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MD300 Chapter 1&2

Chapters 1&2 UHI

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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