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MOP110

Vocabulary test

QuestionAnswer
ABUSE Action inconsistent with accepted, sound medical. business, or fiscal practices.
FRAUD Intentional deception or misrepresentation that could result in an unauthorized payment.
SCOPE OF PRACTICE Health care service determined by the state, that NP and PA can perform.
RESPONDEAT SUPERIOR Latin for "let the master answer", legal doctrine holding that the employer is liable for the actions and omissions of employees performed and committed within the scope of their employment.
STATUTE OF LIMITATIONS Laws passed by legislative bodies in common law systems to set the maximum time after the event within which legal proceeding may be initiated.
SUBPOENA An order of the court that requires a witness to appear at a particular time and place to testify.
STAND ALONE CODE CPT Code that includes a complete description of the procedure or service.
MEDICAL MALPRACTICE INSURANCE A type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment.
MEDICAL NECESSATY Involves linking every procedure or service code reported on an insurance claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service.
PREAUTHORIZATION Prior approval
REMMITANCE ADVICE Electronic or paper based report of payment sent by the payer to the provider: includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service (from date/ thru date) type of bill (TOB), charges, payment
COINSURANCE Also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
CONTINUITY OF CARE Documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment .
COPAYMENT Provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received.
DEDUCTIBLE Amount for which the patient is financially responsible before an insurance policy provides coverage.
FEE SCHEDULE List of predetermined payments for health care services provided to patients (e.g., a fee is assigned to each CPT Code).
POLICYHOLDER A person who signs a contract with a health insurance company and who, thus, owns the health insurance policy; the policyholder is the insured (or enrollee) and the policy might include coverage for dependents.
SOCIALIZED MEDICINE Type of single-payer system in which the government owns and operates health care facilities and providers (e.g., physicians) receive salaries; the VA health care program is a form of socialized medicine.
THIRD PARTY PAYER A health insurance company that provides coverage, such as BlueCross, BlueShields.
ACCREDITTATION Voluntary process that a health care facility or organization (e.g., hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law.
CAPITATION Provider accepts pre established payments for providing health care services to enrollees over a period of time (usually one year).
FEE FOR SERVICES Reimbursement methodology that increases payment of the health care services fee increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services (e.g., brnad-name vs. generic prescription
GAG CLAUSE Prevents providers from discussing all treatment options with patient whether or not the plan would provide reimbursement for services.
GATEKEEPER Primary care provider for essential health care services at the lowest possible cost, avoiding nonessentials care and referring patients specialist.
ACCEPT ASSIGMENT Provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts).
ALLOWED CHARGES The maximum amount the payer will reimburse for each procedure or service., according to the patient's policy.
ASSIGMENT OF BENEFITS The provider receives reimbursement directly from the payer.
BENEFICIARY The person eligible to receive health care benefits .
BIRTHDAY RULE Determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.
CHARGE MASTER Documents that contains a computer-generated list of procedures, services and supplies with charges for each; charge master data are entered in the facilities, patient accounting system, to the patients bill (UB-04).
ADJUDICATION Judicial dispute resolution process in which an appeals board makes a final determination.
APPEAL Documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment.
CLEAN CLAIM A correctly completed standardized claim (e.g., CMS-1500 claim)
CLEARINGHOUSE Performs centralized claims processing for providers and health plans.
DOWNCODING Assigning lower-level codes than documented in the record.
GUARANTOR Person responsible for paying health care fees.
LITIGATION Legal action to recover a debt; usually a last resort for a medical practice.
SUPERBILL Term used for an encounter form in the physician's office.
UNBUNDLING Submitting multiple CPT Codes when one code should be submitted.
CONFIDENTIALITY Restricting patient information access to those with proper authorization and maintaining the security of patient information.
UPCODING Assignment of an ICD-10CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement (e.g., assigning the ICD-10-CM code for heart-attack when angina was actually documented in the record).
DUAL ELIGIBLE Individuals entitled to Medicare and eligible for some type of Medicaid benefits.
ARBITRATION Dispute-resolution process in which a final determination is made by an impartial person who may not have judicial powers.
Created by: frla5938