AMA
American Medical Association
Policy Holder
a person or entity who buys and insurance plan; the insured
Health Plan
a plan, program, or organization that provides health benefits
Premium
The periodic amount of money the insured pays to a health plan for insurance coverage
What are the most common government plans?
Medicare, Medicaid, Tricare, CHAMPVA, workers comp
payer
private or government organization that insures or pays for health care on behalf of beneficiaries
Fee-for-service
health plan that repays the policy holder for covered medical expenses
deductible
amount due before benefits start
coinsurance
percentage of charges that an insured person must pay for healthcare services after payment of the deductable amount
managed care
a type of insurance in which the carrier is responsible for both the financing and the delivery of healthcare
Preferred provider organizatio (PPO)
Managed care network of health care providers who agree to perform services for plan members at discounted rates
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
Capitation
payment to a provider that covers each plan member's health care services for a certain period of time
copayment
a small fixed fee paid by the patient at the time of an office visit
Consumer driven health plan (CDHP)
a type of managed care in which a high-deductible low premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses
patient information form
Form that includes a patient's personal, employment, and insurance data needed to complete an insurance claim.
documentation
a record of health care encounters between the physician and the patient, created by the provider
medical record
a chronological record of a patient's medical history and care that includes information that the patient provides, as well as the physician's assessment , diagnosis, and treatment plan.
diagnosis
physician's opinion of the nature of the patient's illness or injury
procedure
medical treatment provided by a physician or other health care provider
coding
the process of translating a description of a diagnosis or procedure into a standardized code
diagnosis code
a standardized value that represents a patient's illness, signs, and symptoms
procedure code
A code that identifies a medical service
modifier
a two-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service
encounter form
a list of the procedures and charges for a patient's visit
electronic health record (EHR)
a computerized lifelong health care record for an individual that incorporates data from providers who treat the individual
Practice management program (PMP)
a software program that automates many of the administrative and financial tasks required to run a medical practice
medical coder
a person who analyzes and codes patient diagnoses, procedures, and symptoms
medical necessity
treatment provided by a physician to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and provided in accordance with generally accepted standards of medical practice
remittance advice (RA)
an explanation of benefits transmitted electronically by a payer to a provider
explanation of benefits (EOB)
Paper document from a payer that shows how the amount of a benefit was determined
statement
a list of all services performed for a patient, along with the charges for each service
accounting cycle
The flow of financial transactions in a business
accounts receivable (AR)
Monies that are flowing into a business.
health information technology (HIT)
technology that is used to record, store, and manage PT health care information
clearinghouse
a service company that recieves electronic or paper claims from the provider, checks and prepares them for processing, and transmits them in HIPAA-complaint format to the correct carriers
audit/edit report
a report from a clearinghouse that lists errors to be corrected before a claim can be submitted to the payer
walkout statement
a document listing charges and payments that is given to a patient after an office visit
autoposting
an automated process for entering information from a remittance advice (RA) into a practice management program
electronic medical records (EMR)
the computerized records of one physician's encounters with a pt over time (lab's, x-rays, tests)
personal health records (PHR)
private, secure electronic files that are created, maintained, and owned by the patient
electronic prescribing
the use of computers and handheld devices to write and transmit prescriptions to a pharmacy in a secure digital format
evidence based medicine
medical care based on the latest and most accurate clinical research
Health information technology for economic and clinical health act (HITECH)
part of the american recovery and reinvestment act of 2009 that provides financial incentives to DR's and hospitals to adopt EHRs and strengthens HIPPA privacy and security regulations
workflow
a set of activities designed to produce a specific outcome
computer assisted coding
assigning preliminary diagnosis and procedure codes using computer software
health insurance portability and accountability act of 1996 (HIPAA)
Federal act that set forth the guidelines for standardizing the electronic data interchange pf administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information
HIPAA electronic tranaction and code sets standards
regulations requiring electronic transactions such as claim transmission to use standardized formats
electronic data interchange (EDI)
the exchange of routine business transactions from one computer to another using publicly available communications protocols
electronic funds transfer (EFT)
electronic routing of funds between banks.
x12-837 health care clain (837P)
HIPAA standard format for electronic transmission of a professional claim from a provider to a health plan
CMS 1500
health insurance claim form
national provider identifier (NPI)
a standard identifier for all health care providers consisting of ten numbers
HIPAA privacy rule
regulations for protecting individually identifiable information about a patient's past, present, or future physical and mental health and payment for health care that is created or received by a health care provider
Protected health information (PHI)
information about a patient's past, present, or future physical or mental health or payment for health care that can be used to identify the person
HIPAA security rule
regulations outlining the minimum administrative, technical, and physical safeguards required to prevent unauthorized access to protected health care information
Administrative safeguards
administrative policies and procedures designed to protect electronic health information outlined by the HIPAA security rule.
physical safeguards
Mechanisms required to protect electronic systems, equipment, and data from threats, enviromental hazards, and unauthorized intrusion
technical safeguards
automated processes used to protect data and control access to data
audit trail
a report that traces who has accessed electronic information, when information was accessed, and whether any information was changed
breach
the acquisition, access, use, or disclosure of unsecured PHI in a manner not permitted under the HIPAA privacy rule
Five states and one US territory have state disability insurance, what are they?
