Understanding Health Insurance Chapters 1-5

11th edition A Guide to Billing and Reimbursement Michelle A. Green JoAnn C. Rowell
Involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices.
Ambulatory Payment Classifiacton (ACP)
Prospective payment for out patient care according to similar clinical charateristics and in terms of resources required.
Balance budget ACT of 1977 (BBA)
Address healthcare fraud and abuse issues, and provides for department of Health and Human Services (DHHS) office of inspector general (OIG) investigative and audit services in helathcare fraud cases.
Base Period
Period of time that usually covers 12 months: and is divided in to four consecutive quarters.
Bonding insurance
Insurance agreement that guarantees repayment due to finacial losses resulting from an employess acts or failure to act, protects the finacial operation of the business.
Business liability Insurance
protects the assets and covers lawsuits resulting in bodily injury, personal injury and false advertisement
cafeteria plan
also called triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party administrator.
Payment method in which a prepayment covers the provider's services to a plan member for a specified period of time.(e.g.1year)
Case law (common law)
This is based on court decisions that establish a precedent or standard.
Center of medical and Medicaid Services (CMS)
Administrative agancy with the federal department of Health and Human Services (DHHS). Was formerly known as the Healthcare Financing Administration (HCFA)
Check digit
A one-digit character, alphabetic or numeric, used to verify the validity of a unique identifier.
Civil Health Medical program of the dept of Veteran's affairs.
Program that provided health benifits for Veterans that are rated 10% permanently and totally disabled as a result of services connected conditions. Veteran's who died as a result of service connected conditions, and Veteran's who died on duty with less than 30 days of active duty.
Civil law
This deals with all areas of the law that are not classified as criminal.
Clinical Data Abstracting Centers (CDASs)
These became responsible for initially requesting and screening medical records for PEPP surveillance sampling for medical review, DRG validtion, and medical necessity; medical review criteria were developed by peer review organizations.
Clinical laboratory Improvement ACT (CLIA)
Established qualitiy standards for all laboratory testing: to ensure the accuracy, reliability, and timliness of patient test results regadless of where the test was performed.
Form used to submit medical claims: previously called HCFA-1500
Co-Payment (COPAY)
Provision in an insurance policy that requires the policy holder or patient to pay a specified dollar amount to a healthcare provider for each visit or medical service received.
Code pairs, or edit pairs
Codes that cannot be reported on the same claim for the same date of sevice, and they are based on coding conventions defined in CPT, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practices.
Process of asigning ICD-9-CM and CPT/HCPCS codes to diagnoses, procedures and services.
Percentage the patient pays for covered services after the decuctible has been paid
Consolidated Omnibus Budget Reconciliation ACT of 1985 (COBRA)
Allows enployees to continue healthcare coverage beyond the benefit termination date.
Consumer Driven Health Plan
Also called Consumer-Directed Health Plan, a healthcare plan that encorrages indiviuals to locate the best healthcare at the lowest possible price, with the goal of holding down cost.
Continuity of Care
Primary purpose of a medical ot patient record, involves the documentation of patient diagnoses and services and the resutls of treatment
Criminal law
Public law (statute or ordinance) that defines crimes and their prosecution.
Current Procedural Terminology CPT
Published by the American Medical Association used to report procedures and services performed during outpatient and physician office encounters and professional services provided to inpatient.
contains present conditions, social, past, personal medical history, review of symptoms, physical examination
Amount for which the patient is financially reponsible before an insurance policy provides coverage.
Testimony under oath taken outside of court (e.g., at the provider's office).
Diagnosis-related group (DRP)
Prospective payment system that reimburse hospitals for patient X-Ray.
Electronic data interchange (EDI)
The process of sending data from one party to another using computer linkages.
Electronic Health Record (EHR)
Collection of patient information that allows patient information to be documented by a number of providers at different facilities.
Electronic Medical Record (EMR)
Colection of patient information for a single medical practice.; using a computer, key board and mouse or optical pen. Allows providers to prescribe medications, order and view results and can alert for drug interactions ena review ancillary test.
Electronic transaction standards
A uniform language for electronic data interchange.
Emplyee retirment incom Security ACT of 1974 (ERISA)
Mandated report and disclosure requirement for group life and health plans (including managed car plans), permitted large employers to self insure employee health care benefits, and excepmt large employers from taxes on health insurance premiuns.
emplyees and dependents who join a managed care plan
Exclusive Provider Organization; One that limits an enrollee's choice to providers belonging to one organization. Sometimes able to use outside providers at additional
Principles of right and good conduct and rules that govern the conduct of members of a profession
Evaluation and Management (E/M)
Services that decribe patient encounters with providers used for evaluation and management of their general health status.
