Week 13- Medical Insurance and Billing Flashcards
In an insurance contract, first party is the
insured/patient
In an insurance contract, second party is the
healthcare provider
In an insurance contract, third party is the
health plan
amount of money patient must pay before health plan kicks in
deductible
when the policyholder and insurance share the costs, its called _____ (usually 80/20)
coinsurance
amount of money paid at time of service (paid by the insured)
copayment
amount of money paid at time of service (paid by the insured)
copayment
providers that agree to write off the difference between amount charged and amount allowed by insurance company
participating provider
max amount insurance company will pay for services
allowable amount
form given to patient when its believed Medicare will not cover the amount patient responsible for payment
ABN (advanced beneficiary notice)
covers patients 65 +
Medicare
covers hospitilizations
Medicare Part A
covers routine visits and outpatient services
Medicare Part B
optional and additional coverage offered by private insurance and approved by Medicare
Medicare part C
covers prescriptions and medications
Medicare part D
covers low income and mentally indigent
Medicaid
covers military personnel and dependents
Tricare
covers surviving spouses and dependents of veterans who died as a result of service related disabilities
CHAMPVA
provides low cost coverage to children who earn too much money to qualify for Medicaid (in some states, CHIP covers pregnant women)
CHIP- Children’s health insurance plan
covers workers against lost of wages due to accidents on the job
Workers compensation
plans that provide healthcare for payments
Managed Care plans
INN plan that costs less than PPO, requires referral, pre auth, and requires PCP
HMO plans
plan that offers INN & OON benefits, more flexible than HMO, does not need referral
PPO plans
When a provider is INN, they are also considered a
participating provider
Birthday rule states
person/parent born earliest in the year becomes primary payer for dependent
type of fee schedule that compensates providers only if certain measures are met for quality and efficiency
pay-for-performance
type of fee schedule that compensates providers only if certain measures are met for quality and efficiency
pay-for-performance
type of claims processing that allows provider to submit all insurance claims at one time through software
Clearinghouse
money owed to provider for services rendered
accounts receivable
