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MA Admin Skills

Administrative Skills for the Medical Assistant

FFS fee for service
fee for service insurance reimbursement based on fee charged and the service provided
capitation payment of a fixed amount monthly per member regardless of the amount of care
premium amount of money paid to purchase health insurance or other insurance
benefit a service covered by an insurance plan
beneficiary each individual covered by the insurance
insured individual who has the insurance
deductible payment by member each calender year before health insurance pays for any services
coinsurance percentage the member must pay
copayment fixed dollar amount the member must pay each time he or she receives services
primary insurance insurance to whom the insurance claim must be sent first
secondary insurance insurance that covers an individual in addition to primary insurance
coordination of benefits rules insurance companies use to coordinate insurance payments
birthday rule primary insurance for a child covered by insurance of both parents is that of the parent whose birthday comes first in the calender year
PAR participating provider; if physician has a contract or agreement with insurance carrier (must accept insurance carrier's determination of allowable fee)
nonPAR nonparticipating provider; has no contract with the insurance carrier (can bill patient for difference between billed amount and amount paid by insurance
indemnity obligation to compensate an individual for loss or damage
UCR usual, customary and reasonable fee
medicare deductible amount $147
what factors involved in UCR? most commonly charged fee by the office for the service, what charged by other physicians in same geographic area, fee meets the criteria of usual and customary or other special circumstances
managed care movement to control health costs while improving preventative care while improving preventative care and a general term for insurance provided with these goals
health insurance contract between patient and insurance company
claim request for payment
CMS Center for medicare and medicaid services
CMS-1500 universal claim form
traditional health insurance FFS
MCO managed care organization
HMO health maintainance orginazation
PPO prefered provider organization
balance billing the difference between the amount charged for service and the amount allowed by insurance
PCP primary care provider; physician who provides most care and determines what other services are necessary; "gatekeeper"
POS point of service
DRGs diagnosis-related groups; system that classifies patients according to diagnosis, treatment, and length of hospital stay
RBRVS resource-based relative value scale; system of reimbursement that assigns relative value units to procedures based on amount of work, overhead expenses, and cost of malpractice insurance
Medicare Part A covers hospital services except first day
Medicare Part B covers office visits and equiptment
Medicare Part C medicare advantage plan; choice
Medicare Part D covers medications
CHIP children's health insurance program; state programs to provide insurance for children whoses parents cannot afford health insurance for them
Tricare provides health benefits for spouses and children of active military personnel
CHAMPVA provides benefits for spouses and dependents of some military veterans
referral directing a patient to a medical specialist by primary care physician
formulary list of medications that are approved for prescription drug benefits
workers' compensation program in each state to cover medical care and lost wages for workers injured during employment
CPT current procedural terminology; for billing
WHO World Health Organization
ICD-9-CM international classification of diseases, 9th revision, clinical modification; for diagnosis
ICD-9 volume 1 tabular list
ICD-9 volume 2 alphabetic index
ICD-9 volume 3 used primarily by hospitals
HAC hospital aquired condition
NEC not elsewhere classified
NOS not otherwise specified
late effect codes something thats important to note that has happened in the past but current problem is related
V codes factors that influence patient care
E codes supplementary classification of external causes of injury and poisoning; never a stand alone or primary code
what are the 3 tables of ICD-9 hypertension, neoplasms, drugs and chemicals
health insurance in the US is primarily a ________ market private
amount of americans that do not have health insurance 44 million
IPA independant practice association
pre-authorization authorization from insurance company before service is provided
pre-certification more strict then pre-authorization for services rendered over period of time
who covered by medicare retired 65 & over, perminatly disabled for 2 years or longer, legally blind, retired railroad or some federal employee, end stage renal disease patients, kidney donors
limiting charge maximum fee that can be collected per Medicare; 115% of medicare allowed charges
what must be done for a worker conpensation case? check with patient's employer immediately, establish seporate medical record, physician must file a first report, physician must submit a statement of services and monthly report, physician must accept payment as paid in full
what information is required for preauthorization? discription of service, diagnosis, info to justify need, proposed date of service, patient demographic information as well as insurance information and NPI
who is considered a new patient? not treated in that office in the last 3 year
who is considered an established patient? patient that has been treated in the last 3 years
HCPCS healthcare common procedure coding system
what purpose of procedural coding? classify care given, justify medical services, collect ststistics about outcome and effectiveness of treatments, set fees
purpose of modifiers needed in addition to a CPT code if there are unusual circumstances related to the procedure
anesthesia administration of medication that causes total or partial loss of sensation
what factors determine the level of service extent of history, extent of physical exam, complexity of MDM
what does not play a factor in E & M code selection Time; unless more that 50% of visit includes counseling
Created by: jabert1