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Principles in Healthcare Reimbursement
Common terms covered in chapters 1-4 of text
Terms in this set (75)
Assignment of benefits
authorization by policyholder that allows a health plan to pay benefits directly to a provider
the portion of charges that an insured person must pay for health care services after payment of the deductible amount; usually stated as a percentage
An amount of money that an insured person must pay annually before health services are covered by the insurance plan
a physician's opinion of the nature of patients' illness or injuries
Paperless claims (a.k.a. electronic media claims)
standards of conduct based on moral principles
Explanation of benefits
a document from a payer sent to a patient that shows how the amount of benefit was deteremined
Health care claim
an electronic transaction or a paper document filed with a health plan to receive benefits
insurance company's agreement to reimburse a policy holder a predetermined amount for covered losses
health plan; also known as insurance company, payer, or third-party payer
A system that combines the financing and the delivery of appropriate, cost-effective health care services to its members.
a financial plan that covers the cost of hospital and medical care due to illness or injury
payment criterion of payers that requires medical treatments to be appropriate and provided in accordance with generally accepted standards of medical practice. The reported procedure or service (1) matches the diagnosis, (2) is not elective (3) is not experimental, (4) has not been performed for the convenience of the patient or the patient's family; and (5) has been provided at the appropriate level
A person who buys an insurance plan; the insured, subscriber, or guarantor.
An illness or disorder of a beneficiary that existed before the effective date of insurance coverage.
health plan document describing a payment resulting from a claim adjudication; also called an explanation of benefits
Document signed by a patient that permits release of particular medical information under the specific states conditions.
A medical practice's written plan for (a) the appointment of a compliance officer and committee, (b) a code of conduct for physicians' business arrangements and employees' compliance, (c) training plans, (d) properly prepared and updated coding tools such as job reference aids, encounter forms, and documentation templates, (e) rules for prompt identification and refunding of overpayments, and (f) ongoing monitoring and auditing of claim preparation.
Intentional deceptive act to obtain a benefit.
Health Insurance Portability and Accountability Act
Nation Provider Identifier
Under HIPAA, unique 10 digit identifier assigned to each provider by the National Provider System; replaces both the UPIN and Medicare PIN
Case Mix Index
Calculated based on classification schemes such as diagnosis related groups
A order of a court for a party to appear and testify in a court of law.
The number assigned to a diagnosis in the International Classification of Diseases
Abbreviated title of International Classification of Diseases, 9th revision, Clinical modification.
a diagnosis that represents the patient's major illness or condition for an encounter
An alphanumeric code in the ICD-9-CM that identified factors that influence health status and encounters that are not due to illness or injury.
An alphanumeric ICD code for an external cause of injury or poisoning.
Add on code
procedures that are performed and reported only in addition to a primary procedure; indicated in CPT by a + sign next to the code
current procedural terminology
The number of days surrounding a surgical procedure during which all services relating to the procedure-preoperative, during the surgery, and postoperative-are considered part of the surgical package and are not additionally reimbursed.
single procedure code used to report a group of related procedures
A combination of services included in a single procedure code for some surgical procedures in CPT.
Consumer-driven health plan
Type of medical insurance that combine a high deductible health plan with a medical savings plan which covers some out of pocket expenses.
A fixed, periodic amount that must be met by the combination of payments for covered services to each individual of an insured/dependent group before benefits from a payer begin.
a managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payements from the plan; usually members must receive medical services only from the plan's providers
a managed care organization structrured as a network of health care providers who agree to perform services for plan members at discounted fees; usually plan members can receive services from non-network providers for a higher charge Preferred Provider Organization
False Claims Act
Legislation passed during the Civil War that prohibits contractors from making a false claim to a governmental program; used to reinforce the prevention of healthcare fraud and abuse
Resource Based Relative Value Scale
federally mandated relative value scale for establishing Medicare charges
Local Coverage Determination
Reimbursement and medical-necessity policies established by regional fiscal intermediaries
National Correct Coding Initiative
National Correct Coding Initiative (NCCI) Coding policies to standardize bundled codes and control improper coding that would lead to inappropriate payment for Medicare claims for physician services.
Office of Inspector General
OIG , government agency that investigates and prosecutes fraud against government health care programs such as Medicare.
Recovery Audit Contractor
RAC a third party entity working under the direction of CMS to detect improper med payments through review of providers medical records and medicare claims data
Average or maximum amount a third party payer will reimburse providers for a service
a payer's review and reduction of a procedure code (often an E/M code) to a lower level than reported by the provider
Electronic data interchange
The exchange (system to system) of data in a standardized format.
the health plan that pays benefits after the primary plan when a patient is covered by more than one plan
Health insurance was "born" in the Texas in 1929 with this plan
Advance beneficiary notice
Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program.
A governmental contractor that processes claims for governmental programs. (For Medicare the fiscal intermediary processed Part A claims.
Medicare plans other than the Original Medicare Plan, A Medicare program, formerly known as Medicare+Choice, that provides additional health plan options such as HMOs and PPOs as alternatives to the original Medicare fee-for-service plan.
insurance plan offered by a private insurance carrier to supplement Medicare Original Plan coverage
the Medicare fee-for-service plan, a federal insurance program for persons over the age of 65 and qualified disabled or blind persons regardless of income
Term used to describe which health insurance policy will pay "second" when an individual is covered by more than one health insurance policy
a person who receives assistance from government programs such as Temporary Assistance for Needy Families (TANF)
a federal and state assistance program that pays for health care services for people who cannot afford them
a government program that provides cash assitance for low-income families Temporary Assistance for Needy Families
Welfare reform act
1996 law that established the Temporary Assistance for Needy Families program in place of the Aid to Families with Dependent Children program and tightened Medicaid eligibility requirements
The Civilian Health and Medical Program of the Veterans Administration (now known as the Department of Veterans Affairs) which shares health care costs for families of veterans with 100 percent service-connected disability and the surviving spouses and children of veterans who die from service-connected disabilities.
A government health program that serves dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members; formerly called CHAMPUS.
Defense Enrollment Eligibility Reporting System
The office of the U.S. Department of Labor that administers the Federal Employee's Compensation Act
Costs include the deductible, cost-sharing arising from the operation of the coinsurance clause, and medical expenditures
Civil Service Retirement System
The federal law that authorizes payroll deductions for the Social Security Disability Program
the federal disability compensation program for salaried and hourly wage earners, self-employed people who pay a special tax, and widows, widowers, and minor children with disabilities whose deceased spouse/parent would qualify for Social Security benefits if alive Social Security Disability Insurance
a government program that helps pay living expenses for low-income older people and those who are blind or have disabilities Social Security Income
Balanced Budget Act of 1997
Legislation intended to reduce Medicare spending, create incentives for development of managed care plans, encourage enrollment in managed care plans, and limit fee-for-service payment and programs
Current Dental Terminology
A system of analyzing conditions and treatments for similar groups of patients used to establish Medicare fees for hospital inpatient services.
Health information management
hospital department that organizes and maintains patient medical records; also profession devoted to managing, analyzing, and utilizing data vital for patient care, making it accessible to healthcare providers
Master patient index
A hospital's main patient database.
Coordination of Benefits
Health insurance policy clause that applies to an individual covered by more than one medical insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.
A condition that after study is established as chiefly responsible for a patient's admission to a hospital
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