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insurnce terminology
43 words
| fraud | Intentional deception for unfair or unlawful gain |
| abuse | Incidents, not usually considered fraudulent, that are inconsistent with accepted medical practices. |
| respondeat superior | responsibility of an employer for the acts of an employee |
| Statute of limitations | time limit on legal action |
| subpoena | a legal document summoning someone to court |
| stand alone code | a CPT code that contains the full description of the procedure without additional explanation |
| medical malpractice insurance | a type of liability insurance that covers physicians and other healthcare professionals for claims arising from patient treatment |
| medical necessity | medical services & procedures that must be justified by patient symptoms & diagnosis |
| preauthorization | prior approval of insurance coverage and necessity of procedure |
| remittance advice (remit) | report of payment sent by the payer to the provider |
| coinsurance | 80/20 percentage of insurance paid to provider |
| continuity of care | documenting patient care for other providers who treat the patient |
| copayment | a small fixed fee paid by the patient at the time of an office visit |
| deductible | Specified amount of money that the insured must pay for covered medical expenses before the insurance policy begins to pay; usually annual amount per individual or family |
| Fee schedule | a list of payments for services performed |
| Policy holder | a person who buys an insurance plan; the insured |
| socialized medicine | single payer healthcare system in which the government owns and operates most medical facilities and employs most physicians. |
| third party payer | private or government organization that insures or pays for health care on behalf of beneficiaries |
| accreditation | Recognition that a health care organization has met higher standard |
| capitation | payment to a provider that covers each plan member's health care services for a certain period of time |
| fee for service | payment system that increases payment if the healthcare service fee increase |
| gag clause | prevents providers from discussing all treatment options with patients |
| gatekeeper | primary-care provider, who is given control of patient access to specialists and services in a managed care organization. |
| accept assignment | The provider agrees to accept what the insurance company approves as payment in full for the claim. |
| allowed charges | the maximum amount the insurance company will pay for each procedure or service, according to the patient's policy |
| assignment of benefits | authorization by policyholder that allows a health plan to pay benefits directly to a provider |
| beneficiary | person entitled to benefits or proceeds of an insurance policy or will |
| birthday rule | The guidelines that determines which of two married parents with medical coverage from different employers has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary |
| charge master | encounter form used in a hospital |
| ajudication | A judical dispute resolution process in which an appeals board make a final determination. |
| appeal | letter explaining why a claim should be reconsidered for payment |
| clean claim | a correctly completed claim |
| clearinghouse | a service company that recieves electronic or paper claims from the provider, checks and prepares them for processing, and transmits them in HIPAA-complaint format to the correct carriers |
| downcoding | assigning lower level codes than reported by the provider |
| guarantor | person who promises to pay the medical bill by signing a form agreeing to pay |
| litigation | legal action to recover a debt |
| superbill | encounter form used in physicians office |
| unbundling | involves reporting multiple codes for a service when a single should be assigned. |
| dual eligible | Patients who are eligible for Medicaid and Medicare coverage |
| arbitration | Settlement of a dispute by a person or panel chosen to listen to both sides and come to a decision |
| scope of practice | legal description of what a specific health professional may and may not do |
| upcoding | Deliberate manipulation of CPT codes for increased payment |
| confidentiality | the act of holding information in confidence, not to be released to unauthorized individuals |
Created by:
alexis003