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INSUR {CBCS-CPC}
Intro to Revenue cycle
| Term | Definition |
|---|---|
| accounts payable (AP) | The practice’s operating expenses, such as for overhead, salaries, supplies, and insurance. |
| accounts 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 health 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 health 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 services | 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 | Under HIPAA, 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, Medicare Part A or B, Medicaid, TRICARE, and other government and nongovernment plans. |
| indemnity plan | Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits. |
| 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.k.a.: health 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 | Payment criterion of payers that requires medical treatments to be clinically appropriate and provided in accordance with generally accepted standards of medical practice. 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; often includes scheduling, billing, and electronic medical records features. |
| 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. |
| 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. |
| 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 | An organization that assumes the risks of paying for health insurance directly and sets up a fund from which to pay. |
| third-party payer | Private or government organization that insures or pays for healthcare on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party. |
| a trillion-dollar healthcare industry trend | shifting of payment responsibility from employers and insurance companies to patients |
| the average medical practice works with | 20 different health plans, and some with more than 80 |
| accounting | "the language of business" |
| GAAP | Generally Accepted Accounting Principles |
| three roles of a medical insurance specialist | 1. carefully following procedures 2. communicating effectively using 3. using health info tech-med billing software & EHR to improve efficiency |
| types of Medical Insurance providers: | physicians, nurses, PA's, NP's, clinical social workers, PT's, OT's, speech therapists, audiologists, clinical psychologists |
| EMR | electronic medical records |
| other names for Policyholder | insured, member, subscriber, sponsor (TRICARE) |
| AHIP | America's Health Insurance Plans |
| Three participants in the medical insurance relationship | patient (policyholder) | physician | health plan (third-party payer) |
| types of preventative medical services | annual physical exams | pediatric & adolescent immunizations | prenatal care | routine procedures |
| types of noncovered services | dental | eye exam or glasses | employment related injuries | cosmetic procedures | experimental/investigational procedures | vocational rehab | surgical treatment of obesity | prescription drug benefits |
| group medical insurance | cost less for policyholders | bought by employers or organizations | |
| individual medical insurance | cost more for policyholder | bought by the individual directly from health plans either private, gov't, or state sponsored |
| other types of health-related insurances | disability | automotive | worker's compensation |
| two essential types of healthcare plans | indemnity and managed care |
| indemnity | protection against loss |
| number of conditions that must be met before insurance company makes a payment | four |
| four health care claim conditions | 1. med charge must be for med necessary services & covered by insured's health plan 2. the insured's premium payment is current and policy is in effect 3. the insured's deductible has been met (paid) 4. the insured's coinsurance has been taken into account |
| health plan payment formula | charge - deductible - patient coinsurance = health plan payment |
| payment method indemnity plans usually use to reimburse medical costs | fee-for-service basis |
| managed care offerings | more restricted choice and access to providers and treatments in exchange for lower premiums, deductibles, and other charges. |
| managed care organizations establish links between | provider, patient, and payer |
| managed care organizations arrangements | give the MCO more control over what services the provider performs and the fees for the services |
| first introduction of managed care plans | in California, 1929 |
| the predominant type of insurance | managed care plans |
| basic types of managed care plans | health maintenance organizations | point-of-service plans | preferred provider organizations | consumer-driven health plans |
| advantages of being a participating (PAR) provider | more patients | more contractual duties | reduced fees |
| combines coverage of medical costs and delivery of healthcare for a prepaid premium | health maintenance organization (HMO) |
| creates a network of physicians, hospitals, and other providers by employing or negotiating contracts with them | health maintenance organization (HMO) |
| a fixed prepayment to a medical provider for all necessary contracted services provided to each patient who is a plan member | capitation |
| a prospective payment - a payment BEFORE the patient visit - that covers a specific period of time | capitation |
| are licensed in most states and are legally required to provide certain services to members and their dependents. | health maintenance organization (HMO) |
| preventative care is often required for each age group | health maintenance organization (HMO) |
| the health plan makes the payment whether the patient receives many or no medical services during that specified period | capitation |
| the physician agrees to share the risk that an insured person will use more services than the fee covers | capitation |
| the physician shares in the prospect that an insured person will use fewer services | capitation |
| the payment per patient remains the same, and the provider risks receiving lower per-visit revenue | capitation |
| capitated rate | a.k.a: per member per month (PMPM) |
| is usually based on the health-related characteristics of the enrollees, such as age and gender | per member per month (PMPM) |
| covers only services listed on the schedule of benefits for the plan (the provider may bill the patient for any other services) | per member per month (PMPM) |
| this health plan analyzes health-related factors and sets a rate based on its prediction of the amount of healthcare each person will need | per member per month (PMPM) |
| these organizations seek to control rising medical costs and at the same time improve healthcare | health maintenance organization (HMO) |
| HMO cost-containment methods | restricting patients' choice of providers | requiring preauthorization for services | controlling the use of services | controlling drug costs | cost-sharing | requiring referrals |
