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KE Health Insurance
Understanding Health Insurance
| Question | Answer |
|---|---|
| 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 |
Created by:
karen.evans83@yahoo.
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