California, Hawaii, New Jersey, New York, Rhode Island, & Puerto Rico
temporary disability
the status of an injured worker, who for a specified amount of time, is incapable of performing their normal work duties
Permanent disability
When the employee ability to work at any occupation is totally and permanently lost.
Waiting period (WP)
for disability insurance the initial period of time when a disabled individual is not eligible to receive benefits even though unable to work.
OSHA
Occupational Safety and Health Administration. Develops and publishes guidelines concerning safety in the workplace.
deposition
the testimony of a witness made under oath but not in open court
CPT 99080
CPT code 99080 may be used t bill for workers' compensation reports.
ROM
Range of motion
exclusions
when insurance policy does not cover certain medical conditions (illness or injuries not covered by policy) examples: pre-existing conditions such as diabetes, smoking related, cancer, etc.
Types of appreal processes are
reconsideration, hearing before an administrative law judge, review by the Appeals Counsil, a review by a federal court
Disability benefit programs are
Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Civil Service Retirement System (CSRS), Federal Employees Retirement System (FERS), Armed Services Disability, Veterans Affairs (VA) disability program
accident
Anything that happens in an unplanned way, especially when it causes injury or damage.
compulsory law
each employer is required to accept its provisions and provide for specified benefits.
dismemberment benefit
A policy that offers an insured person protection when loss of sight or less of limb(s) occurs is called.
benefit period
a specified amount of time during which benefits will be paid.
appeals evaluation process
reconsideration, hearing before and administrative law judge, review by the appeals counsil, review by the federal court
disability income insurance
A form of health insurance that replaces a portion of earned income when an individual is unable to perform the requirements of his or her job because of injury or illness that is not work related
exlusions
provisions written into the insurance contract denying coverage or limiting the scope of coverage. Example: pre-existing conditions
ajudication
A case that is rated for permanent disability and settled, is called?
workers compensation benefits include...
medical treatment, temporary disability indemnity, permanent disability indemnity, death benefits for survivors, rehabilitation benefits
deposition
the testimony of a witness made under oath but not in open court
waiting period
the initial period of time that an injured person must wait before they are eligible to receive the financial benefits
social history (SH)
An age-appropriate review of past and current activities E.G. (smokes, consumes alcohol
family history (FH)
A review of medical events in the patient's family including diseases that may be hereditary or place the patient at risk
ergonomic
The applied science of equipment design, as for the workplace, intended to maximize productivity by reducing operator fatigue and discomfort
medical necessity
treatment provided by a physician to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and provided in accordance with generally accepted standards of medical practice
concurrent care
When a patient receives similar services (e.g., hospital visits) by more than one healthcare provider on the same day.
consultation
Services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem.
continuity of care
continuation of care smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care.
counseling
discussion iwth a patient, family, or both concerning one or more of the following: diagnostic results, impressions, or recommended diagnostic studies, etc
critical care
intesive care provided in a variety of acute life threatening conditions requiring constant full attention of a physician.
emergency care
Heath care services provided to prevent serious impairment of bodily functions or serious dysfunction to any body organ or part. Advanced support may be necessary. not all care provided in an emergency department of a hospital can be termed "emergency car
referral
the transfer of the total care or specific care of a patient from one physician to another for known problems.
Location
Area of the body where the symptom is occuring
quality
character of the symptom/pain (burning, gnawing, stabbing, fullness)
severity
degree of symptom or pain on a scale from 1-10. Severity also can be described with terms such as severe, slight, and persistant.
duration
how long the symptom/pain has been present and how long it lasts when the patient has it.
timing
when the pain/symptom occurs (E.G. morning,evening, after or before meals)
context
the situation associated with the pain/symptom (e.g.) dairy,products, big meals, activity)
modifying factors
Things done to make the symptom/pain worse or better
associated signs and symptoms
The symptom/pain and other things that happen when the symptom/pain occurs (chest pain leads to shortness of breath)
attending physician
Medical staff member who is legally responsible for the care and treatment given to a patient.
consulting physician
a provider whose opinion or advice about evaluation or management of a specific problem is requested by another physician
ordering physician
is the individual directing the selection, preparation, or administration of tests, medication, or treatment
referring physician
is a provider who sends the patients for testing or treatment
Treating or performing physician
is the provider who renders a service to a patient