Term
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Definition
| – Hospitals create a new account for each episode of care, whereas medical practices create a new account on the first visit and use the same account for the life of the patient (except for family accounts). |
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Term
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Definition
| – The person, often the patient, responsible for paying amounts not covered by insurance; the guarantor may also be a parent, guardian, or spouse. |
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Term
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Definition
| -A health plan may be a for-profit or not-for-profit insurance company, employer self-insurance fund, or government program such as Medicare. Although not technically health plans, government programs are set up in the registration computer system the same way because CMS programs contract with various companies, called fiscal intermediaries, to process claims and disburse payments for them. |
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Term
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Definition
| Another name for health plans |
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Term
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Definition
| – The primary person who is named on the health insurance card is referred to as the subscriber, insured party, enrollee, member, or beneficiary. That person’s insurance ID is used to determine eligibility and during claims processing to determine which dependents and services are covered. |
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Term
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Definition
| – A unique ID is assigned by a health plan to each policy or by a government program to each participant. This is called the member number, policy number, or sometimes insurance ID. Some plans assign a unique member number to each dependent as well. Keeping accurate records of these IDs is vital to getting paid by the health plan. |
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Term
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Definition
| – The beneficiary is the person who is entitled to receive benefits from the plan, and may also include spouses and children, called dependents. |
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Term
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Definition
| – A number used to further identify the policy and the benefits to which a patient is entitled; generally used in cases where insurance is obtained through an employer who has negotiated special rates and coverage. |
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Term
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Definition
| bill sent insurer – most are electronic now caused by HIPPA |
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Term
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Definition
| - A document signed by the patient during registration that authorizes the plan to pay a doctor directly. |
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Term
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Definition
| - big health insurance type word means received claim and determines if accepted or rejected |
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Term
| Explanation of benefits (EOB) or remittance advice |
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Definition
| – Insurance company sends Document shows how munch provider billed and what you owe to provider – paper copy and (doctor gets electronic form ERA) |
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Term
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Definition
| – Amount doctors and hospitals bill they know no where close to what will be paid |
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Term
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Definition
| - The amount the provider receives from the insurance plan. |
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Term
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Definition
| – Amountt paid back from insurance company and rarely full amount |
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Term
| Adjustments (Also called a contractual adjustment or a write-down adjustment.) |
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Definition
| An entry made in the patient accounting system to reduce the original charge to the allowed amount based on the provider’s contractual agreement with the health plan. -- An entry made in the patient accounting system to reduce the original charge to the allowed amount based on the provider’s contractual agreement with the health plan. |
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Term
| Coordination of benefits, crossover or piggyback claims |
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Definition
| – if patient has 2 insurance companies than 1 takes the lead and pays majority of bill and the other one comes in and takes over the rest that’s left |
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Term
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Definition
| - The portion of the charges, usually a fixed amount per visit, that a patient is required to pay. Also called a coinsurance amount. |
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Term
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Definition
| - A percentage of the allowed amount determined after the health plan has adjudicated a claim. |
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Term
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Definition
| – for more the procedure stuff when they actually do something i.e. surgery |
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Term
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Definition
| A fixed minimum that the patient must pay, usually within a calendar year, before the plan begins paying. Some plans have several deductibles, for example, one amount for doctor visits and another deductible for hospital stays.- going up in future |
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Term
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Definition
| - Amounts that are determined to be the responsibility of the patient are sent on a bill. Different than a statement, which is a list of charges, payments, and adjustments posted to the account during the period covered by the statement. |
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Term
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Definition
- Standardized codes required for healthcare transactions, such as insurance claims and remittance advice
- Procedure codes assigned for services rendered and supplies used (HCPCS/CPT-4 codes)
- Diagnosis codes assigned to represent disease or medical condition treated (ICD-9-CM codes) |
