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Insurance Terms
MOP110
| Question | Answer |
|---|---|
| Abuse | "Description" Actions inconsistent with accepted sound medical, business, or fiscal practices |
| Fraud | Intentional deception or misrepresentation that could result in an unauthorized payment |
| Scope of Practice | Healthcare services determined by state, that a NP & PA can perform |
| Respondent Superior | Latin for "Let the Master Answer"; legal doctrine that the employer is liable for the actions & omission of employees performed & committed within the scope of their employment |
| Statue of Limitations | a statue prescribing a period of limitation for bringing certain kinds of legal action |
| Subpoena | An order of the court that requires a witness to appear at a particular time & 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 & other healthcare professionals for liability claims arising from patient treatment |
| Medical Necessity | Involves linking every procedure or service code reported on an insurance claim to a condition code that justifies the need to perform that procedure or service |
| Preauthorization | Prior approval |
| Remittance Advice, Remit | Also called transaction rule; a uniform language for electronic data |
| Co-insurance | Also called coinsurance payment; the percentage the patient pays for covered services after the deductible had been met & the copayment had 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 policy holder or patient to pay a specified dollar amount to a healthcare 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 payment for healthcare services provided to patients ( fee 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 & operates healthcare facilities & providers receive a salary; the VA is a form of this |
| Third-Party Payer | a health insurance company that provides coverage, BCBS |
| Accreditation | Voluntary process that a health care facility or organization, undergoes to determine that it had 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 1-year) |
| Fee for Service | Reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of a less expensive services |
| Gag Clause | Prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services |
| Gatekeeper | PCP for essential health care services at the lowest possible cost, avoiding nonessential care & referring provide reimbursement for services |
| Accept Assignment | Provider accepts as payment in full whatever paid on the claim by the payer |
| Beneficiary | the person eligible to receive health care benefits |
| Birthday Rule | Determines coverage by primary & secondary policies when each patient subscribes to a different health insurance plan |
| Chargemaster | Document that contains a computer generated list of procedures, services, & supplies with charges for each; Chargemaster data are entered in the facility's patient accounting system & charges are automatically posted to patient's bill (UB-04) |
| Adjudication | Judicial dispute resolution process in which an appeals board makes a final determination |
| Appeal | Documented as letter, signed by the provider, explaining why a claim should be reconsidered for payment |
| Clean claim | A correctly completed standardized claim (CMS-100) |
| Clearinghouse | Performs centralized claims processing for providers & health plans |
| Downloading | 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 from in a physician's office |
| Unbundling | submitting multiple CPT codes when one code should be submitted |
| Confidentiality | Restricting patient information access to those with proper authorization & maintaining the security of patient information |
| Upcoding | Assignment of an ICD-10-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement |
| Dual Eligible | Individuals entitled to Medicare and eligible for some type of Medicaid benefit |
| Arbitration | Dispute resolution process in which a final determination is made by an impartial person who may not have judicial powers |
| Allowed Charges | That maximum amount the payer will reimburse for each procedure or service, according to the patient's policy |
| Assignment of Benefits | the provider receives reimbursement directly from the payer |
Created by:
Cristinacholi
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