Medical billing Flashcards
privacy act of 1974
prohibits disclosure of certain medical info by government agencies unless the patient gives written consent
healthcare operations
certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business and to support the core functions of treatment and payment
Three groups to which HIPAA regulations apply
- Healthcare providers
- health plans
- healthcare cleaning houses
protected health information (PHI)
any individual identifiable health information
identifiable information
data about a specific person
de-identifiable information
information stripped of data that may identify an individual
limited data set
middle ground between identifiable and de-identifiable information
risk management
identifies areas of risk to medical service providers
payment
the activities of healthcare providers to obtain payment or be reimbursed for their services
treatment
the provision of healthcare and related services
peer review committees
consists of healthcare providers who monitor the quality and use of healthcare services
biometrics
technologies that identify people through bodily characteristics, such as finger prints, retinal patterns & voice patterns
loss prevention
a planned, systematic, and proactive process; in the area of healthcare providers identify those activities, problems, and situations that may result in potential liability
loss reduction
the steps taken after an event or incident occurs
virtue theory
pertains to the character of a person as displayed by the virtues he or she possesses
duty theory
pertains to a persons obligations from the standpoint of morality
consequentialist theory
based on the consequences of peoples actions based on their own ethics & morals
false claims act
punishes those who knowingly engage in false billing
misdemeanor
any crime that’s punishable by imprisonment for less than one year
statues
legislation passed by governing bodies on federal and state levels
PPE
personal protective equipment
statue of limitations
the time period during which a lawsuit must be brought
contributory negligence
when a patient contributes to causing themselves harm
arbitration
two parties present evidence to an impartial person, who makes a binding decision
appeal
during an appeal, the question is whether an error of law was made at the trial court level
perjury
false swearing under oath
burden of proof
what the plaintiffs are obligated to prove
bench trial
a trial in which there’s no jury and the judge serves as the fact finder, weighs the evidence & decides how the law applies to it
expert witnesses
people who have skill, experience, training, or education in a specialized field that ordinary people don’t have
types of malpractice
failure to diagnose, failure to inform of diagnosis, errors in treatment, lack of informed consent
battery
the harmful touching of a patient without consent
product liability
the legal responsibility that a manufacturer or distributer of an unreasonably dangerous product has for damages cause by the dangerous condition
Actus Reus
latin for “guilty act” or the criminal act
Mens Rea
latin for “guilty mind” referring to the state of mind associated with the criminal act
OSHA
the occupational safety and health administration
joint commission
an external accrediting body for health care facilities
CMS
the centers for medicare and medicaid services
Malpractice
professional negligence
defensive medicine
consists of medical responses that are motivated by a desire to avoid potential liability claims more than by the needs of the patient
mediation
occurs when a neutral third party helps the parties in a dispute reach a settlement agreement
ordinances
legislation adopted by local legislative bodies
certification
refers to a professional organization or institution representing that a certified person has passed a test, completed a course of study, or demonstrated knowledge or skill in some other way
negligence
failing to meet a standard of reasonable care
due care
the responsibility of a physician to hire qualified personnel and supervise the personnel accordingly
vicarious liability
when one person is held responsible for the actions of another
litigation
the process of resolving disputes through the court system
alternative dispute resolution (ADR)
a process of resolving disputes outside of the court system that may be used before or after litigation has begun
alternative dispute resolution (ADR)
a process of resolving disputes outside of the court system that may be used before or after litigation has begun
litigate
to begin a legal process involving a court
plaintiff
the person who is suing
defendant
the person who is being sued
deposition
the taking of oral testimony under oath before trial
jury trial
a trial in which the jury is the fact finder, and the judge explains the law to the jury and supervises the presentation of evidence
common law
a system of law developed on a case by case basis from court decisions
right
an individual power, privilege or immunity
duty
an individual obligation
three branches of government
- federal
- state
- local
civil law
concerns the private rights & duties of individuals who live within a society
crime
an offense against a locale, a state, or the United States
criminal law
prohibits and punishes certain conduct for the benefit of society
law
the set of rules that govern our behavior
wrongful birth
a parents claim against a doctor for damages caused by birth of a child that occur when a doctor fails to detect and disclose a Childs birth defects in time to permit abortion
euthanasia
occurs when a person takes an action that causes death to another person sometimes called mercy killing
assisted suicide
occurs when a patient takes actions to terminate his or her life using means supplied by someone else
use of biometrics
to identify a patient to simplify secure access to records
health insurance
created important rules regarding safeguarding health information
Hippocratic oath
taken by physicians and pertains to the ethical practice of medicine
durable power of attorney (DPA)
authorizes a person to make medical decisions for a patient when the patient is unable to do so
do - not - resuscitate (DNR)
prevents efforts to resuscitate those who have exhibited the signs of death; doesn’t go into effect until the person is permanently unconscious without realistic hope of recovery
