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KE Health Insurance

Understanding Health Insurance

Insurance carrier one who provides the benefits plan
Group Insurance employees and their dependents are insured under one policy
Pre-paid Health Plan pre-determined set of benefits covered under one set annual fee
PPO Preferred Provider Organization basically the same as HMO except you do not need to go to a provider within network .
Indemnity Insurance fee-for-service which services that are paid for are listed in the policy and payments are based on the fees physicians charge
Personal Insurance an individual insurance plan
Relative Value Payment Schedules Method use of relative value scales which assign a relative weight to services according to the basis for the scale.
Preferred Provider plan you can see a provoider outside of plan and you the patient is responsible to pay the higher portion of the fee.
UCR Fee schedule (Usual amount doctor charge), (Customary amount average charge by all providers) and (Reasonable amount submitted on claim...the lowest amount used as a basis for payment.
RBRVS(Medicare's Resource Based Relative Value Scale Payment Schedule) sum total of three elements: Work, Overhead and Malpractice
Relative Value Payment Schedules Method use of relative value scales which assign a relative weight to services according to the basis for the scale.
RVP (St. Anthony Relative Value for Physicians) Has no geographic adjustment factor or individual RVU component to calculate.
Contracted Rates with MCOs Physicians agree to provide services at a discount of their usual fee in return for a pool of existing patients.
Capitated Rates Physician provides a full range of contracted services to covered patients for a fixed amount on a periodic basis assuming the risk of the cost of providing the care.
Medicare Federal funded health insurance for persons 65 older, retired on SS benefit, spouse of a person paying into SS system, kidney donors.
Pre-paid Health plan pre-determined set of benefits covered under one set annual fee
Medicare A Hospital insurcance for Wage earner (upon retirement) also for aged and disabled.
Medicare B Supplementary Medical Ins. Coverage supp. to part A. Usually deducted from SS check.
Medicare C Addition coverage to Par A and Part B.
Medicare D Prescription Drugs...choice of plans to pay monthly premium.
Medigap Pay for medical services and items Medicare does not cover provided by federal govenment
Medicaid federal program administered by stat to provide medical assistance to the needy.
Workers Compensation Provides benefits to employees and their dependents for work related injury.
Disability insurance reimbursement insurance for income lost as a result of a temporary or permanent illness or injury.
Liability insurance insurance policy that coversw losses to a third party caused by the insured,
Tricare insurance for active duty and retired members of the armed forces and families.
Champva insurance for veterans and families.
BlueCross/Blue Shields Plans Blue Cross - covers hospital, outpatient care and home care. Blue Shield -covers physician, dental, outpaitent and vision care.
Paper Claim submitted on CMS-1500 form
Electronic Claim claim sent through a clearinghouse
Clearinghouse entity that receives transmissions of claims from physicians offices, separates the claims by carriers and performs softwre edits on each claim to check for errors.
CMS-1500 universal claim form blocks blocks 1-13 patient info. blocks 14-33 physician info.
Basic Billing & Reimbursement Steps: Collect patient info, verify ins, prepare encounter form, code diagnosis and procedures, review linkage and compliance, calculate physician charges, prepare claims, transmit claims, payer adjudication, follow up reimbursement/record retention.
Consultation Service performed by a physician whose opinion or advice is requested by another physican.
Fiscal Intermediary insurance company that bids for a contract with CMS to handle the Medicare program in a specific area.
Explanation of Benefits describes the services billed and includes a breakdown od how the payment is determined.
Premium cost of insurance coverage to keep a policy in effect.
Deductible Out-of-pocket amount that must be paid annually by policyholder before benefits will be paid by the insurance company.
co-payment cost-sharing requirement for the insured to pay at time of service.
Coinsurance a percentage of the cost of covered services that a policyholder or a secondary insurance pays.
Coding the process of converting diagnoses, procedures and services into numeric and alph. characters.
Medical necessity the determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury.
Exclusions and Limitations conditions, situations and services NOT covered by the insurance carrier.
Pre-certification to determine coverage for a specific treatment under policy.
Pre-determination to determine the patient's benefits and dollar amount insurance will pay.
Pre-authorization a requirement for some health ins. plans to obtain permission for a service or procedure before it is done.
Qualified diagnosis a working diagnosis which is not yet established.
Eligibility qualifying factor or factors that must be met before a patient receives benefits.
Coordination of Benefits two insurance companies work together to coordinate payment of the benefits
Encounter form also called the superbill; it is a listing of the dignoses, procedures, and charges for a patient's visit.
Itemized statement statement of the patient's account history, showing DOS, detailed chargtes, payments, date the insurance claim was submitted and account balance.
Peer Review Organization(PRO) state based group of physicans working under government guideline to review cases and determine their appro. and quality of professional care.
HIPAA(Health Insurance Portability and Accountability) prevention of healthcare fraud/abuse of patients on Medicare and Medicaid.
Nonparticipating physician one who has no contract with the insurance plan.
Participating physician one who has a contract with a insurance and accepts what the plan pays for service.
Group practice two or more physicians and non-physician legally organized.
Physicians Identification Numbers State license #, EIN #, SS #, PIN #, UPIN #, PPIN #, group provider number.
Policyholder one who purchases the contrac