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MOP 110

Insurance Terminology Assessment Study Guide

QuestionAnswer
Abuse actions inconsistent with accepted, sound medical, business, or fiscal practices.
Fraud intentional deception or misinterpretation that could result in an authorized payment.
Scope of Practice health care services, determined by the state, that an NP and PA can perform.
Respondent Superior Latin for " Let the master Answer"; legal doctrine holding that the employer is liable for the actions and omissions of the employees performed and committed within the scope of their employment.
Statue of Limitation time limit for bringing certain kinds of legal actions.
Subpoena an order of the court that requires a witness to appear at a particular time and place to testify.
Stand Alone Codes CPT codes that includes a complete description of the procedure or services.
Medical Mal Practice Insurance a type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment.
Medical Necessity involves liking every procedure or service codes reported on an insurance claim to a condition code( e.g. disease, injury, sigh, symptoms, other reason for encounter) that justifies the need the perform that procedure or service.
Preauthorization prior approval.
Remittance Advise also called transaction rule, a unformed language for electronic data enter change.
Coinsurance also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
Continuity of care documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment.
Copayment provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received.
Deductible amount for which the patient is financially responsible before an insurance policy provides coverage.
Fee schedule list of predetermined payments for health care services provided to patients ( e.g., a fee is assigned to each CPT code.)
Policyholder a person who signs a contract with a health insurance company and who, thus, owns the health insurance policy; the policyholder is the insured ( or enrollee), and the policy might include coverage for dependents.
Socialized Medicine type of single-payer system in which the government owns and operates health care facilities and provides (e.g., physicians) receive salaries; the VA health care program is a form of socialized medicine.
Third Party payer a health insurance company that provides coverage, such as BlueCross BlueShield.
Accreditation voluntary process thata health facility or organization (e.g., hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law.
Capitation providers accept preestablish payments for providing health care services to enrollees over a period of time( usually 1 year).
Fee For Service reimbursement methodology that increase payment if the health care service fees increase, if multiply units of service are provided, or if more expensive services are provided instead of less expensive services.
Gag Clause prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.
Gatekeeper primary care provider for essential health care services, at the lowest possible cost, avoiding nonessential care, and referring patient to specialist .
Accept Assignment providers accept as payment I full whatever is paid on the claim by the payer ( Except for any copayment and / or coinsurance amounts.)
Allowed Charges the maximum amount the payer will reimburse for each procedure or services, according to the patient's policy.
Assignment of Benefits the provider receives reimbursement directly form payer.
Beneficiary the person eligible to receive health care benefits.
Birthday rule determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.
Chargemaster document that contains a computer-generated list of procedures, services, and supplies with a charge for each; chargemaster data are entered in the facility's patient accounting system , and charges are automatically posted to the patient's bill (UB-04)
Adjudication judicial dispute resolution process in which an appeals board make a final determination.
Appeal documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment.
Clean Claim a correctly completed standardized claim (e.g. CMS-1500 claim).
Clearinghouse performs centralized claims processing for providers and healthcare plans.
Downcoding assigning lower-level codes than documented in the record.
Guarantor person responsible for paying health care fees.
Litigation legal action to recover a debt, usually a last resort for a medical practice.
Super bill terms used for an encounter form in the physician's office.
Unbundling submitting multiples CPT codes when one code should be submitted.
Confidentiality restricting patient information access to those with proper authorization and maintaining the security of patients information.
Upcoding assignment of an ICD-10 diagnosis code that does not match patient record documentation for the purpose of illegally increase reimbursement .
Dual Eligible individuals entitled to Medicare and eligible for some type of Medicaid benefits.
Arbitration dispute-resolution process in which a final determination is made by an impartial person who may not have judicial powers.
Created by: mariaparra
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