advance medical directives
instructions people give to others regarding their medical wishes in case they are unable to
fetal homicide laws
laws that make causing the death of a fetus a crime separate and independent from any crime committed against the woman carrying the fetus
etiquette
the proper form of social interaction in a given culture or community
affordable care act (ACA)
signed into law by president Barak Obama in 2010; makes health insurance coverage mandatory
ethical theories
attempt to systemize, defend, and recommend concepts of right and wrong behavior
ethics v. law
while moral obligation focuses on an individuals conscience - legal obligations are enforced by the states power w/o regard to conscience
meta ethics
a branch of ethical theory that considers the origin and meaning of ethical principles
normative ethics
involves determining the moral standards that regulate right and wrong conduct
3 theories
- virtue theory
- duty theory
- consequentialist theory
roe v. wade
in 1973, in a landmark decision regarding abortion, the US Supreme Court in roe v. wade applied the right to privacy to abortion
amniocentesis
a medical technique used to test DNA in amniotic fluid; allows physicians to identify genetic abnormalities before birth
negative eugenics
limits or discourages reproduction by those considered genetically inferior
eugenics
a science that deals with “improving” hereditary qualities
positive eugenics
encourages reproduction by those considered genetically superior
methods on conception
test tube fertilization artificial insemmination
medical paternalism
takes away patient autonomy and gives the power to medical personnel or the government for societys benefit
patient autonomy
requires that the patient give informed consent prior to the start of any medical treatment
formulary
a list of approved drugs from which doctors must prescribe to have insurance cover the pharmaceuticals
doctor-patient privilege
a relationship in which a patients medical history, conditions, and related info can’t be made known without the patients consent
medical record
document that includes a patients history, condition, diagnostic & therapeutic treatment and the results of treatment
author of a medical record
the provider who has created the data that appear in the record
age of maturity
when a person becomes an adult
certificate of destruction
documents that records were properly destroyed in the ordinary course of business
substituted consent
an authorized person makes a decision for a person who is unable to do so
legal basis for confidentiality
the right of privacy derived from the U.S. constitution, statues, and the common law
accounts receivable (AR)
payments that hospitals receive from third party payers for providing healthcare services
CMS-1500 claim form
standard insurance claim form used to report outpatient services to insurance companies
coordination of benefits (COB)
also known as crossover; group policy provision that helps determine the primary carrier in situations in which an insured party is covered by more than one policy, thus preventing the insured from receiving claims overpayments
explanation of benefits (EOB)
statement sent to a participant in a health plan as well as the healthcare provider that lists services, amounts paid by the plan, and total amount billed to the patient
fiscal intermediaries (FI)
insurance companies contracted by the government to process claims for government insurance programs, such as medicare parts A & B
remittance advice
communication from third party payer to payee that provides a detailed accounting of payments and healthcare services provided
revenue codes
UB-92 payment codes for healthcare services or items
UB-92 claim form
also known as the CMS-1450 form; standardizes the processing of billing for hospital inpatient and outpatient services
reimbursement
the way that healthcare providers are paid for providing medial services
healthcare providers
doctors, hospitals, and healthcare facilities
medical coding
the process of assigning codes to certain pieces of information in the health record
preventable health threats
illnesses that can be prevented before they occur by routine physical examinations and immunizations
third-party payers
responsible for providing an insurance arrangement that provides benefits in the form of healthcare services
fee-for-service reimbursement
healthcare provider receives reimbursement based on the amount that they charge for service
covered medical expenses
medical expenses that are listed in the benefits section of the insurance policy as being reimbursable by the insurance company
chargemaster
a list of healthcare supplies and services with specific charges assigned for each supply and service
facility fee
fee paid to hospital for services provided
service fee
fee paid to physicians for services provided, such as medical consultation and surgery
skilled nursing facility
a facility designed to treat medicare-eligible patients
outcome and assessment information set (OASIS)
a dataset used in home healthcare for patient assessments to help monitor and improve the outcomes of home healthcare
CMS
centers for medicare and medicaid services’ professional, universal health claim form; used by providers of outpatient health services to bill their fees to health carriers (or third-party payers)
CMS-1450
institutional claim form used by hospitals to receive payment from third-party payers; also known as the UB-04 or the uniform bill
medicare carriers
private companies that have a contract with medicare to process medicare part B bills for physicians and medical suppliers
audit trails
information maintained on coding reviews and the actions needed for improvement
upcoding
assigning codes that aren’t supported by the information in the patients health record
unbundling
breaking down codes that are normally assigned as a set into separate codes for the purpose of obtaining higher reimbursement
coinsurance
provision stating that the insured and the insurer will share all losses covered by the policy in porportion agreed upon in advance; for example, an 80-20 policy means that the insurer pays 80 percent and insured pays 20 percent of expenses
copayment
an arrangement in which the covered person pays a specified amount for various services and the healthcare provider pays the remainder. copayment is usually paid at service.
