Intro Flashcards
cash flow?
The movement of monies into or out of a business.
accounts receivable (AR)
Monies owed to a medical practice by its patients and third-party payers.
revenue cycle
All administrative and clinical functions that help capture and collect patients’ payments for medical.
health information technology (HIT)
Computer hardware and software information systems that record, store, and manage patient information.
practice management program (PMP)
Business software designed to organize and store a medical practice’s financial information; often includes scheduling, billing, and electronic medical records features.
electronic health record (EHR)
A computerized lifelong healthcare record for an individual that incorporates data from all sources that provide treatment for the individual.
PM/EHR
A software program that combines both a PMP and an EHR into a single product.
medical insurance
A written policy stating the terms of an agreement between a policy-holder and a health plan.
policyholder
Person who buys an insurance plan.
benefit
The amount of money a health plan pays for services covered in an insurance policy.
third-party payer
Private or government organization that insures or pays for healthcare on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party.
schedule of benefits
List of the medical expenses that a health plan covers.
medical necessity
Payment criterion of payers that requires medical treatments to be clinically appropriate and provided in accordance with generally accepted standards of medical practice. To be medically necessary, the reported procedure or service must match the diagnosis, be provided at the appropriate level, not be elective, not be experimental, and not be performed for the convenience of the patient or the patient’s family.
covered services
Medical procedures and treatments that are included as benefits under an insured’s health plan.
preventive medical services
Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests.
noncovered services
Medical procedures that are not included in a plan’s benefits.
excluded service
A service specified in a medical insurance contract as not covered.
indemnity plan
Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits.
healthcare claim
An electronic transaction or a paper document filed with a health plan to receive benefits.
premium
Money the insured pays to a health plan for a healthcare policy.
deductible
An amount that an insured person must pay, usually on an annual basis, for healthcare services before a health plan’s payment begins.
fee-for-service
A payment method based on provider charges.
managed care
System that combines the financing and the delivery of appropriate, cost-effective healthcare services to its members.
managed care organization (MCO)
Organization offering some type of managed healthcare plan.
participation
Contractual agreement by a provider to provide medical services to a payer’s policyholders.
health maintenance organization (HMO)
A managed healthcare system in which providers agree to offer healthcare to the organization’s members for fixed periodic payments from the plan; usually members must receive medical services only from the plan’s providers.
capitation
Payment method in which a fixed prepayment covers the provider’s services to a plan member for a specified period of time.
network
A group of healthcare providers, including physicians and hospitals, who sign a contract with a health plan to provide services to plan members.
out-of-network
Description of a provider who does not have a participation agreement with a plan. Using out-of-network providers is more expensive for the plan’s enrollees.
preauthorization
Prior authorization from a payer for services to be provided; if preauthorization is not received, the charge is usually not covered.
copayment
An amount that a health plan requires a beneficiary to pay at the time of service for each healthcare encounter.
primary care physician (PCP)
A physician in a health maintenance organization who directs all aspects of a patient’s care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper.
adjudication
The process followed by health plans to examine claims and determine benefits.
preferred provider organization (PPO)
Managed care organization structured as a network of healthcare providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.
consumer-driven health plan (CDHP)
Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses.
medical insurance specialist
Medical office administrative staff member who handles billing, checks insurance, and processes payments.
medical coder
Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records.
procedure code
Code that identifies medical treatment or diagnostic services.
patient ledge
Record of all charges, payments, and adjustments made on a particular patient’s account.
compliance
Actions that satisfy official guidelines and requirements.
professionalism
For a medical insurance specialist, the quality of always acting for the good of the public and the medical practice being served. This includes acting with honor and integrity, being motivated to do one’s best, and maintaining a professional image.
ethics
Standards of conduct based on moral principles.
etiquette
Standards of professional behavior.
certification
The recognition of a person demonstrating a superior level of skill on a national test by an official organization.
