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Insurance and billing
Terms in this set (57)
Assignment of benefits
insurance reimbursement to health service rather than the insured individual
billing the patient for the balance or difference between the physician's charges and the Medicare-approved charges; prohibited by most managed care contracts
Determination of which policyholders insurance is the first to pay when a patient is covered by two policies. The policyholder whose birth month and day comes first in the calendar is primary.
Managed care plan that pays a certain amount to a provider over a specific time for caring for the patients in the plan regardless of what or how many services are performed.
requests to an insurance company for reimbursement of costs
an individual who manages the third-party reimbursement policies for a medical practice
the agreed upon amount paid to the provider by a policy holder; also called "copayment"
Coordination of benefits
the method of designating the order in which multiple carriers pay benefits to avoid duplication of payment
a claim that crosses over automatically from one coverage to another for payment
a specific amount paid by the policyholder before the carrier begins paying
spouse, children, and sometimes other individuals designated by the insured who are covered under a health care plan
diagnosis related groups ( DRG)
categories used to determine hospital and physician reimbursement for medicare patients inpatient services
the determination of an insured's right to receive benefits from a third-party payer based on such criteria as payment of premiums and date of start of coverage
Explanation of Benefits (EOB)
a statement that accompanies a payment from an insurance carrier and outlines which dates and services are being paid
an established set of fees charged for specific services and paid by the patient or insurance carrier
a list of pre-established fee allowances set for specific services and procedures performed by a provider
a policyholder who is a member of a group and covered by the group's insurance carrier
health care savings account (HSA)
a benefit offered by some employers that allows employees to save money through payroll deduction to accounts that can only be used for medical care
Independent Practice Association (IPA)
Several independently practicing physicians contracted with a health maintenance organization to provide services to health maintenance organization (HMO) members.
the practice of third-party payers to control costs by requiring physicians to adhere to specific rules as a condition of payment
Peer Review Organization (PRO)
organization of a group of physicians and specialists that conducts a review of a disputed case and makes a final reccomadtion
Physician-Hospital Organization (PHO)
a coalition of physicians and a hospital contracting with large employers, insurance carriers, and other benefits groups to provide discounted health services
the highest amount paid by a third-party payer for any given service
Medical problem treated by a physician before an insurance plans effective date. A third party payer may exclude coverage for pre existing conditions.
Preferred Provider Organization (PPO)
An organization whose purpose is to contract with providers and then lease this network of contracted providers to health care plans.
resourced-based relative value scale (RBRVS)
a value scale designed to decrease medicare part b costs and establish national standards for coding and payments
third party administrator
administrator who processes claims for the sponsor of self-funded benefit planning
usual, customary, reasonable (UCR)
the basis of a physician's fee schedule, the usual and customary cost of the same service or procedure in a similar geographic area and under the same or similar circumstances
an analysis of individual cases by a committee to make sure services and procedures being billed to a third-party payer are medically necessary and to ensure compliance with its rules and regulations regarding reimbursement
What are 3rd Party Payers?
insurance companies, medicare, medicaid, bcbs
Does the providers NPI need to be on a claim form?
A referral and authorization process and transaction produces what necessary piece of information?
Can a speciality physician see a patient with a managed care plan without a referral from his or her primary care physician?
What is the needed necessary information for filling a 3rd party claim?
patient personal info, employment data, and insurance info
Preauthorization is required for what?
HMO/current office may make appointments with another physician for the patient.
Yes, it can be done.
A contract that usually establishes what prices will be charged for each service and the condition under which a service would covered is known as what type of coverage?
What is the definition of fraud?
Intention to conceal the truth
What is the definition of Assignment of Benefits?
insurance or 3rd party payer pays the provider directly
Team based model of care led by a personal physician who provides continuous coordinated care throughout a patient's lifetime to maximize health outcomes is called what?
patient centered medical home (PCMH)
Can certain PHI be released without the patients consent?
yes, through legally required disclosures
What is a referral?
When a provider seeks consultation of another provider
At what steps are insurance benefits verified?
before the patient encounter
What is an ABN?
Advanced beneficer notice
Is Medicaid known as the payer of last resort for what reason?
Who is eligible for medicaid?
even people who are employed are eligible
What is secondary insurance? When does it pay?
pays after the primary
What charges are usually collected at the time of service?
co-payments; non-covered or over limit fees, charges for non-participating providers, charges for self pay patients
What is tertiary insurance?
pays after the first and second
Who get paid the "capitated rate"
What is required for a referral for a patient to a managed care provider?
a referral form from a third party provider, referral approval #, physician name and #, referral insurance info, degree of urgency
3 parts to medicare
a) hospital coverage; hospital expenses
b) physician service; inpatient outpatient
D) Drugs; medications
A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment.
The one that pays second (secondary payer) only pays if there are costs the primary insurer didn't cover.
assignment of benefits
an arrangement by which a patient requests that his or her health insurance benefit payments be made directly to a designated person or facility, such as a physician or hospital.
one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years
disability compensation programs
programs that provide partial reimbursement for lost income when a disability prevents an individual from working
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