deductible
portion of an insured loss paid by the insured before they’re entitled to benefits from the insurer
group health insurance
health insurance provided to a group, most often a group of employees, providing coverage in the form of lump-sum payment or periodic payments to compensate for income losses due to bodily injury, sickness, or disease as well as medical expenses
insured
party to an insurance arrangement who’s secured against losses and provided benefits or services; this term is preferred to terms such as policy holder and policy owner
insurer
party to an insurance arrangement who undertakes to indemnify for losses, provide benefits, or render services. the term insurer is preferred to company or carrier. aka third party payer
major medical insurance
a type of health insurance that provides benefits up to a high limit for most types of medical expenses incurred, subject to a large deductible. these policies usually pay covered expenses whether an individual is in or out of the hospital
out-of-pocket expenses
amount not covered by insurance that the covered (or insured) person must pay out of their own pocket, such as coinsurance and a deductible; aka out of pocket costs
provider
any individual or group of individuals that provide a healthcare service (such as physicians or hospitals)
fee-for-service
the method by which a physician or provider bills for each service or visit instead of on a prepaid (that is, all-inclusive) basis. this was the initial way that patients received treatment, for which they usually paid cash.
managed care
a system of healthcare where the goal is to deliver quality, cost of effective healthcare through monitoring and recommending utilization and cost of services
prospective payment system (PPS)
a system wherein reimbursement is made to the provider based on a predetermined reimbursement level rather than on actual charges after the services have been provided
retrospective payment system
a system wherein reimbursement is made to providers after healthcare services have been given
usual, customary, and reasonable charges (UCR)
charges for healthcare services that are based on the physicians “usual” charge for the service, which is the “customary” amount that other physicians in the area charge, and a “reasonable” amount for the service performed
prepaid health plan
contract that covers specific medical expenses for individuals or groups
health insurance
protection against income losses for illness or injury, disability income, and accidental death or dismemberment
medical insurance
coverage for specific medical expenses
fee for service basis
healthcare providers receive payment for actual charges after healthcare services were provided
prospective basis
predetermined reimbursement level
premiums
regular, pre-established amounts paid by private insurance holders
government-sponsored healthcare programs
healthcare plans that are funded and administered by the federal or state government; examples include Medicare and Medicaid
medicare part A
hospital insurance coverage for those meeting medicare criteria
Medicare part B
supplemental insurance coverage for those meeting medicare criteria
inpatient hospital care
care for patients who are expected to remain in the hospital for at least 24 hours or more to receive care from a physician
long term care
care for persons with chronic disease or disabilities
skilled nursing facility (SNF) care
care including rehabilitation, 24 hour nursing coverage, and physical occupational, and speech therapies
hospice care
an organization that’s primarily designed to provide pain relief symptom management and supportive services for the terminally ill and their families
out of pocket expenses
expenses that aren’t covered by insurance
managed care plan
a collection of interdependent systems that integrate the delivery of healthcare services to a specific population
Health Maintenance organization (HMO)
a prepaid medical service plan that provides services to plan members
preferred provider organizations (PPO)
represent an organization of hospitals and physicians who, for a set fee, provide services to insurance company clients
accountable care organizations
groups of doctors, hospitals, and healthcare providers who organize into a group to provide care to medicare patients
