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Chapter 1
Medical Billing Key Terms
| Question | Answer |
|---|---|
| accounting cycle | the flow of financial transactions in a business |
| accounts receivable | monies that are flowing into a business |
| adjudication | series of steps that determine whether a claim should be paid |
| billing cycle | regular schedule of sending statements to patients |
| capitation | advance payment to a provider that covers each plan member's health care services for a certain period of time |
| coding | a way of translating a description of a condition into a shorter, standardized code |
| coinsurance | part of charges that an insured person must pay for health care services after payment of the deductible amount |
| consumer-driven health plan (CDHP) | a type of managed care in which a high-deductible/low-premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses, up to the deductible limit |
| copayment | a small fixed fee paid by the patient at the time of an office visit. |
| diagnosis | physician's opinion of the nature of the patient's illness or injury |
| diagnosis code | a standardized value that represents a patient's illness, signs, and symptoms. |
| encounter form | a list of the procedures and charges for a patient's visit. |
| explanation of benefits (EOB) | paper document from a payer that shows how the amount of a benefit was determined |
| fee-for-service | health plan that repays the policyholder for covered medical expenses |
| Health Maintenance Organization (HMO) | a managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan |
| health plan | a plan, program, or organization that provides health benefits |
| managed care | a type of insurance in which the carrier is responsible for both the financing and the delivery of health care |
| medical coder | a person who analyzes and codes patient diagnoses, procedures, and symptoms |
| medical necessity | treatment provided by a physician to a patient for the purpose fo preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and provided in accordance with generally accepted standards of medical practice. |
| patient information form | form that includes a patient's personal, employment, and insurance data needed to complete an insurance claim |
| payer | private or government organization that insures or pays for health care on the behalf of the beneficiaries |
| policyholder | a person who buys an insurance plan; the insured |
| practice management program (PMP) | a software program that automates many of the administrative and financial tasks required to run a medical practice |
| Preferred Provider Organization (PPO) | managed care network of health care providers who agree to perform services for plan members at discounted fees |
| premium | the periodic amount of money the insured pays to a health plan for insurance coverage |
| procedure | medical treatment provided by a physician or other health care provider |
| procedure code | a code that identifies a medical service |
| remittance advice (RA) | an explanation of benefits transmitted electronically by a payer to a provider |
| statement | a list of all services performed for a patient, along with the charges for each service. |
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