Chapter Twenty-Four: Health Insurance Flashcards
(43 cards)
advance beneficiary notice (ABN)
document used to notify a Medicare beneficiary that it is either unlikely that Medicare will pay or certain that Medicare will not pay for the service they are going to be provided. Beneficiaries are required to sign this document if they wish to have the service with the understanding that they will be responsible for payment
allowed amount
the maximum amount an insurer will pay for any given service
assignment of benefits
the authorization, by signature of the patient, for payment to be made directly by the patient’s insurance to the provider for services
beneficiary
person entitled to benefits of an insurance policy. This term is most widely used by Medicare
birthday rule
a means to identify primary responsibility in insurance coverage; identifies the primary insurance carrier when children have coverage through more than one parent. The insurance of the parent with the birthday earliest in the year, month and day only, is identified as the primary insurer. If both parents have the same birth date, the policy that has been in effect the longest is the primary carrier
capitation
the health care provider is paid a fixed amount per member per month for each patient who is a member of a particular insurance organization regardless of whether services were provided
CMS-1500
the standard claim form designed by the Centers for Medicare and Medicaid Services to submit physician services for third-party (insurance companies) payment; the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed
coinsurance
a percentage that a patient is responsible for paying for each service after the deductible has been met
conversion factor
the dollar amount that converts the RVUs into a fee
coordination of benefits (COB)
when both spouses have health insurance, the policy provision that limits benefits to 100 percent of the cost; also known as dual coverage; procedures insurers use to avoid duplication of payment on claims when the patient has more than one policy. One insurer becomes the primary payer, and no more than 100 percent of the costs are covered
co-payment
a specified amount the insured must pay toward the charge for professional services rendered at the time of service
deductible
an amount to be paid before insurance will pay
dependent
person covered under a subscriber’s insurance policy; refers to spouses and dependent children
Diagnosis-related groups (DRGs)
method of determining reimbursement from medical insurance according to diagnosis on a prospective basis
exclusive provider organization (EPO)
EPOs are like HMOs in that patients must use their EPO’s provider network when receiving care. There is no partial coverage for out-of-network care
explanation of benefits (EOB)
a printed description of the benefits provided by the insurer to the beneficiary; provides information to the patient about how an insurance claim from a health provider (such as a physician or hospital) was paid on their behalf
fee-for-service
payment for each service that is provided; individuals who choose to pay high premiums so that they have the flexibility to seek medical care from health care professionals of their choice
fee schedule
a list of predetermined payment amounts for professional services provided to patients
flexible spending arrangement (FSA)
pretax funds set aside for use in payment of medical services and supplies not covered by insurance; referred to as a cafeteria plan. Qualified medical expenses are those specified in the plan that would generally qualify for the medical and dental expenses deduction, which is explained in IRS Publication 502. The plan is usually funded by the employee with pretax dollars. In some instances, an employer might contribute small amounts. This is a “use it or lose it’ type plan.
gatekeeper
one who regulates access to someone or something; in insurance, a primary care physician who coordinates the patient’s referral to specialists and hospital admissions
geographic practice cost index (GPCI)
each of the RSRVS components is then adjusted for geographical cost differences by multiplying each by a geographic practice cost index. This results in different payment amounts, depending on the location of the provider’s practice, and amounts can vary from state to state and even within the same state, depending on whether the location is considered urban or suburban.
Health maintenance organizations (HMOs)
a type of managed care operation that is typically set up as a for-profit corporation with salaried employees; group insurance that entitles members to services provided by participating hospitals, clinics, and providers
health reimbursement arrangement (HRA)
pays for medical expenses. It can be paired with a standard or high-deductible health plan. An employer can contribute to an HRA, but an employee cannot
health savings account (HSA)
a tax-sheltered savings account, which contributions from the employer and employee, which can be used to pay for medical expenses.
