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B&C Chapter !
Key Terms
| Term | Definition |
|---|---|
| Accounts payable (AP) | to pay the practice’s operating expenses |
| Account receivable (AR) | Monies owed to a medical practice by its patients and third-party payers. |
| Adjudication | The process followed by health plans to examine claims and determine benefits. |
| Benefits | The amount of money a health plan pays for services covered in an insurance policy. |
| Capitation | Payment method in which a fixed prepayment covers the provider’s services to a plan member for a specified period of time |
| Cash flow | The movement of monies into or out of a business. |
| Certification | The recognition of a person demonstrating a superior level of skill on a national test by an official organization |
| Coinsurance | The portion of charges that an insured person must pay for healthcare services after payment of the deductible amount; usually stated as a percentage. |
| Compliance | Actions that satisfy official guidelines and requirements. |
| Consumer- driven heath plan (CDHP) | Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses. |
| Copayment | An amount that a health plan requires a beneficiary to pay at the time of service for each healthcare encounter. |
| Covered services | Medical procedures and treatments that are included as benefits under an insured’s health plan. |
| Deductible | An amount that an insured person must pay, usually on an annual basis, for healthcare services before a health plan’s payment begins. |
| Diagnosis code | The number assigned to a diagnosis in the International Classification of Diseases. |
| Electronic heath record (EHR) | A computerized lifelong healthcare record for an individual that incorporates data from all sources that provide treatment for the individual. |
| Ethics | Standards of conduct based on moral principles. |
| Etiquette | Standards of professional behavior. |
| Excluded servises | A service specified in a medical insurance contract as not covered. |
| fee-for-service | A payment method based on provider charges. |
| healthcare claim | An electronic transaction or a paper document filed with a health plan to receive benefits. |
| health information technology (HIT) | Computer hardware and software information systems that record, store, and manage patient information. |
| health maintenance organization (HMO) | A managed healthcare system in which providers agree to offer healthcare to the organization’s members for fixed periodic payments from the plan |
| health plan | an individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers, health maintenance organizations |
| managed care | System that combines the financing and the delivery of appropriate, cost-effective healthcare services to its members. |
| managed care organization (MCO) | Organization offering some type of managed healthcare plan. |
| medical coder | Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records. |
| medical insurance | A written policy stating the terms of an agreement between a policy-holder and a health plan. |
| medical insurance specialist | Medical office administrative staff member who handles billing, checks insurance, and processes payments. |
| medical necessity | To be medically necessary, the reported procedure or service must match the diagnosis, be provided at the appropriate level, not be elective, not be experimental, and not be performed for the convenience of the patient or the patient’s family. |
| network | A group of healthcare providers, including physicians and hospitals, who sign a contract with a health plan to provide services to plan members. |
| noncovered services | Medical procedures that are not included in a plan’s benefits. |
| out-of-network | Description of a provider who does not have a participation agreement with a plan. Using out-of-network providers is more expensive for the plan’s enrollees. |
| out-of-pocket | Description of the expenses the insured must pay before benefits begin. |
| participation | Contractual agreement by a provider to provide medical services to a payer’s policyholders. |
| patient ledger | Record of all charges, payments, and adjustments made on a particular patient’s account. |
| payer | Health plan or program. |
| per member per month (PMPM) | Periodic capitated prospective payment to a provider who covers only services listed on the schedule of benefits. |
| PM/EHR | A software program that combines both a PMP and an EHR into a single product. |
| policyholder | Person who buys an insurance plan. |
| practice management program (PMP) | Business software designed to organize and store a medical practice’s financial information; |
| preauthorization | Prior authorization from a payer for services to be provided; if preauthorization is not received, the charge is usually not covered. |
| preferred provider organization (PPO) | Managed care organization structured as a network of healthcare providers who agree to perform services for plan members at discounted fees |
| premium | Money the insured pays to a health plan for a healthcare policy |
| preventive medical services | Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests. |
| primary care physician (PCP) | A physician in a health maintenance organization who directs all aspects of a patient’s care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper. |
| procedure code | Code that identifies medical treatment or diagnostic services |
| professionalism | For a medical insurance specialist, the quality of always acting for the good of the public and the medical practice being served. This includes acting with honor and integrity, being motivated to do one’s best, and maintaining a professional image. |
| provider | Person or entity that supplies medical or health services and bills for, or is paid for, the services in the normal course of business. |
| referral | Transfer of patient care from one physician to another. |
| revenue cycle | All administrative and clinical functions that help capture and collect patients’ payments for medical. |
| schedule of benefits | List of the medical expenses that a health plan covers. |
| self-funded (self-insured) health plan | A company that creates its own insurance plan for its employees, rather than using a carrier |
| third-party payer | rivate or government organization that insures or pays for healthcare on the behalf of beneficiaries; |
Created by:
kamand5605
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