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Chapter 6: Payment Methods and Checkout Procedures
Terms in this set (31)
A participating physician's agreement to accept the allowed charge as payment in full.
A change to a patient's account, such as a returned check fee.
The maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms.
Collecting the difference between a provider's usual fee and a payer's lower allowed charge from the insured.
A single predetermined payment for an entire episode of care.
The contractually set periodic prepayment to a provider for specified services to each enrolled plan member.
Payment mthod in which a prepayment covers the provider's services to a plan member for a specified period of time.
consumer-driven health plan (CDHP)
Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses.
Dollar amount used to multiply a relative value unit to arrive at a charge.
A negotiated payment schedule for health care services based on a reduced percentage of a provider's usual charges.
A list of the usual fees a physician charges for procedures and services.
a practice's rules governing payment from patients for medical services.
flexible savings account (FSA)
Type of consumer-driven health plan funding option that has employer and employee contributions; funds left over revert to the employer.
health maintenance organization (HMO)
A managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan; usually members must receive medical services only from the plan's providers.
health reimbursement account (HRA)
Type of consumer-driven health plan funding option under which an employer sets aside an annual amount an employee can use to pay for certain types of health care costs.
health savings account (HSA)
Type of consumer-driven health plan funding option under which employers, employees, both employers and employees, orindividuals set aside funds that can be used to pay for certain types of health care costs.
high-deductible health plan (HDHP)
Type of health plan combining high-deductible insurance, usually a PPO with a relatively low premium, and a funding option to pay for patients' out-of-pocket expenses up to the deductible.
independent practice association (IPA)
Type of health maintenance organization in which physicians are self-employed and provide services to both HMO members and nonmembers.
The utilization of certified EHR technology to improve quality, efficeincy, and patient safety in the health care sustem.
Medicare Physician Fee Schedule (MPFS)
The RBRVS-based allowed fees that are the basis for Medicare reimbursement.
A patient payment made during the checkout process based on an estimate by the practice of what the patient will owe.
per member per month (PMPM)
Periodic capitated prospective payment to a provider that covers only services listed on the schedule of benefits.
point-of-service (POS) plan
In HMOs, a plan that permits patients to receive medical services from non-network providers; this choice requires a larger patient payment than visits with network providers.
preferred provider organization (PPO)
Managed care organization structured 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.
primary care physician (PCP)
A physician in a health maintenance organization who directs all aspects of a patient's care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper.
resource-based relative value scale (RBRVS)
The payment system used by Medicare to establish relative value units for services based on resources.
real-time claims adjudication (RTCA)
A process used to generate the actual amount owed by a patient, as opposed to an estimate of that amount.
A patient who does not have insurance coverage.
UCR (usual, customary, reasonable)
Setting fees by comparing the usual fee the provider charges for the service, the customary fee charged by most providers in the community, and the fee that is reasonable considering the circumstances.
Medical billing program report given to patient that lists the diagnosis, services provided, fees, and payments received and due after an encounter.
To deduct an amont from a patient's account because of a contractual agreement to accept a payer's allowed charge or for other reasons.
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