policyholder
a person who buys an insurance plan; the insured
health plan
a plan, a program, or org. that provides health benefits
premium
a periodic amount of money the insures pays to a health plan for insurance coverage
medicare
common government plan, covers people 65+, those w/ disabilities and dependent widows
medicaid
common government plan, covers people w/ low income who can not afford medical care. Qualifications and benefits vary by state
tricare
common government plan, covers dependent of active-duty members and dependents of military personnel who were killed while on active duty
Workers' compensation
common government plan. people with job-related illnesses or injuries are covered, benefits vary according to state law
fee-for-service
health plan where policyholders are repaid for costs of health care due to illnesses and accidents
coinsurance
portion of charges that an insured person must pay
managed care
organizations that controls both the financing and the delivery of health care to policyholders. Also establishes contracts with physicians and other health care providers that control fees
capitation
advance payment to provider that covers each plan members health care services for a certain period of time
preferred provider organization (PPO)
the MOST common type of managed care health plan
health maintenance organization (HMO)
another common type of managed care system which providers agree to offer health care to the organization's members for fixed periodic payments from the plan
copayment
a small fixed fee paid by the patient at the time of an office visit
patient information form
contains personal, employment, and medical insurance info needed to collect payment for the provider's services
encounter form
also known as a superbill is a list of procedures and charges for a patient's visit
diagnosis
physician's opinion of the nature of the patient's illness or injury
procedure
medical treatment provided by physician or other health care provider
coding
the process of assigning standardized codes to diagnoses and procedures
diagnosis code
a standardized value that represents a patient's illness, signs, and symptoms, found in the ICD-9-CM
procedure code
code that identifies a medical service
adjudication
a series of steps designed to judge whether a claim should be paid. Claims can be paid in full, partially paid, or denied
statement
a list of services performed for a patient, along with charges for each service
billing cycle
regular schedule of sending statements to patients
accounting cycle
a flow of financial transactions in a business
accounts receivable (AR)
monies that are flowing into a business
information technology (IT)
development, management, and support of computer-based hardware/software systems
electronic medical record (EMR)
store physicians reports of exams, surgical procedures, tests, x-rays, and other clinical info (documents patients care). Also provides access to data for research
patient data
personal info about patient
transaction data
info about the date of visit, location of treatment, diagnosis and procedure codes, and the payments made at the time of each office visit
clearinghouse
company that collects electronic insurance claims from medical practices and forwards the claims to the appropriate health plans
audit/edit report
report from clearinghouse that lists errors to be corrected before a claim can be submitted
walkout statement
also known as a receipt, lists charges and payments after an office visit
advantages of computer use (5)
info is stored in electronic files, info is easy to find, less storage space required, computer databases are more efficient than manual filing, and computer can reduce some types of errors
Caution; what computers can not do
they are no more accurate than the individual entering the data
Health Portability and Accountability Act of 1996 (HIPPA) (page 32-33 in medical office book)
Have a basic understanding of what it is for the test
electronic data interchange (EDI)
involves sending info from computer to computer
CMS-1500
paper claim, which is the currently mandated paper claim form
HIPPA Privacy Rule
protects individually identifiable health info
audit trail
an additional security measure. computer programs can keep track of data entry, when info was assessed and by whom, and whether info has been changed