MI&C Chapter 3 & 4 Vocabulary

Question 0

Negligence

Answer 0

Failure to exercise a reasonable degree of care

Question 1

Respondeat Superior

Answer 1

Latin term “ Let the master answer “

Question 2

Ancillary

Answer 2

Staff members of the medical team, MAs, RNs, technicians, health insurance professionals

Question 3

Offer

Answer 3

A proposition to create a contract.

Question 4

Acceptance

Answer 4

After the “offer” has been made, and the information has been verified, the insurance command says, “yes”, and accepts the application.

Question 5

Binds

Answer 5

Acceptance occurs when the company binds, ie agrees to accept the individual.

Question 6

Consideration

Answer 6

Binding force in any contract that gives it legal status.

Question 7

Competency

Answer 7

The parties to the contract must be mentally capable and of proper age when entering into a contractual agreement.

Question 8

Emancipated Minor

Answer 8

An individual younger than 18 whose is living independently, like and 18 year old, away from home.

Question 9

Implied Contract

Answer 9

Contract, not in writing, but has all the components of the a written one, and just as binding.

Question 10

Implied Promise

Answer 10

Promises, neither spoken, nor written, but implicated by the individual’s actions.

Question 11

Ethics

Answer 11

Standards of human conduct. Morals

Question 12

Medical Ethics

Answer 12

Code of ethics for the medical professional.

Question 13

Etiquette

Answer 13

Consists of the rules and conventions governing correct or polite behavior in society.

Question 14

Medical Etiquette

Answer 14

Following the conventions of polite behavior in the healthcare profession.

Question 15

First Party (Party of the First Part)

Answer 15

In legal language, the patient in the implied contract between patient and healthcare provider.

Question 16

Second Party (Party of the Second Part)

Answer 16

In legal language , the healthcare provider in the implied contract.

Question 17

Third Party (Party of the Third Part)

Answer 17

In legal language, the insurance company in the implied contract between patient and healthcare provider.

Question 18

Medical Record

Health Record

Answer 18

. . .is a clinical, scientific, administrative and legal document of facts containing statements relating to a patient.

Question 19

Confidentiality

Answer 19

Concerns the communication of private and personal information from one person to another.

Question 20

Privacy

Answer 20

Denotes a “zone of in accessibility” of mind or body, the right to be left alone and to maintain individual autonomy.

Question 21

Subpoena duces tecum

Answer 21

. . .is a legal document that requires an individual to appear in court with a piece of evidence that can be used by the court.

Question 22

Breach of Confidentiality

Answer 22

Has occurred when information is disclosed to a third party without permission of the patient.

Question 23

Durable Power of Attorney

Answer 23

When someone has been named as an agent of a patient’s affairs should the patient become incapacitated.

Question 24

Fraud

Answer 24

An intentional deception that could lead to a benefit to the individual committing it

Question 25

Abuse

Answer 25

Improper or harmful procedures off that are contradictory to accepted business practices.

Question 26

Abandoning

Answer 26

Ceasing to provide care

Question 27

Accountability

Answer 27

Responsibility the healthcare profession has to patients so that a feeling of confidence exists between patient and dr.

Question 28

Incidental Disclosure

Answer 28

Type of privacy disclosure that is specifically allowed under HIPAA. i.e. two patients in the waiting room know each other.

Question 29

Litigious

Answer 29

Quick to take legal action. Bring a law suit

Question 30

Portability

Answer 30

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.

Question 31

Privacy Statement

Answer 31

Statement patients are asked to sign when they visit their healthcare providers

Question 32

Indemnity

Fee-for-Service

Answer 32

Traditional type of insurance where pts can choose any dr, hospital, and change at any time.

Question 33

Insured

Answer 33

The pt who pays a monthly premium to keep a health insurance plan in force, also policyholder.

Question 34

Deductible

Answer 34

The amount to be paid by policyholder before the insurance “kicks” in and pays.

Question 35

Premium

Answer 35

The monthly payment, paid to the insurance company, to keep a policy in force.

Question 36

Co-insurance

Answer 36

…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.

Question 37

Usual, Customary, and Reasonable

UCR

Answer 37

…are the part of the provider’s charge that the insurance carrier allows as covered expenses.

Question 38

Out of Pocket Maximum

Answer 38

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.

Question 39

CMS-1500 Form

Answer 39

A universal form created by the government for Medicare claims, and has since been adopted by most 3rd party carriers.

Question 40

Comprehensive Plan

Answer 40

Some companies combine basic and major medical in one plan called CP

Question 41

Exclusions

Answer 41

Specific medical conditions not covered by an insurance plan

Question 42

Pre-existing Condition

Answer 42

Some exclusions might be PEC. Which is a condition existing before the policy went into effect. This whole concept slowly fading into the past.

Question 43

Managed Care

Answer 43

…is medical care provided by a corporation established under state and federal laws

Question 44

Enrollees

Answer 44

People covered under a managed care plan.

Question 45

Group Contract

Answer 45

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

Question 46

Medicare

Answer 46

Federal health insurance program that provides benefits to people 65 years or older, and younger with certain disabilities.

Question 47

Medical

Medicare Supplement plans

Answer 47

The policies cover certain expenses such as deductibles, and daily co-insurance amount for hospital stays.

Question 48

Medicaid

Answer 48

Covers some low income people, particularly children and pregnant women and certain disabled people.

Question 49

TRICARE

Answer 49

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.

Question 50

CHAMPVA

Civilian Health And Medical Program of the department of Veteran Affairs

Answer 50

Shares cost with eligible beneficiaries.

Question 51

Disability Insurance

Answer 51

…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.

Question 52

Social Security Disability Insurance

Answer 52

…is an insurance program for people who become unable to work.

Question 53

Worker’s Compensation

Answer 53

Pays people who are injured or disabled on the job, or have job related illness.

Question 54

Medical Savings Account
MSA
Health Savings Plan
HSP

Answer 54

…is a special tax shelter set up for the purpose of paying medical bills. Known as the Archer MSA

Question 55

Flexible Spending Account

FSA

Answer 55

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.

Question 56

Health Insurance Exchange

Answer 56

The intention of this model is to create a more organized, and more competative market for health insurance by offering a choice of plans.

Question 57

Accountable Care Organization

Answer 57

A coverage model to provide a new, more efficient way to deliver care. Similar to HMO.

Question 58

Consolidated Omnibus Budget Reconciliation Act, 1986

COBRA

Answer 58

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.

Question 59

Maintenance of Benefits

MOB

Answer 59

MOB allows pts to receive benefits from all health insurance plans they are covered under, while still being responsible for paying their co-pays.

Question 60

Coordination of Benefits

Answer 60

This is about determining which insurance policy is primary and which is secondary when a pt is covered by 2 insurance policies.

Question 61

Medically Necessary

Answer 61

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.

Question 62

Balance Billing

Answer 62

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

Question 63

Participating Provider

PAR

Answer 63

…is one who contracts with a 3rd party payer and agrees to abide by certain rules.

Question 64

NonParticipating Provider

NonPAR

Answer 64

…has no contractual agreement with the insurance carrier. Provider doesn’t have to accept insurance company’s reimbursement as full payment.

Question 65

Birthday Rule

Answer 65

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.