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Chapter 1 From Patient to Payment: Understanding Medical Insurance
Terms in this set (39)
accounts payable (AP)
The practice's operating expenses, such as overhead, salaries, supplies, and insurance.
accounts receivable (AR)
Monies owed to a medical practice by its patients and third-party payers.
The amount of money a health plan pays for services covered in an insurance policy.
The movement of monies into or out of a business
The recognition of a person demonstrating a superior level of skill on a national test by an official organization
The process of translating a description of a diagnosis or procedure into a standardized code
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 that a health plan requires a beneficiary to pay at the time of service for each health care encounter
Medical procedures and treatments that are included as benefits under an insured's health plan
An amount that an insured person must pay, usually on an annual basis, for health care services before a health plan's payment begins.
The physician's opinion of the nature of the patient's illness or injury
The systematic, logical, and consistent recording of a patient's health status - history, examinations, tests, results of treatments, and observations - in chronological order in a patient medical record
electronic claim (e-claim)
Health care claims that are sent electronically.
electronic health record (EHR)
A computerized lifelong health care record with data from all sources.
Method of charging under which a provider's payment is based on each service performed.
health care claim
An electronic transaction or paper document filed with a health plan to receive benefits.
health information techonology (HIT)
Computer hardware and software information systems that record, store, and manage patient information
Under HIPPA, an individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers; health maintenance organizations, Medicare Part A or B, Medicaid, TRICARE, and other government and nongovernment plans
An insurance company's agreement to reimburse a policyholder a predetermined amount for covered losses.
System that combines the financing and the delivery of appropriate, cost-effective health care services to its members.
managed care organization (MCO)
Organization offering some type of managed health care plan.
An administrative medical employee.
medical billing cycle
A ten-step process that results in hospital and medical care.
medical documentation and billing cycle
A combination of the billing cycle and medical documentation cycle of a practice, which explains how using EHRs is integrated with practice management programs.
Financial plan that covers the cost of hospital and medical care.
Medical treatment that is appropriate and rendered in accordance with generally accepted standards of medical practice; the place of service must also be appropriate for the diagnosis and care provided.
noncovered (excluded) services
Medical procedures that are not included in a plan's benefits.
Expenses the insured must pay before benefits begin.
Software program that combines both a PM and an EHR in a single product.
Person who buys an insurance plan; the insured, subscriber, or guarantor.
practice management program (PMP)
Business software designed to organize and store a medical practice's financial information; often includes scheduling, billing, and electronic medical records features.
Prior authorization from a payer for services to be provided; if preauthorization for hospital is not received, the charge is usually not covered.
Money the insured pays to a health plan for a health care policy.
The services and treatments performed by a practice.
Person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business. A provider may be a professional member of the health care team, such as a physician, or a facility, such as a hospital or skilled nursing home.
remittance advice (RA)
Health plan document describing a payment resulting from a claim adjudication; also called an explanation of benefits (EOB).
revenue cycle management (RCM)
All the actions that help to ensure that the provider receives maximum appropriate payment for services.
A report that shows the services provided to a patient, total payments made, total charges, adjustments, and balance due.
Private or government organization that insures or pays for health care on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party.
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