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MA Admin Skills
Administrative Skills for the Medical Assistant
| Term | Definition |
|---|---|
| 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
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