Intro

Question 1

cash flow?

Answer 1

The movement of monies into or out of a business.

Question 2

accounts receivable (AR)

Answer 2

Monies owed to a medical practice by its patients and third-party payers.

Question 3

revenue cycle

Answer 3

All administrative and clinical functions that help capture and collect patients’ payments for medical.

Question 4

health information technology (HIT)

Answer 4

Computer hardware and software information systems that record, store, and manage patient information.

Question 5

practice management program (PMP)

Answer 5

Business software designed to organize and store a medical practice’s financial information; often includes scheduling, billing, and electronic medical records features.

Question 6

electronic health record (EHR)

Answer 6

A computerized lifelong healthcare record for an individual that incorporates data from all sources that provide treatment for the individual.

Question 7

PM/EHR

Answer 7

A software program that combines both a PMP and an EHR into a single product.

Question 8

medical insurance

Answer 8

A written policy stating the terms of an agreement between a policy-holder and a health plan.

Question 9

policyholder

Answer 9

Person who buys an insurance plan.

Question 10

benefit

Answer 10

The amount of money a health plan pays for services covered in an insurance policy.

Question 11

third-party payer

Answer 11

Private or government organization that insures or pays for healthcare on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party.

Question 12

schedule of benefits

Answer 12

List of the medical expenses that a health plan covers.

Question 13

medical necessity

Answer 13

Payment criterion of payers that requires medical treatments to be clinically appropriate and provided in accordance with generally accepted standards of medical practice. To be medically necessary, the reported procedure or service must match the diagnosis, be provided at the appropriate level, not be elective, not be experimental, and not be performed for the convenience of the patient or the patient’s family.

Question 14

covered services

Answer 14

Medical procedures and treatments that are included as benefits under an insured’s health plan.

Question 15

preventive medical services

Answer 15

Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests.

Question 16

noncovered services

Answer 16

Medical procedures that are not included in a plan’s benefits.

Question 17

excluded service

Answer 17

A service specified in a medical insurance contract as not covered.

Question 18

indemnity plan

Answer 18

Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits.

Question 19

healthcare claim

Answer 19

An electronic transaction or a paper document filed with a health plan to receive benefits.

Question 20

premium

Answer 20

Money the insured pays to a health plan for a healthcare policy.

Question 21

deductible

Answer 21

An amount that an insured person must pay, usually on an annual basis, for healthcare services before a health plan’s payment begins.

Question 22

fee-for-service

Answer 22

A payment method based on provider charges.

Question 23

managed care

Answer 23

System that combines the financing and the delivery of appropriate, cost-effective healthcare services to its members.

Question 24

managed care organization (MCO)

Answer 24

Organization offering some type of managed healthcare plan.

Question 25

participation

Answer 25

Contractual agreement by a provider to provide medical services to a payer’s policyholders.

Question 26

health maintenance organization (HMO)

Answer 26

A managed healthcare system in which providers agree to offer healthcare to the organization’s members for fixed periodic payments from the plan; usually members must receive medical services only from the plan’s providers.

Question 27

capitation

Answer 27

Payment method in which a fixed prepayment covers the provider’s services to a plan member for a specified period of time.

Question 28

network

Answer 28

A group of healthcare providers, including physicians and hospitals, who sign a contract with a health plan to provide services to plan members.

Question 29

out-of-network

Answer 29

Description of a provider who does not have a participation agreement with a plan. Using out-of-network providers is more expensive for the plan’s enrollees.

Question 30

preauthorization

Answer 30

Prior authorization from a payer for services to be provided; if preauthorization is not received, the charge is usually not covered.

Question 31

copayment

Answer 31

An amount that a health plan requires a beneficiary to pay at the time of service for each healthcare encounter.

Question 32

primary care physician (PCP)

Answer 32

A physician in a health maintenance organization who directs all aspects of a patient’s care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper.

Question 33

adjudication

Answer 33

The process followed by health plans to examine claims and determine benefits.

Question 34

preferred provider organization (PPO)

Answer 34

Managed care organization structured as a network of healthcare providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.

Question 35

consumer-driven health plan (CDHP)

Answer 35

Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses.

Question 36

medical insurance specialist

Answer 36

Medical office administrative staff member who handles billing, checks insurance, and processes payments.

Question 37

medical coder

Answer 37

Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records.

Question 38

procedure code

Answer 38

Code that identifies medical treatment or diagnostic services.

Question 39

patient ledge

Answer 39

Record of all charges, payments, and adjustments made on a particular patient’s account.

Question 40

compliance

Answer 40

Actions that satisfy official guidelines and requirements.

Question 41

professionalism

Answer 41

For a medical insurance specialist, the quality of always acting for the good of the public and the medical practice being served. This includes acting with honor and integrity, being motivated to do one’s best, and maintaining a professional image.

Question 42

ethics

Answer 42

Standards of conduct based on moral principles.

Question 43

etiquette

Answer 43

Standards of professional behavior.

Question 44

certification

Answer 44

The recognition of a person demonstrating a superior level of skill on a national test by an official organization.