FINALS - Key Terms Flashcards
(22 cards)
The amount the policy holder pays the insurance company for the insurance coverage
Premium
Payments for medical services, for a specified time period
Benefits
Third party who agrees to carry the risk of paying for services
Third party payer
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-party payer begins to cover medical expenses
Deductible
A fixed percentage of covered charges after the deductible is met
Coinsurance
A fixed fee collected at the time of the visit
Copayment
Planned procedure that is done at the convenience of the provider or surgeon and the patient
Elective procedure
The process of confirming with an insurance company that a patient’s insurance plan offers coverage for a specific procedure or visit
Precertification
Receipt of confirmation from the patient’s insurance plan that the proposed procedure or service will be considered a covered service because of the individuals’ patient’s specific circumstances that requires the procedure or service to be performed
Preauthorization
A list established by physicians of their usual fees charged for procedures and services they frequently perform
Fee schedule
A plan that pays the practitioner a set amount for each service provided based on a fee schedule listed in the insurance policy, and the patient is responsible for the balance.
Fee-for-service
A payment structure in which a physician is paid an annual set fee per patient enrolled in their practice regardless of how often the patient is seen
Capitation
A managed care plan that established a network of providers to perform services for plan members
PPO
(Preferred Provider Organization)
A healthcare organization that provides specific services to individuals and their dependents who are enrolled in the plan. Doctors who enroll agree to provide certain services in exchange for a prepaid fee.
HMO
(Health Maintenance Organization)
The process of reviewing medical care in individual cases to be sure that all services provided were medically necessary and that there was appropriate use of medical resources; performed by medical peers and used as a cost control measure by managed care organizations.
Utilization Review
Term used when a patient is covered by Medicare & Medicaid
Dual Coverage
The payment system used by Medicare. It establishes the relative value units for services, replacing the providers consensus on usual fees
RBRVS
(Resource based relative value scale)
The maximum amount the payer will pay any provider for each procedure or service.
Allowed charge
A group that takes nonstandard medical billing software formats and translates them into the standard EDI formats
Clearinghouse
A form that the patient and the practice receive 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 explanation of why that service is not covered; also called an explanation of benefits.
Remittance Advice (RA)
Information that explains the medical claim in detail; also called remittance advice (RA).
Explanation of Benefits (EOB)
