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Medical Insurance--Revenue Cycle Process Approach (Chapter 1/Key Terms)

Terms in this set (54)

cash flow
movement of monies into or out of a business
accounts receivable (AR)
monies owed to a medical practice
accounts payable (AP)
a practice's operating expenses
revenue cycle
all administrative and clinical functions that help capture and collect patient payments
health information technology (HIT)
computer information systems that record, store, and manage patient information
practice management program (PMP)
account software used for scheduling appointments, billing, and financial record keeping
electronic health record (EHR)
computerized lifelong healthcare record for an individual that incorporates data from all sources
PM/EHR
software program that combines both a PMP and an EHR into a single product
medical insurance
a written policy stating the terms of an agreement between a policyholder and a health plan
policyholder
person who buys an insurance plan
health plan
individual or group plan that provides or pays for medical care
benefits
health plan payments for covered medical services
payer
health plan or program
third-party payer
private or government organization that insures or pays for healthcare on behalf of beneficiaries
schedule of benefits
list of medical expenses covered by a health plan
medical necessity
payment criterion that requires medical treatments to be appropriate and provided in accordance with generally accepted standards
provider
person or entity that supplies medical or health services and bills for, or is paid for, the services in the normal course of business
covered services
medical procedures and treatments that are included as benefits in a health plan
preventive medical services
care provided to keep patients healthy or prevent illness
noncovered services
medical procedures that are not included in a plan's benefits
excluded services
services not covered in a medical insurance contract
indemnity plan
health plan that offers protection from loss
healthcare claim
electronic transaction or a paper document filed to receive benefits
premium
money the insured pays to a health plan for a policy
deductible
amount the insured must pay for healthcare services before a health plan's payment begins
coinsurance
portion of charges an insured person must pay for covered healthcare services after the deductible
out-of-pocket
expenses the insured must pay prior to benefits
fee-for-service
payment method based on provider charges
managed care
system combining the financing and delivery of healthcare services
managed care organization (MCO)
organization offering a managed healthcare plan
participation
contractual agreement to provide medical services to a payer's policyholders
health maintenance organization (HMO)
managed healthcare system in which providers offer healthcare to members for fixed periodic payments
capitation
a fixed prepayment covering provider's services for a plan member for a specified period
per member per month (PMPM)
periodic capitated prospective payment to a provider that covers only services listed on the schedule of benefits
network
a group of healthcare providers, including physicians and hospitals, who sign a contract with a health plan to provide services to plan members
out-of-network
provider that does not have a participation agreement with a plan
preauthorization
prior authorization from a payer for services to be provided
copayment
specified amount of beneficiary must pay at the time of a healthcare encounter
primary care physician (PCP)
physician in a health maintenance organization who directs all aspects of a patient's care
referral
transfer of a patient care from one physician to another
preferred provider organization
managed care organization in which a network of providers supplies discounted treatment for plan members
consumer-driven health plan (CDHP)
medical insurance that combines a high-deductible health plan with a medical savings plan
self-funded (self-insured) health plan
organization pays for health insurance directly and sets up a fund from which to pay
medical insurance specialist
staff member who handles billing, checks insurance, and processes payments
medical coder
staff member with specialized training who handles diagnostic and procedural coding
diagnosis code
number assigned to a diagnosis
procedure code
code that identifies medical treatment or diagnostic services
patient ledger
record of a patient's financial transactions
compliance
actions that satisfy official requirements
adjudication
health plan process of examining claims and determining benefits
professionalism
acting for the good of the public and the medical practice
ethics
standards of conduct based on moral principles
etiquette
standards of professional behavior
certification
recognition of a superior level of skill by an official organization
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