Outside treatment is not reimbursed
Explanation of benefits (EOB)
Report detailing the resuts of a claim
Federal Employee's Compensation Act
Replaced the 1908 Workers Compensation legistration civilian employee of federal governmant: are provided medical are, survival benefits, and compensation for lost wages.
Federal register
A legal newspaper published every business day by the National Archives and Records Administration (NARA).
Fee schedule
List of predetermined payments for healthcare services provided to patients( example: a fee assigned to each CPT code)
reimbursement methodology that increase payment if the healthcare services fees increase, if multipe units of service are provided, or if more expensive services are provided instead of less expensive services (eg brand name vs generic prescrption medication)
Financial Services Modernization ACT
Prohibits sharing of medical information amoung health financial institutions for use in making credit decisions, also allows banks to merge with the investment and insurance houses, which allows them to make a profit mo matter what the status of the economy.
First-look Analysis for Hospital Outlier Monitoring (FATHOM)
A data analysis tool, which provides administrative hospital and state-specific data for specific CMS target areas to QIOs.
flexible benefit plan
see cafeteria plan and triple option plan
An intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment.
Primary care provider for essential heathcare services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists.
Group Helath Insurance
Traditional Healthcare coverage subsidized by Employers and other organizations (Labor Unions), wherby part or all the premium cost are paid for and or discounted rates are offered to eligible individuals.
HCPCS Level II codes
National codes published by the CMS Center of Medicare and Medicaid Services that is used to report procedures, services, and supplies not classified in CPT
Health Insurance
Contract between the policy holder and a third party payer or government program to reimburse the policy holder for all or portion of the cost of medically necessary treatment or preventative care provided by a healthcare professional.
Health insurance Claim
Documentation submitted to a third-party payer or government program requesting reimbursement for health care services provided.
Health Insurance Specialist / Reimbursement Specialist
Reviews health related claims to determine the medical necessity for procedures and services performed before payment is made to the provider.
Healthcare provider
Physician or other healthcare practitioner
Expands the definition of medical care to include preventative services.
Hill Burton Act
Provided federal grants for modernizing hospitals that had become obsolete; bacause of lack of capital investment during the great depression and WWII. In return were required to offer helathcare services for free or at reduced rates.
Health Maintenance Organization:
Hold Harmless clause
Patient is not responsible for paying what the insurance plan denies.
Integrated delivery system- organization of provider sites with contracted relationship that offers services to subscribers
Independent contractor
Performs services for another unser an expressed or implied agreement and is not subjected to the others control of how the job is to performed.
Individual Healthcare Insurance
Private healthcare insurance policy, purchased by individuals and families who do not have access to group helath coverage.
Inital plan
Contains the strategy for managing patient care and any actons taken to investigate patients condition
International Classification of diseases (ICD)
The clarification system used to collect data for statistical purposes.
International Classification of Diseases, 9th revision Cliinical Modification (ICD-9-CM)
Used for reporting diagnoses and procedures performed during out patient and physician office encounters and professional services provided to inpatient.
On the job experience
A document containing a list of questions that must be answered in writing.
Integrated Provider Organization-Manages the delivery of healthcare services offered by hospitals, physicians employed by the IPO & other healthcare organizations(e.g. ambulatory surgery clinics & nursing facilities)
Lifetime Maxium amount
Maximum benefit payable to a health plan participant
A subscriber-based question-and-answer forum available through e-mail.
Major Medical Insurance
Coverage for catastrophic or prolonged illness and injuries
Medical / Patient Records
Documents healthcare services provided to a patient
Medical Assistant
Employed by a provider to perform administrative and clinical task that keep the office running smoothly.
Medical malpractice insurance
Type of liability insurance which covers physicians and other healthcare providers from liability for claims arising from patient treatment
Medical Necessity
Involves linking every prodcedure or service code reported on the claim to an ICD-9-CM condition code that justifies the necessity for performing the procedure.
Medicare administrative contractor
An organization (e.g., insurance company) that contracts wtih CMS to process health care claims and perform program integrity tasks for both Medicare Part A and Part B.
National Health PlanID (PlanID)
(formerly called PAYERID) is assigned to third-party payers;it has 10 numeric positions, including a check digit as the tenth position.
