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MED 112
Chapter 1 Terms
| Question | Answer |
|---|---|
| medical insurance (aka health insurance) | A written policy stating the terms of an agreement between a policy-holder and a health plan |
| policyholder | Person who buys an insurance plan |
| health plan | an individual or group plan that either provides or pays for the cost of medical care |
| benefit | The amount of money a health plan pays for services covered in an insurance policy |
| payer | Health plan or program |
| First party | The patient (policyholder) |
| Second party | The physician |
| Third party | Private or government organization that insures or pays for healthcare on the behalf of beneficiaries |
| schedule of benefits | List of the medical expenses that a health plan covers |
| 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 |
| 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 |
| covered services | Medical procedures and treatments that are included as benefits under an insured’s health plan |
| preventive medical services | Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests |
| cash flow | The movement of monies into or out of a business |
| accounts receivable (AR) | Monies owed to a medical practice by its patients and third-party payers |
| accounts payable (AP) | The practice’s operating expenses, such as for overhead, salaries, supplies, and insurance |
| GAAP | Generally accepted accounting principles |
| revenue cycle | All administrative and clinical functions that help capture and collect patients’ payments for medical |
| health information technology (HIT) | Computer hardware and software information systems that record, store, and manage patient information |
| 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 |
| electronic health record (EHR) | A computerized lifelong healthcare record for an individual that incorporates data from all sources that provide treatment for the individual |
| PM/EHR | A software program that combines both a PMP and an EHR into a single product |
| preventive medical services | Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests |
| noncovered/excluded services | Medical procedures that are not included in a plan’s benefits |
| indemnity plan | Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits |
| healthcare claim | An electronic transaction or a paper document filed with a health plan to receive benefits |
| premium | Money the insured pays to a health plan for a healthcare policy |
| deductible | An amount that an insured person must pay, usually on an annual basis, for healthcare services before a health plan’s payment begins |
| 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 |
| out-of-pocket | Description of the expenses the insured must pay before benefits begin |
| fee-for-service | A payment method based on provider charges |
| 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 |
| 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 |
| capitation | Payment method in which a fixed prepayment covers the provider’s services to a plan member for a specified period of time |
| per member per month (PMPM) | Periodic capitated prospective payment to a provider who covers only services listed on the schedule of benefits |
| network | A group of healthcare providers, including physicians and hospitals, who sign a contract with a health plan to provide services to plan members |
| 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 |
| prior authorization (PA) | Advance approval for procedures/services |
| copayment | An amount that a health plan requires a beneficiary to pay at the time of service for each healthcare encounter |
| 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 |
| referral | Transfer of patient care from one physician to another |
| 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 |
| 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 |
| 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 |
| medical insurance specialist | Medical office administrative staff member who handles billing, checks insurance, and processes payments |
| medical coder | Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records |
| diagnosis code | The number assigned to a diagnosis in the International Classification of Diseases |
| Glossary procedure code | Code that identifies medical treatment or diagnostic services |
| patient ledger | Record of all charges, payments, and adjustments made on a particular patient’s account |
| compliance | Actions that satisfy official guidelines and requirements |
| adjudication | The process followed by health plans to examine claims and determine benefits |
| 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 |
| ethics | Standards of conduct based on moral principles |
| etiquette | Standards of professional behavior |
Created by:
Felicia26