medical insurance/health insurance
a written contract in the form of a policy between a policy holder and a health plan(insurance carrier)
premium
the charge for keeping the insurance policy in effect
benefits
payments for medical services
lifetime maxium benefit
a total sum the health plan will pay out over the patient's lifetime
first party
the patient/policyholder
second party
the physician who provides medical services
policy
a written contract
patient-physician contract
a contract that is created when a physician agrees to treat a patient who seeks medical services
third-party payer
a health plan that agrees to carry the risk of paying for patient services
deductible
a fixed dollar amount that must be paid by the insured for charges of providers, or "met" once a year, in addition to the premium, before the third-payer begins to cover medical expenses
coinsurance
a fixed percentage of covered charges after the deductible is met
copayment
a fixed fee collected at the time of visit
exclusions
expenses that may not be covered under the insured's contract
formulary
a list of approved prescription brands
elective procedure
a procedure that is done at the convenience of the physician or surgeon and the patient
preauthorization
the process of the provider contacting the insurance plan to see if the proposed procedure is a covered service under the patient's insurance plan
group policies
in the US, the majority of individuals with insurance are covered by this type of policy
49.9 million
the number of uninsured Americans as of 2010
Affordable Healthcare Act
-the extension of insurance coverage to all Americans
-bans the ability of private insurance carriers to impose lifetime limits on coverage
-bans denial of coverage for preexisting conditions
-bans policy cancellations when an insured person becomes ill
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fee-for-service plan
the oldest and most expensive type, it repays policy holders for healthcare costs due to illnesses and acicidents
managed care organizations
control both the financing and delivery of healthcare to policyholders; enroll policyholders, physicians, and other care providers to provide services for their members at reduced rates
participating physicians
physicians who enroll with managed care plans
capitation
a payment structure in which a health maintenance organization prepays an annual set fee per patient to physician
preferred provider organization
a managed care plan that establishes a network of providers to perform services for plan members
health maintenance organization
a healthcare organization that provides specific services to individuals and their dependents who are enrolled in an HMO agree to provide certain services in exchange for a prepaid fee
health maintenance organization
-physicians are often paid a capitated rate
-patients pay premiums and usually also pay a copay
-patients must usually choose from a specific group of healthcare providers
-patients also pay for excluded services
utilization review
in this process, committee members who have training similar to that of the physician providing the medical care review individual cases to be sure that all services provided were medically necessary and that there was appropriate use of medical resources
Blue Cross Blue Shield
a nationwide federation of nonprofit and for profit service organizations that provide prepaid healthcare services to BCBS
liability insurance
covers injuries caused by the insured or that occurred on the insured's property
disability insurance
may be offered to employees, provided by an employer for its employees, or purchased privately; activated when the insured is injured or disabled for non-work related reasons
Medicare
-the largest federal program which provides health insurance for citizens aged 65 and older, the disabled, the blind, and workers of any age who have chronic kidney disease requiring dialysis or end-stage renal disease
-managed by CMS
-divided into two pa
Medicare Part A
the hospital benefit of Medicare, which is billed by hospitals or other healthcare facilities and financed through contributions collected from the Federal Insurance Contributions Act tax on income earned by workers and the self employed
Medicare Part B
-covers a portion (usually 80%) of the allowed charges for a wide range of outpatient procedures and supplies
-individuals entitled to Part A benefits automatically qualify
-must enroll because coverage is not automatic; has 6 months to enroll (3 months p
Medicare Part C
provides several plan choices for individuals called Medicare Advantage plans; include PPOs, HMOs, private fee-for-service plans, special need plans, and Medicare savings account plans
Medicare Part D
prescription drug plan offered to Medicare beneficiaries
medicare fee for service
allows the beneficiary to choose any licensed physician certified by Medicare
medicare managed care plans
charges a monthy premium and a small copaymet for wach office visit, but not a deductible
medicare preferred provider organization plan
patients pay less when they use doctors within a network, but they may choose to go outside the network for additional costs, such as a higher copayment or higher coinsurance
medicare private fee for service plan
patients receive services from the provider they choose, as long as medicare has approved the provider or facility
recovery audit contractor program
program where four institutions audits one-fourth of the country, designed to guard the Medicare Trust Fund by fighting fraud, waste, and abuse in the medicare program
Medicaid
a health benefit program designed for low income, blind, or disabled patients; needy families; foster children; and children born with birth defects
accepting assignment
agreement in which physicians who agree to treat medicaid pstients also agrees to accept tje established medicaid payment for covered services as payment in full
dual coverage
term used when a patient id covered by medicare and medicaid
TRICARE
a healthcare benefit for families of uniformed personnel and retirees from the Uniformed Services
CHAMPVA
Civilian Health and Medical Program of the Veterans Administration; covers the expenses of the families (dependent spouses and chilldren) of veterans with total, permanent, service-connected disabilities.
SCHIP/CHIP
State Children's Health Inusrance Plan; allows statesto provide health coverage to unisured children in families whose incomes are too high to qualify for Medicaid but too low to afford private insurance
Worker's Compensation Insurance
covers employment related accidents or diseases
fee schedule
a list of a physician's usual fees, charged to most of their patients most of the time under typical conditions
resource based relative value scale
the payment system Medicare uses; establishes the relative value units for services, replacing the providers'consensus on fees with amounts based on resources;
national uniform relative value unit
based on three cost elements: the physician's work, the practice cost (overhead), and the cost of malpractice insurance
geographic adjustment factor
used to adjust each relative value to reflect a geographical area's relative costs, such as office rent and utilities
nationally unifrim conversion factor
a dollar amount used to multiply the relative values to produce a payment amount
allowed charge
the maximum amount the payer will pay any provider
balance billing
billing a patient for the difference between a higher usual fee and a lower allowed charge
The Advance Beneficiary Noticeof Noncoverage/ABN
a notice giventoMedicare beneficiaries to convey that Medicare is not likely to provide coverage in a specific case
birthday rule
states that the insurance policy oF the policyholder whose birthday comes first in the calendar year is the primary payer for all dependents
data elements
the information entered on electronic claims
taxonomy code
a 10 digit number representing a physician's medical specialty
HIPAA Electronic Health Care Transactions and Code Sets
means that all health plans are required to accept the standard claim submitted electronically, although the information required by each payer may vary
direct transmission to the payer, clearinghouse use, direct data entry
three major methods used to transmit claims electronically
direct ransmissions to the payer
medical offices and payers exchange transmissions directly, using the necessary information systems-inlcuding a transkator and communications technology-to conduct electronic data interchange
clearinghouse
a group that takes nonstandard medical billing software formats and translates them into the standard EDI formats
direct data entry
uses an internet based service into which employees can key the standard data elements
remittance advice/explanation of benefits
a form that the patient and the practice recieve for each encounter that outlines the amount billed by the practice, the amount allowed, the amount of subscriber liability, the amount paid, and notations of any service not covered, including an explanatio