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Term
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Definition
| Two-digit codes used in conjunction with HCPCS/CPT-4 codes for billing purposes |
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Term
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Definition
- Used to bill for alternative medicine
- Not part of the CPT or HCPCS code sets; only accepted by some payers |
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Term
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Definition
- Numeric standardized codes for reporting medical services, procedures, treatments performed by medical staff
- Five digits long |
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Term
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Definition
- Coding system used for billing for procedures, services, supplies
- Includes CPT-4 codes |
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Term
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Definition
| Two-digit codes used in conjunction with HCPCS/CPT-4 codes for billing purposes |
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Term
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Definition
- Used to bill for alternative medicine
- Not part of the CPT or HCPCS code sets; only accepted by some payers |
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Term
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Definition
| - Used to classify ICD-9-CM codes into 25 major diagnostic categories (MDCs) |
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Term
| Reimbursement Examples: Fee for service: |
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Definition
| Control what provider can charge |
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Term
| Reimbursement Examples: Allowed amount: |
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Definition
| Discounted fees agreed to by provider for services; listed on EOB |
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Term
| Reimbursement Examples: Managed care: |
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Definition
| Control patients’ utilization of services |
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Term
| Reimbursement Examples: Capitation: |
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Definition
| Flat rate paid to provider by HMO based on per member per month |
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Term
| Reimbursement Examples: PPO: |
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Definition
| Allows patients to use both PPO and non-PPO providers, but pay more when going out of network |
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Term
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Definition
- Covers inpatient hospital stays, skilled nursing facilities
- Most beneficiaries do not pay premiums (previously collected as Medicare taxes) |
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Term
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Definition
- Covers professional services
- Beneficiaries pay premium; uses fee-for-service model based on RBRVS |
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Term
| Medicare Part C (Medicare Advantage Plans) |
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Definition
- HMO plans authorized by Medicare
- Patient pays HMO a premium, which supplies all of patient’s Part A, Part B, Medigap, and sometimes Part D coverage |
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Term
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Definition
- Helps patients purchase prescription drugs at lower cost
- Patients pay premium to private insurance plans this coverage |
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Term
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Definition
-Supplemental private insurance
- Pays portion of Medicare claims and deductibles for which patient is responsible |
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Term
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Definition
- Developed to help control costs of use of healthcare services
- Designed to make PCP into gatekeepers who control access to additional services
+HMOs act as both insurer and provider
+HMO patients must use HMO for all services, except emergencies |
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Term
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Definition
| HMO owns facilities and employs doctors. This is a Managed Care Plan Examples |
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Term
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Definition
| HMO contracts with facilities and physicians to provide services. This is a Managed Care Plan Examples |
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Term
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Definition
| Independent physicians form business arrangement for purpose of contracting with HMO and thus receives payment from HMO. This is a Managed Care Plan Examples |
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Term
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Definition
| Facilities and physicians form business arrangement for purpose of contracting with HMO to provide both hospital and physician services. This is a Managed Care Plan Examples |
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Term
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Definition
- Hospitals do not bill insurance plans in same way as physicians
- Hospital claim coders must identify principal diagnosis and associate revenue codes with procedures
- Not used for children’s hospitals, cancer hospitals, critical access hospitals
(Stands for Prospective Payment System) |
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Term
| Medicare Part A Reimbursement |
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Definition
- PPS uses DRGs to determine reimbursement for inpatient stays
- PPS determines DRG from principal diagnosis
- Hospital reimbursement calculated by multiplying hospital’s PPS rate (operating and capital base rate) times RW of DRG code |
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Term
| Medicare Hospital Outpatient PPS |
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Definition
- Reimburses hospital outpatient services
- Does not use DRGs nor apply to doctor’s offices
- Uses Ambulatory Payment Classifications (APC) – based on procedure codes not diagnosis codes. Predetermined price for a procedure although can perform, and bill for multiple procedures in one encounter
- RBRVS-used to calculate hospital APCs and to calculate physican Part B charges
- RBRVS based on: physician work (physician's time, mental effort, technical skill, judgment, stress and an amortization of the physician's education, practice expense, malpractice expense |
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