Vocab Flashcards
define ACCEPT ASSIGNMENT
provider agrees to accept insurer’s payment as payment in full for services provided
define ADVANCE BENEFICIARY NOTICE (ABN)
doc used to notify Medicare beneficiary that is either unlikely Medicare will pay/certain Medicare will not pay for service
define AFFORDABLE CARE ACT (ACA)
law signed by Obama in 2010 to lower costs, expand Medicaid, and make insurance more accessible
define ALLOWED AMOUNT
max amount insurer will pay for any service
define ASSINMENT OF BENEFITS
authorization by signature of pt for payment to be made directly by insurance to provider for insurance
define BENEFICIARY
person entitled to benefits of insurance policy (generally Medicare)
define BIRTHDAY RULE
way to identify primary responsibility in insurance coverage when kids are covered by more than 1 parent; primary coverage is parent with earlier birthday
define CAPITATION
provider paid fixed amount per member per month for each pt who is member of particular insurance organization regardless of whether services were provided
define CARRIER
company that sells insurance
define CMS-1500
standard claim form designated by Centers for Medicare & Medicaid services to bill third party/Medicare FFS
define COINSURANCE
percent pt is responsible for paying for each service after deductible has been met
define CONVERSION FACTOR
dollar amount that coverts RVUs into fee
define COORDINATION OF BENEFITS (COB)
aka dual coverage; when both spouses have insurance, policy provision limits to 1 insurer being primary & no more than 100% of cost covered to avoid duplication of payment
define COPAYMENT
specified amount insured must pay toward charge for services
define DEDUCTIBLE
amount to be paid before insurance will pay
define DEPENDENT
person covered under subscriber’s insurance policy
define DIAGNOSIS-RELATED GROUPS (DRGs)
method of determining reimbursement from medical insurance according to diagnosis on prospective basis
define EXCLUSIVE PROVIDER ORGANIZATION (EPO)
like HMOs where pt must use provider network & no partial coverage for out of network care
define EXPLANATION OF BENEFITS (EOB)
printed description of benefits provided by insurer to beneficiary; explanation to pt about how insurance claim from provider was paid on their behalf
define FEE-FOR-SERVICE (FFS)
payment for each service provided, individual can choose to pay high premiums for flexibility of providers
define FLEXIBLE SPENDING ARRANGEMENT (FSA)
aka: cafeteria plan; use it or lose it plan where pretax funds from employee/sometimes employer set aside for use in payment of medical services & supplies not covered by insurance and only able to be used for qualified expenses
aka: FSA
cafeteria plan
what are qualified expenses according to FSA
expenses specified in plan that would generally qualify for medical & dental expenses deduction explained in IRS publication 502
define GATEKEEPER
PCP who coordinates pt referrals & hospital admissions
define GEOGRAPHIC PRACTICE COST INDEX (GPC)
index/number multiplied to each of RSRVS components to adjust for geographical cost differences to generate different payment amounts depending on provider’s practice, urban/suburban area, state/part of state, etc
define HEALTH MAINTENANCE ORGANIZATIONS (HMOs)
type of managed care operation group insurance entitling members to services provided by participating hospitals, clinics, & providers
define HEALTH REIMBURSEMENT ARRANGEMENT (HSA)
pays for medical expenses and can be paired w/standard or high deductible plan; only employer can contribute
define HEALTH SAVINGS ACCOUNT (HSA)
tax-sheltered savings account w/contributions from employer & employee which can be used to pay for medical expenses
define INDEMNITY-TYPE INSURANCE
insurance w/least amount of structural guidelines for pts to follow, pts able to see provider of choice w/o having to deal with network or other managed care guidelines
define INDEPENDENT PRACTICE ASSOCIATIONS (IPA)
association of independent physicians/other organizations that contracts independent physicians in their own office w/own staff & provides services to managed care organizations on negotiated per capita rate/flat retrainer fee/negotiated fee-for-service basis
aka: independent practice associations
individual practice associations
define MEDICARE
federal program for providing health care coverage for individuals over age of 65 or disabled
define MEDICARE ADVANTAGE
part C segment of Medicare that enables beneficiaries to select managed care plan as primary coverage
define MEDICAID
joint funding program by federal & state (except AZ) governments for medical care of low income pts on public assistance
define MEDIGAP
private insurance to supplement medicare benefits for payment of deductible, copay, & coinsurance
define PREAUTHORIZATION
prior approval of insurance coverage & necessity of procedure
define PRECERTIFICATION
obtaining plan approval for services prior to pt receiving them under pt’s insurance contract
define PREDETERMINATION
refers to discovery of max amount of money carrier will pay for primary surgery, consultation service, post-op care, etc
define PREFERRED PROVIDER ORGANIZATION (PPO)
organization of physicians who network together to offer discounts to purchasers of healthcare insurance
define PRIMARY
occurring 1st in time
define QUALITY ASSURANCE
inclusive policies, procedures, & practices as standards for reliable lab results including documentation, calibration, maintenance of all equipment, quality control, proficiency testing, & training
define SECONDARY
one step removed from first
define SUBSCRIBER
person who has been insured (insured policyholder)
define THIRD-PARTY REIMBURSEMENT
indicates payment of services rendered by someone other than pt (gen. fed & state agencies, insurance companies, & worker’s comp)
define THIRD-PARTY LIABILITY (TPL)
refers to legal obligation of 3rd parties (eg. certain individuals/entities/insurers/programs) to pay part/all expenditures for medical assistance furnished under state plan
define TRIC ARE FOR LIFE
medicare wraparound coverage for tri-care eligible beneficiaries who have Medicare part a & B
define UTILIZATION MANAGEMENT (REVIEW)
includes preauthorization, precertification, predetermination, concurrent review, & discharge planning
define WAIVERS
document outlining services not covered by insurance & cost associated w/services. signature means pt understands & will pay out of pocket
