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Chapter 17: medical insurance

Terms in this set (36)

Co-payment
Payment required when seen by the provider
Medigap policy
Individual plan covering the patients medicare deductible and co-pay obligations
Medicare part A
Benefits covering patient hospital and skilled nursing facilities hospice care and blood transfusion
Medicare part B
Benefits covering outpatient hospital and health care provider services
Medicare part C
Commonly referred to as Medicare advantage plans plans are approved by Medicare and are run by private companies
Medicare part D
Prescription drug coverage by Medicare
Exclusive provider organization (EPO)
A closed panel preferred organization (PPO) plan where enrollees receive no benefits if they opt to receive care from a provider who is not in the EPO
Explanation of benefits (EOB)
Insurance report that is sent with claim payments explaining the reimbursement of the insurance carrier
Donut hole
Within the Medicare part D prescription drug program the donut hole is the phase of coverage
Capitation
Use of the number of members enrolled in a plan to determine salary of the provider, provider is paid by the times member sees provider
Birthday rule
Method to determine which of two or more policies covering a dependent child will be primary , parent with birthday falling first had primary policy
Coordination of benefits (COB)
The provision of an insurance contract limits benefits to 100% of the cost
Coinsurance
Percentage paid by the company or that paid by the insured
Beneficiary
Person under a policy eligible to receive benefits
Triple option plan
Managed care model allowing enrollees the option of tradition HMO or PPO health plans
Fiscal intermediary
Local administration for Medicare
Fraud
Deliberate misrepresentation of facts
Point of service (POS) plan
Plan that allows direct communication between a medical office and health insurance company
Remittance advice (remit)
Summarize all of the benefits paid to a provider within a particular period of time
Preauthorization
Obtaining an insurance carrier consent to proceed with patient care and treatment
Referral
Term used by managed care facilities for authorization for someone other than the patients care provider to treat patient
Primary care provider (PCP)
Primary care provider for a patient
Tricare
Formerly the civilian health and medical program for uniformed services
Workers compensation insurance
Medical and paycheck insurance for workers who sustain injuries associated with employment
Resources based relative value scale (RBRVS)
Basis for the Medicare fee schedule
Self insurance
Insurance carried by large companies nonprofit organizations and government to reduce costs and gain control
Integrated delivery system (IDS)
Health care organization of affiliated provider sites combined under single ownership
Exclusion
Specific disease or condition listed in an insurance policy for which the policy will not pay
Deductible
That amount of incurred medical expenses that must be met before the insurance policy will begin to pay
Benefit period
Specified time during which benefits will be paid under certain types of health insurance coverages
Assignment of benefits
Signing over if benefits by the beneficiary to another party
Adjustment
Increases or decreases to patient accounts not due to charges incurred or payments received
Abuse
Misuse, excessive or improper use specially of narcotic drugs
Centers for Medicare and Medicaid services (CMS)
Formerly know as HCFA. CMS is federal agency within the US department of health and human services
Defense enrollment eligible reporting system (DEERS)
System operated by the department of defense and used by tricare contractors to determine and confirm eligibility
Usual, customary and reasonable (UCR)
Fee schedule often used by Medicare and some insured carriers
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