MI&C Chapter 3 & 4 Vocabulary Flashcards
Negligence
Failure to exercise a reasonable degree of care
Respondeat Superior
Latin term “ Let the master answer “
Ancillary
Staff members of the medical team, MAs, RNs, technicians, health insurance professionals
Offer
A proposition to create a contract.
Acceptance
After the “offer” has been made, and the information has been verified, the insurance command says, “yes”, and accepts the application.
Binds
Acceptance occurs when the company binds, ie agrees to accept the individual.
Consideration
Binding force in any contract that gives it legal status.
Competency
The parties to the contract must be mentally capable and of proper age when entering into a contractual agreement.
Emancipated Minor
An individual younger than 18 whose is living independently, like and 18 year old, away from home.
Implied Contract
Contract, not in writing, but has all the components of the a written one, and just as binding.
Implied Promise
Promises, neither spoken, nor written, but implicated by the individual’s actions.
Ethics
Standards of human conduct. Morals
Medical Ethics
Code of ethics for the medical professional.
Etiquette
Consists of the rules and conventions governing correct or polite behavior in society.
Medical Etiquette
Following the conventions of polite behavior in the healthcare profession.
First Party (Party of the First Part)
In legal language, the patient in the implied contract between patient and healthcare provider.
Second Party (Party of the Second Part)
In legal language , the healthcare provider in the implied contract.
Third Party (Party of the Third Part)
In legal language, the insurance company in the implied contract between patient and healthcare provider.
Medical Record
Health Record
. . .is a clinical, scientific, administrative and legal document of facts containing statements relating to a patient.
Confidentiality
Concerns the communication of private and personal information from one person to another.
Privacy
Denotes a “zone of in accessibility” of mind or body, the right to be left alone and to maintain individual autonomy.
Subpoena duces tecum
. . .is a legal document that requires an individual to appear in court with a piece of evidence that can be used by the court.
Breach of Confidentiality
Has occurred when information is disclosed to a third party without permission of the patient.
Durable Power of Attorney
When someone has been named as an agent of a patient’s affairs should the patient become incapacitated.
Fraud
An intentional deception that could lead to a benefit to the individual committing it
Abuse
Improper or harmful procedures off that are contradictory to accepted business practices.
Abandoning
Ceasing to provide care
Accountability
Responsibility the healthcare profession has to patients so that a feeling of confidence exists between patient and dr.
Incidental Disclosure
Type of privacy disclosure that is specifically allowed under HIPAA. i.e. two patients in the waiting room know each other.
Litigious
Quick to take legal action. Bring a law suit
Portability
According to HIPAA, people with pre-existing medical conditions cannot be denied health insurance coverage when moving from one employer-sponsored group healthcare plan to another.
Privacy Statement
Statement patients are asked to sign when they visit their healthcare providers
Indemnity
Fee-for-Service
Traditional type of insurance where pts can choose any dr, hospital, and change at any time.
Insured
The pt who pays a monthly premium to keep a health insurance plan in force, also policyholder.
Deductible
The amount to be paid by policyholder before the insurance “kicks” in and pays.
Premium
The monthly payment, paid to the insurance company, to keep a policy in force.
Co-insurance
…is the portion of the cost of the insurance paid by the patient in the form of a “copayment” or a “percentage”, after the deductible has been met.
Usual, Customary, and Reasonable
UCR
…are the part of the provider’s charge that the insurance carrier allows as covered expenses.
Out of Pocket Maximum
Fee-for-service policies usually have an out of pocket maximum, which means, when some established amount is reached, the insurer will pay 100% of the UCR.
CMS-1500 Form
A universal form created by the government for Medicare claims, and has since been adopted by most 3rd party carriers.
Comprehensive Plan
Some companies combine basic and major medical in one plan called CP
Exclusions
Specific medical conditions not covered by an insurance plan
Pre-existing Condition
Some exclusions might be PEC. Which is a condition existing before the policy went into effect. This whole concept slowly fading into the past.
Managed Care
…is medical care provided by a corporation established under state and federal laws
Enrollees
People covered under a managed care plan.
Group Contract
A contract of insurance made with a company, a corporation, or other group of common interest where all individuals are insured under a single policy
Medicare
Federal health insurance program that provides benefits to people 65 years or older, and younger with certain disabilities.
Medical
Medicare Supplement plans
The policies cover certain expenses such as deductibles, and daily co-insurance amount for hospital stays.
Medicaid
Covers some low income people, particularly children and pregnant women and certain disabled people.
TRICARE
US Military’s comprehensive healthcare program for active duty personnel, and eligible family members younger than 65 years old and survivors of all branches of the military.
CHAMPVA
Civilian Health And Medical Program of the department of Veteran Affairs
Shares cost with eligible beneficiaries.
Disability Insurance
…is insurance that pays the policyholder a specific sum of money in place of his usual income if the person cannot work b/c of illness or injury.
Social Security Disability Insurance
…is an insurance program for people who become unable to work.
Worker’s Compensation
Pays people who are injured or disabled on the job, or have job related illness.
Medical Savings Account
MSA
Health Savings Plan
HSP
…is a special tax shelter set up for the purpose of paying medical bills. Known as the Archer MSA
Flexible Spending Account
FSA
An IRS Section 125 Cafeteria Plan. A plan falls into the cafeteria category when the cost of the plan (premium) is deducted from the employees wages before withholding taxes are deducting.
Health Insurance Exchange
The intention of this model is to create a more organized, and more competative market for health insurance by offering a choice of plans.
Accountable Care Organization
A coverage model to provide a new, more efficient way to deliver care. Similar to HMO.
Consolidated Omnibus Budget Reconciliation Act, 1986
COBRA
The law amends the Employee Retirement Income Security Act, the Internal Revenue Code, and the Public Health Service Act or provide continuation of group health coverage that would be terminated when someone left a job.
Maintenance of Benefits
MOB
MOB allows pts to receive benefits from all health insurance plans they are covered under, while still being responsible for paying their co-pays.
Coordination of Benefits
This is about determining which insurance policy is primary and which is secondary when a pt is covered by 2 insurance policies.
Medically Necessary
A third party payer won’t pay for services unless they are proper and needed. i.e. they are needed for the diagnosis, direct care, they meet the standards of good medical practice, and are NOT mainly for the convenience of the pt.
Balance Billing
When the provider charges more than the insurance company’s UCR charges, AND the provider bills the pt for the difference between what the insurance company paid and and the dr’s higher fee. That’s balance billing.. Not allowed
Participating Provider
PAR
…is one who contracts with a 3rd party payer and agrees to abide by certain rules.
NonParticipating Provider
NonPAR
…has no contractual agreement with the insurance carrier. Provider doesn’t have to accept insurance company’s reimbursement as full payment.
Birthday Rule
Informal procedure used to help determine which health plan is consider primary when individuals have 2 policies. So in the case of a child have parent each with a policy. The parent with the earlier calendar birthday would be considered primary insurance.