National Individual Identifier
(patient identifier)has been put on hold. Several bills in Congress would eliminate the requirement to establish a National Individual Identifier.
National Provider Identifier (NPI)
Assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position.
National Standard Employer Identification Number (EIN)
Assigned to employers who, as sponsors of health insurance for their employees, must be identified in health care transactions. It is the federal employer identification number (EIN) assigned by the Internal Revenue Service (IRS) and has nine digits with a hypen.
National Committee for Quality Assurance
Funds a provider or beneficiary receives in excess of amounts due and payable under Medicare and Medicaid.
Payment error rate
Number of dollars paid in error out of the total dollars paid for inpatient prospective payment system services.
gatekeeper, Primary Care Provider, a physician who is part of am managed care plan that provides all primary health care services to members/enrollees of the plan.also refers patient to specialist & inpatient hospital addmissions(except in emergencies)
Point of Service - Members use a primary physician who refers them as needed to participating specialists or members can see non-participatings specialist members. But, members pay more to use non-participating health providers.
Preffered Provider Organization- is a net-work of physician and hospitals that have joined together to contract with insurance companies, employers or other organization to provided health care to subscribers for a discount fee.
Prior approval for treatment specialist and documentation of post-treatment report. If preauthorization requirements are not met, the claim is denied.
Problem list
Serves as a table of contents for the patient record from the begining to the end.
Problem-Oriented record (POR)
Systematic method for documentation that consist of four components.(database,problem list, initial plan, and progress notes.
Professional Credentials
Once certified, the professional is responsible to maintain credentials by continuing educational reguirements established by the sponsoring association.
professional liablity insurance or errors and omission insurance
Provides protection of claims that contain errors and omissions resulting from services provided
Conduct or qualities that characterize a professional person.
Program for Evaluating Payment Patterns Electronic Report (PEPPER)
Contains hospital-specific administrative claims data for a number of CMS-identified problem areas (e.g., specific DRGs, types of discharges). A hospital uses PEPPER data to compare their performance with that of other hospitals.
Program transmittals
Contain new and changed Medicare policies and/or procedures that are to be incorporated into a specific CMS program manual (e.g., Medicare Claims Processing Manual).
progress notes
Uses the SOAP format to document each problem assigned to a patient
progress notes
Uses the SOAP format to document each problem assigned to a patient.
Property insurance
Protects contents against fire, theft, and other risk
prospective review
Reviewing appropriateness and necessity of care provided to patients prior to administration of care.
Public Health Insurance
State and Federal Health programs (Medicare, Medicaid, SCHIP, and TRICARE) available to eligible individuals.
Qui tam
An abbreviation for the Latin phrase qui tam pro domino rege quam pro sic ipso in hoc parte sequitur, meaning "who as well for the king as for himself sues in this matter."
Record retention
The storage of documentation for an established period of time, usually mandated by federal and/or state laws.
Guidelines written by administrative agencies (e.g., CMS)
remittance advice
Notice sent to the provider from the insurance company which contains payment information
Respondeat Superior
Latin for let the master answer, the healthcare facility or physician that employs the health insurance specialist is legally responsible for the emplyoee's action while employed
retrospective review
Reviewing appropriateness and necissity of care provided to patients AFTER the admininstation care.
scope of pratice
Defines the profession delineates qualifications and responsibilities
Single-payer Insurance
Centralized helathcare system funded by taxes. the government paus for each resident's healthcare, which is considered a basic social service; adopted by Canada and Great Britain.
SOAP format
Subject, Objective, Assessment, and Plan
Socialized Medicine
Type of single-payer system in which the government owns and operates the healthcare facility and providers recieve saleries. The VA helathcare plan is a type of socialized medicine
Laws passed by legislative bodies (e.g., federal Congress and state legislatures).
An order of the court that requires a witness to appear at a particular time and place to testify.
Subpoena duces tecum
Requires documents (e.g., patient record) to be produced.
The charateristics of a sucessful health insurance specialist include:
Ability to work independently, strong sense of ethics, attention to detail, and the ability to think critically.
Total Practice Management software (TPMS)
Software used to generate the Electronic Medical Record
Universal Healthcare Insurance
Goal of providing every individual with access to health coverage, regardless of the system implemented to acheive that goal.
utilization management
method of controlling healthcare cost and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care.
Worker's Compensation Insurance
Mandated by state, to cover emplyees and their dependents against injury or death during the course of employment: with the purpose of providing finacial and medical benefits to those with work related injuries and their families regardless of fault.