay
