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MOP110 Ins. Terms
| Question | Answer |
|---|---|
| Abuse | Actions incincistant with accepted sound medical. business or fiscal practices. |
| Fraud | Intentional deception or misrepresentation that could result in a unauthorized payment |
| Scope of Practice | Healthcare services determined by a state, that a NP and PA can perform |
| Respondent Superior | Latin for " Let the Master Answer"; legal doctrine that the employer is liable for the action & omission of employees performed & committed within the scope of their employment |
| Statue of Limitations | a statue prescribing a period of limitation for bringing certain kind of legal action |
| Subpoena | an order of a 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 & other healthcare professionals for liability 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 has been met & 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 specified dollar amount to a healthcare provider for each visit or medical 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 provide to patients ( fee assigned to each CPT code) |
| PolicyHolder | a person who signs a contact 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 own & 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 has met standards beyond those required by law. |
| Capitation | provider accepts pre-established payments if the healthcare services to enrollees over a period of time. ( usually Fee of one year ) |
| Fee for service | reimbursement methodology that increases payment if the health care services fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services |
| Gag Clause | prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement of services. |
| Gatekeeper | PCP for essential health care services at the lowest possible cost, avoiding nonessential care & referring patient to specialist |
| Accept Assignment | provider accepts as payment in full what ever is paid on the claim by the payer |
| Allowed Charges | that maximum amount that payer will reimburse for each procedure or service according to the patient's policy |
| Assignment of Benefits | the provider receives reimbursement directly from 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 charge for each; Charge master data are entered in the facility patient accounting system & charges are automatically posted to patient bill (UB-04) |
| adjudication | judicial dispute resolution process in which an appeals board makes a final determination |
| Appeal | documented as a letter , signed by a provider , explaining why claim should be reconsidered |
| Clean Claim | A Clean Claim is a complete and accurate claim form that includes all provider and member information, as well as records, additional information, or documents needed from the member or provider to enable Security Health Plan to process the claim. |
| Clearinghouse | an agency or organization that collects and distributes something, especially information. |
| Downloading | assigning lower-level codes than documented in the record |
| Guarantor | person responsible for paying health care fees |
| Litigation | legal action to recover debt; usually the last resort for physicians medical practice |
| Superbill | term used for an encounter form in a physicians office |
| unbundling | submitting multiple CPT codes when one code should be determined |
| Confidentiality | restriction of patient information to those who do not proper authorization to secure the patience information |
| Upcoding | Assignmenet of an ICD-10CM diagnosis code that does not match the procedure or services for t he patient increasing reimbursement |
| Dual Eligible | Individuals entitled to Medicare and eligible for some type of Medicaid benefit |
| Arbitration | dispute resolution process in which a final decision is made by an impartial person who may nopt have judicial powers |
Created by:
IzzyMOA
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