Insurance Terminology
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| Abuse | actions inconsistent with accepted, sound medical, business, or fiscal practices
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| Fraud | intentional deception or misrepresentation that could result in an unauthorized payment
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| Scope of Practice | health care services, determined by the state, that an NP and PA can perform
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| Statute of Limitations | a law which sets the maximum period which one can wait before filing a lawsuit depending of type of case or claim, varies by state
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| Subpoena | an order of the court that requires a witness to appear at a particular time and place to testify
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| Stand Alone Code | CPT code that includes a complete description of the procedure or service
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| Medical Malpractice Insurance | a type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment
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| Medical Necessity | involves linking every procedure or service code reported on an insurance claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or services
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| Preauthorization | prior approval
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| Remittance Advice | electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim HIC/TOB patient info, code remarks
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| Coinsurance | also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid
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| Continuity of Care | documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment
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| Copayment | provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received
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| Deductible | amount for which the patient is financially responsible before an insurance policy provides coverage.
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| Fee schedule | list of predetermined payments for health care services provided to patients (a fee is assigned to each CPT code).
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| Policy Holder | a person who signs a contract with a health insurance company and who, thus, owns the health insurance policy; the policyholder is the insured (or enrollee), and the policy might include coverage for dependents
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| Socialized Medicine | type of single-payer system in which the government owns and operates health care facilities and providers (e.g. physicians)
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| Third Party Payer | a health insurance company that provides coverage, such as BlueCross BlueShield
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| Accreditation | voluntary process that a health care facility or organization (hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law.
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| Capitation | provider accepts pre-established payments for providing health care services to enrollees over a period of time (usually one year).
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| Fee for Service | reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services
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| Gag Clause | prevents from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services
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| Gatekeeper | primary care provider for essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists
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| Accept Assignment | provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts)
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| Allowed Charge | the maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy
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| Assignment of Benefits | the provider receives reimbursement directly from the payer
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| Beneficiary | the person eligible to receive health care benefits
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| Birthday Rule | determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan
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| Chargemaster | document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility’s patient accounting system and charge are automatically poste to the patient’s bill
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| Adjudication | judicial dispute resolution process in which an appeals board makes a final determination
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| Appeal | documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment
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| Clean Claim | a correctly completed standardized claim (CMS-1500 claim)
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| Clearinghouse | performs centralized claims processing for providers and health plans
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| Downcoding | assigning lower-level codes than documented in the record
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| Guarantor | person responsible for paying health care fees
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| Litigation | legal action to recover a debt; usually a last resort for a medical practice
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| Superbill | term used for an encounter form in the physician’s office
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| Unbundling | submitting multiple CPT codes when one code should be submitted
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| Confidentiality | restricting patient information access to those with proper authorization and maintaining the security of patient information
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| Upcoding | assignment of an ICD-10-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement (assigning the ICD-10-CM code for heart attack when angina was actually documented in the record)
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| Dual Eligible | individuals entitled to Medicare and eligible for some type of Medicaid benefit
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| Arbitration | dispute-resolution process in which a final determination is made by an impartial person who may not have judicial powers
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