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HealthCare/Insurance
Module C - Unit 3
| Question | Answer |
|---|---|
| Assignment of Benefits | patient's written authorization giving the insurance company the right to pay the physician directly for billed charges. |
| Bankruptcy | a condition in which a patient is protected by the court and all collection attempts muct cease. |
| Collections | |
| Copayment | amount specified by an insurance plan that the patient must pay before the plan pays (commonly used in managed care plans) |
| CPT | Current Procedure Terminology |
| Crossover Claim | patient is eligible for both Medicare and Medicaid (also called Medi/Medi) |
| Cycle Billing | type of billing divided into groups |
| Deductible | amount of eligible charges each patient must pay each calendar year before the plan begins to pay benefits. |
| Delinquent | account past due |
| Fee Schedule | schedule of the amount paid by a specific insurance company for each procedure or service. Amounts are determined by a claims administrator and applied to claims subject to the fee schedule of a provider's managed care contract. |
| Hospice | patient-centered interdisciplinary program of care and supportive services for terminally ill patients and their families. |
| HCFA | Healthcare Financing Administration |
| HMO (Health Maintenance Organization) | type of managed care plan in which a range of health care services are made available to plan members for a predetermined fee (the capitation rate) per member, by a limited group of providers (such as physicians and hospitals). |
| Inpatient | patient who remains within the medical facility at least overnight for care and/or treatment. |
| Insured | individual who is covered under an insurance plan. |
| Outpatient | patient undergoing medical treatment which does not necessitate staying overnight in the facility. Also referred to as ambulatory or a "23 hour hold." |
| Medicare | health insurance for the elderly provided by the United States government. |
| Medicaid | designed for the medically indigent, or persons without funds, comes from state funds, with some money to offset costs. |
| Preauthorization | a requirement of Medicare and insurance companies to obtain prior approval for surgery and other procedures in order to receive reimbursement. |
| PCP | Primary Care Physician or Primary Care Provider |
| PPO | Preferred Provider Organization |
| Premium | amount paid for insurance coverage. |
| Statute | refers to time a legal collections suit may be brought against debtor |
| Subscriber | person who holds a health benefit plan/contract. This plan, contract, or policy may include other family members. |
| UCR | Usual, Customary, Reasonable Method |
| Acquired Immune Deficiency Syndromes (AIDS) | series of infections that occur as a result of infection by the human immunodeficiency virus (HIV) wich causes the immune system to break down. |
| Ambulatory Care | referes to health service facility which provides health care to individuals who are not hospitalized. |
| Diagnostic Related Groups (DRGs) | designations used to identify reimbursement per condition in a hospital. Used for Medicare patients. |
| Legionnaires' Disease | severe, sometimes fatal disease, caused by a baccilus that is inhaled. First occurence was at the Legionnaire's convention in 1976. |
| Medical Privileges | ability of a physician to admit patients and practice medicine at a particular hospital. |
| Primary Care | basic or general health care a person receives for common illnesses. A primary care physician is the one to whom the patient and/or family will go to seek most medical care. |
| Proprietary Hospital | a hospital that operates on a for-profit basis. |
| Benefit Period | period of time for which payments for Medicare inpatient hospital benefits are available. |
| Claim | written and documented request for reimbursement of an eligible expense under an insurance plan. |
| Coding | Transferring narrative description of diseases and procedures into a number |
| Coinsurance | a cost-sharing provision requires the insured to assume a portion of the cost of covered services. |
| Indemnity Schedule | list of determined amounts to be paid for specific services by the insurance carrier on behalf of the insured. |
| Medically Indigent | person without insurance coverage and with no funds. |
| Nonparticipating Provider | provider who decides not to accept an allowable charge as the full fee for care. |
| Participating Provider | one who accepts assignment and is paid directly by the plan. |
| Prepaid Plan | a group of physicians or other health care providers who have a contractual agreement to provide services to subscribers on a negotiated fee-for-service or capitated basis (also called managed care plan). |
| Rider | a written exception to an insurance contract, expanding, decreasing, or modifying coverage of an insurance policy. |
Created by:
sgaston712
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