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ins_3

insurance principals

TermDefinition
Medicaid Health insurance program in which the federal government makes payments to states under the Federal Medicaid Assistance Percentage (FMAP); individuals who qualify for Medicaid meet federal and state set income requirements
Medical necessity The determination by an insurance payer using evidence-based clinical standards that a procedure or service is medically necessary
Medical policy Medical guidelines utilized by insurance carriers to determine coverage decisions
Medicare Administrative Contractors (MAC) One of the 15 contractors responsible for process and payment of Medicare Part A and Part B claims
Medicare Part A Medicare benefits that pay for portions of inpatient hospital care, skilled nursing care, home health care, and hospice care; also called Hospital Insurance Benefits
Medicare Part B Medicare benefits that help pay for provider services, outpatient hospital services, medical equipment, and other supplies and services; also called Supplemental Medical Insurance
Medicare Part C CMS contracts with private health insurance companies to offer Medicare beneficiaries Medicare Advantage plans with comparable benefits to the original Medicare plans
Medicare Part D Private prescriptions plans that help with the cost of prescription medication for Medicare beneficiaries
Open enrollment A period of time each year when enrollment is open to members and providers for Medicare
Open-panel HMO Allows providers who meet their standards to join the HMO and see patients who are HMO members
Point of service (POS) plan Hybrid of the PPO and HMP plans; member can choose from a primary or secondary network
Policyholders Owners of a health insurance policy
Integrity Adherence to moral and ethical principles
Latex sensitivity Occurs when someone is allergic to latex, a component of commonly used medical equipment, such as disposable rubber gloves; can cause serious harm
Malpractice The professional liability of providers involved in the delivery of health care
Medicolegal Legal aspects of the practice of medicine
Morals The difference between right and wrong or how a person perceives he/she should behave in a given situation
Negligence Failure to do what a prudent person would normally expect a provider to do in a similar circumstance
Nonverbal communication Written forms of communication, facial expressions, physical gestures, and body positions and movements
Patients Bill of Rights A list developed by the American Hospital Association (AHA) that delineates patients rights; also outlined in the Affordable Care Act
Phlebitis Inflammation of blood vessel; can be caused by a disease or a complication of medical procedures
Privacy A patients right to keep his/her information from being disclosed
Privileged communication Any communication involving patient care that takes place between a provider and a patient
Scope of duty A legal term that refers to the understanding that the provider has a duty to diagnose and treat a patient in accordance with the standards of acceptable medical practice and to continue to do so until the termination of the relationship
Social media Media specifically designed for social interaction, includes online technology tools that enable persons to communicate and share resources and information
Stressors Any agents or conditions that cause stress
Created by: tina.reynolds