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MackeyHIT2Reimburse
| Question | Answer |
|---|---|
| Reimbursement | means to be repaid. |
| Capitation | involves the payment to a health care provider regardless of whether the patient comes into the facility for a visit or how frequently the patient visits the provider. |
| Insurance | purchased contract (policy) in which the purchaser (insured) is protected from loss by the insurer’s (the company) agreeing to reimburse for such loss. |
| Beneficiary | One who is eligible to receive or is receiving benefits from an insurance policy or a managed care program. |
| Claim | Request for payment by the insured or the provider for services covered. |
| Coverage | Types of diseases, conditions, and diagnostic and therapeutic procedures for which the insurance policy will pay. |
| Payer | Party who is financially responsible for reimbursement of health care costs. |
| Premium | Payment required to maintain policy coverage. |
| Rider | Policy amendment that either increases or decreases benefits. |
| Policy | Written contract between insurance company and subscriber (insured) that specifies the coverage, benefits, exclusions, co-pays, deductibles, benefit period, and so on. |
| Subscriber | Person who elects to enroll or participate in managed care or purchase of health care insurance. |
| Fiscal Intermediary | Contractor that manages the health care claims. |
| Exclusion | Specific conditions or hazards for which a health care policy will not grant benefit payments. |
| Deductible | Amount of cost that the beneficiary must incur before the insurance will assume liability (their part) for the remaining cost. |
| Co-Payment | Type of cost-sharing in which the insured(subscriber) pays out-of-pocket a fixed amount for health care service. |
| Benefit Period | Time frame in which the insurance benefits are covered; varies from insurance policy to policy. |
| Benefit | Amount of money paid for specific health care services or in managed care, the health care services that will be provided or for which will be paid. |
| Prospective Payment | Method of determining the reimbursement to a health care provider based on predetermined factors, not on individual services. |
| Discounted Fee For Service | • When a physician or other health care provider offers services at a discounted rate, that is the fee is lower what they would ordinarily charge to person walking in off the street. |
| Fee-for-Service | This term is assigned to the payment for services rendered by the health care provider, whether it is a physician, facility, or another clinician. |
| Encounter Form | A data collection device that facilitates the accurate capture of ambulatory care diagnoses and services. |
| Charges | Fees or costs are also called charges. |
| When the ICD-9-CM diagnosis and procedures codes are used to derive the DRG by the flowchart, this is known as: | Grouper |
| What is the HCFAs prospective payment system for hospital-based ambulatory care based? | Ambulatory Patient Classifications |
| What is the prospective payment for acute care is based? | Diagnosis Related Groups |
| What is the process of submitting claims or rendering invoices? | Billing |
| The process of determining the most accurate DRG payment is known as: | Optimization |
Created by:
Mackey1
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