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MD300 Chapter 1&2
Chapters 1&2 UHI
| Term | Definition |
|---|---|
| CMS | Centers for Medicare and Medicaid Services |
| health care provider | A physician or other health care practitioner |
| health insurance claim | documentation submitted to an insurance plan requesting reimbursement for services provided |
| explanation of benefits | report that details the results of processing a claim, sent to the policyholder |
| remittance advice | electronic or paper report sent by insurance company to the physician that details the result of the claim |
| balance billing | billing patients for amounts not reimbursed by the insurance [lan |
| hold harmless clause | policy clause that holds that the patient is not responsible for paying what the insurance plan denies |
| independent contractor | a person who performs services for another under an express agreement and who is not subject to the other's control |
| medical necessity | linking every procedure code on an insurance claim to a diagnosis code that justifies the need to perform it |
| preauthorization | preapproval for services |
| respondeat superior | "let the master answer"; the employer is responsible for the actions/inactions of their employees |
| Medical Biller | The person responsible for submitting a provider’s charges to the appropriate party. |
| Clearinghouse | An offsite company hired to process medical bills for the physician, and to convert paper claims into electronic format. |
| claims examiner | Employed by aninsurance company; reviews health-related claims to determine whether the charges are reasonable and meet the criteria for medical necessity. |
| Health Insurance | A contract between the subscriber and the insurance company to pay for all or part of medical care and preventive services. |
| Disability Insurance | Insurance providing income to a policyholder who is temporarily or permanently disabled and cannot work. |
| Liability Insurance | Covers losses to a third party caused by the insured, an object owned by the insured, or on property owned by the insured. |
| Worker’s Compensation | Federal and state legislation that requires employers to cover medical expenses and lost wages for workers injured on the job. |
| Professional Liability Insurance | For independent contractors, it provides protection from any expenses (penalties) from errors and/or omissions from claims submissions. |
| Bonding insurance | Guarantees repayment for financial losses resulting from an employee’s act or failure to act. |
| Medical Care | The identification of disease, and the care and treatment to persons that are sick and injured. |
| Health care | Medical Care plus Preventive Services |
| policyholder | Person who signs a contract with the insurance company – “owns” the policy |
| Third-party payer | A healthcare insurance company |
| Group Health Insurance | Health insurance coverage subsidized by employers and other organizations. |
| Individual Health Insurance | Private health insurance policy purchased by individuals or families |
| Single-payer plan | Centralized healthcare system adopted by some nations (Canada, U.K.) and funded by taxes. The government pays for each resident’s health care, which is considered a basic social service. |
| Socialized medicine | A type of single-payer system in which the government owns and operates healthcare facilities and providers receive salaries. |
| Universal Health Insurance | The goal of providing every individual with access to health coverage |
| Hill-Burton Act | Provided grants to modernize hospitals. In return, hospitals must provide services to patients who are unable to pay for care at free or reduced costs |
| COBRA | Federal legislation that allows employees to continue health care insurance beyond their termination date. |
| DRG | Diagnosis-related group; Prospective (pre-determined) payment system that reimburses hospitals for in-patient stays |
| ARRA/HITECH | Legislation that provides incentives to physicians that have a “meaningful use of EHRs” |
| PPACA | Patient Protection and Affordable Care Act |
| medical record | documents healthcare services provided to a patient |
| Continuity of care | involves documenting patient care services so that others who treat the patient have a source of information to assist with additional care and treatment |
| Problem-Oriented Record | Systematic method of documentation consists of four components:Database, Problem list, Initial plan, Progress notes |
| SOAP | Subjective, Objective, Assessment, Plan |
Created by:
Kirkster
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