| also called precertification or prior authorization | preauthorization |
| this health plan may require a second opinion from another provider before authorizing a service | health maintenance organization (HMO) |
| services that are not preauthorized are not covered, and preauthorization is almost always needed for nonemergency hospital admission | health maintenance organization (HMO) |
| holds the provider accountable for any questionable service and may deny a patient's or provider's request for preauthorization | health maintenance organization (HMO) |
| formulary | HMO's list of selected pharmaceuticals and approved dosages |
| also known as a gatekeeper | primary care physician (PCP) |
| Healthcare quality improvements | disease and case management | preventative care | pay-for performance (P4P) |
| point-of-service (POS) plan | reduces restrictions and allow members to choose providers who are not in the HMO's network |
| a.k.a: open HMO | point-of-service (POS) plan |
| this plan does not cover care outside the plan's provider network, and do not usually require referrals to specialists | exclusive provider organization (EPO) |
| health records that can be shared between multiple health providers | electronic health record (EHR) |
| health records that are accessed within a local provider office | electronic medical record (EMR) |
| most popular type of insurance plan | preferred provider organization (PPO) |
| requires payment of a premium and often of a copayment for visits, does not require a PCP to oversee patients' care and referrals to specialists are not required | preferred provider organization (PPO) |
| can use out-of-network providers for higher copayments, increased deductibles, or both | preferred provider organization (PPO) |
| PPO cost-containment methods | directing patients' choices of providers | controlling use of services | requiring preauthorization for services | requiring cost-sharing |
| this plan may require preauthorization for nonemergency hospital admission and for some outpatient procedures | preferred provider organization (PPO) |
| with this plan a member who sees an out-of-network provider usually pays a deductible and a coinsurance that is a higher percentage than in-network visits | preferred provider organization (PPO) |
| a.k.a: high-deductible health plans | consumer-driven health plan (CDHP) |
| two elements of a consumer-driven health plan (CDHP) | 1. a health plan that has a high deductible and low premiums 2. a special "savings account" used to pay medical bills before the deductible has been met |
| policyholder can visit any provider | indemnity plan |
| little to none cost-containment methods | indemnity plan |
| preauthorization required for some procedures | indemnity plan |
| higher costs | deductibles | coinsurance | preventive care coverage limited | indemnity plan |
| policyholder visit only see in-network providers | health maintenance organization (HMO) |
| preauthorization required | health maintenance organization (HMO) |
| no payment for out-of-network nonemergency services | health maintenance organization (HMO) |
| PCP manages care; referral required | health maintenance organization (HMO) |
| low copayment | limited provider network | covers preventive care | health maintenance organization (HMO) |
| policyholders can visit network providers or out-of-network providers | point-of-service (POS) plan & exclusive provider organization (EPO) |
| within network, PCP manages care | point-of-service (POS) plan & exclusive provider organization (EPO) |
| lower copayments for network providers | higher costs for out-of-network providers | covers preventive care | point-of-service (POS) plan & exclusive provider organization (EPO) |
| policyholders can visit in-network or out-of-network providers | preferred provider organization (PPO) |
| referral not required for specialists, preauthorization for some procedures | preferred provider organization (PPO) |
| fees are discounted | preferred provider organization (PPO) |
| higher cost for out-of-network providers | preventive care coverage varies | preferred provider organization (PPO) |
| usually similar to PPO regarding network providers | consumer-driven health plan (CDHP) |
| increases patient awareness of healthcare costs | consumer-driven health plan (CDHP) |
| patient pays directly until high deductible is met | consumer-driven health plan (CDHP) |
| high deductible/low premium | savings account | consumer-driven health plan (CDHP) |
| the largest nonprofit HMO | Kaiser Permanente |
| these plans have contracts with businesses to provide benefits for their employees | private payers |
| this health plan may set up their own provider networks or buy the existing networks from managed care organizations | self-funded (self-insured) health plan |
| four major government-sponsored healthcare programs | medicare | medicaid | TRICARE | CHAMPVA |
| medicare | 100 % federally funded health plan that covers people who are 65 and over and those who (regardless of age) are disabled |
| medicaid | a federal program that is jointly funded by federal and state governments | covers low-income people | each state administers its own program qualifications and benefits under broad federal guidelines |
| TRICARE (a department of defense program) | covers medical expenses for active-duty members of the uniformed services and their spouses, children, and other dependents; retired military and their dependents; and family of deceased active-duty personnel |
| replaced CHAMPUS in 1998 | TRICARE |
| CHAMPVA | covers spouses and dependents of veterans with permanent service-related disabilities | also covers surviving spouses and dependent children of vets who died from service-related disabilities |
| was required until October 1, 2015 | ICD-9-CM |
| is the standard for medical coding | ICD-10-CM |
| CPT | current procedural terminology |
| patient account record | the record of a patient's financial transactions |
| current balance formula | previous balance + charge - payment = current balance |
| PMP uses for medical insurance specialists | schedule patients | organize patient and insurance info | collect data on patients' diagnoses and services | generate, transmit, and report the status of healthcare claims | record payments from insurance companies | generate patients' statements, post payments, and update accounts | create financial and productivity reports |
| HIT | health information technology |
| PMP | practice management programs |
| EHR | electronic health record |
| EMR | electronic medical record |
| HIPAA | health insurance portability and accountability act |
| HITECH | health information technology for economic and clinical health act |
Created by:
VA_MedCod3r