Medical billing Flashcards
(151 cards)
1
Q
privacy act of 1974
A
prohibits disclosure of certain medical info by government agencies unless the patient gives written consent
2
Q
healthcare operations
A
certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business and to support the core functions of treatment and payment
3
Q
Three groups to which HIPAA regulations apply
A
- Healthcare providers
- health plans
- healthcare cleaning houses
4
Q
protected health information (PHI)
A
any individual identifiable health information
5
Q
identifiable information
A
data about a specific person
6
Q
de-identifiable information
A
information stripped of data that may identify an individual
7
Q
limited data set
A
middle ground between identifiable and de-identifiable information
8
Q
risk management
A
identifies areas of risk to medical service providers
9
Q
payment
A
the activities of healthcare providers to obtain payment or be reimbursed for their services
10
Q
treatment
A
the provision of healthcare and related services
11
Q
peer review committees
A
consists of healthcare providers who monitor the quality and use of healthcare services
12
Q
biometrics
A
technologies that identify people through bodily characteristics, such as finger prints, retinal patterns & voice patterns
13
Q
loss prevention
A
a planned, systematic, and proactive process; in the area of healthcare providers identify those activities, problems, and situations that may result in potential liability
14
Q
loss reduction
A
the steps taken after an event or incident occurs
15
Q
virtue theory
A
pertains to the character of a person as displayed by the virtues he or she possesses
16
Q
duty theory
A
pertains to a persons obligations from the standpoint of morality
17
Q
consequentialist theory
A
based on the consequences of peoples actions based on their own ethics & morals
18
Q
false claims act
A
punishes those who knowingly engage in false billing
19
Q
misdemeanor
A
any crime that’s punishable by imprisonment for less than one year
20
Q
statues
A
legislation passed by governing bodies on federal and state levels
21
Q
PPE
A
personal protective equipment
22
Q
statue of limitations
A
the time period during which a lawsuit must be brought
23
Q
contributory negligence
A
when a patient contributes to causing themselves harm
24
Q
arbitration
A
two parties present evidence to an impartial person, who makes a binding decision
25
appeal
during an appeal, the question is whether an error of law was made at the trial court level
26
perjury
false swearing under oath
27
burden of proof
what the plaintiffs are obligated to prove
28
bench trial
a trial in which there's no jury and the judge serves as the fact finder, weighs the evidence & decides how the law applies to it
29
expert witnesses
people who have skill, experience, training, or education in a specialized field that ordinary people don't have
30
types of malpractice
failure to diagnose, failure to inform of diagnosis, errors in treatment, lack of informed consent
31
battery
the harmful touching of a patient without consent
32
product liability
the legal responsibility that a manufacturer or distributer of an unreasonably dangerous product has for damages cause by the dangerous condition
33
Actus Reus
latin for "guilty act" or the criminal act
34
Mens Rea
latin for "guilty mind" referring to the state of mind associated with the criminal act
35
OSHA
the occupational safety and health administration
36
joint commission
an external accrediting body for health care facilities
37
CMS
the centers for medicare and medicaid services
38
Malpractice
professional negligence
39
defensive medicine
consists of medical responses that are motivated by a desire to avoid potential liability claims more than by the needs of the patient
40
mediation
occurs when a neutral third party helps the parties in a dispute reach a settlement agreement
41
ordinances
legislation adopted by local legislative bodies
42
certification
refers to a professional organization or institution representing that a certified person has passed a test, completed a course of study, or demonstrated knowledge or skill in some other way
43
negligence
failing to meet a standard of reasonable care
44
due care
the responsibility of a physician to hire qualified personnel and supervise the personnel accordingly
45
vicarious liability
when one person is held responsible for the actions of another
46
litigation
the process of resolving disputes through the court system
47
alternative dispute resolution (ADR)
a process of resolving disputes outside of the court system that may be used before or after litigation has begun
48
alternative dispute resolution (ADR)
a process of resolving disputes outside of the court system that may be used before or after litigation has begun
49
litigate
to begin a legal process involving a court
50
plaintiff
the person who is suing
51
defendant
the person who is being sued
52
deposition
the taking of oral testimony under oath before trial
53
jury trial
a trial in which the jury is the fact finder, and the judge explains the law to the jury and supervises the presentation of evidence
54
common law
a system of law developed on a case by case basis from court decisions
55
right
an individual power, privilege or immunity
56
duty
an individual obligation
57
three branches of government
- federal
- state
- local
58
civil law
concerns the private rights & duties of individuals who live within a society
59
crime
an offense against a locale, a state, or the United States
60
criminal law
prohibits and punishes certain conduct for the benefit of society
61
law
the set of rules that govern our behavior
62
wrongful birth
a parents claim against a doctor for damages caused by birth of a child that occur when a doctor fails to detect and disclose a Childs birth defects in time to permit abortion
63
euthanasia
occurs when a person takes an action that causes death to another person sometimes called mercy killing
64
assisted suicide
occurs when a patient takes actions to terminate his or her life using means supplied by someone else
65
use of biometrics
to identify a patient to simplify secure access to records
66
health insurance
created important rules regarding safeguarding health information
67
Hippocratic oath
taken by physicians and pertains to the ethical practice of medicine
68
durable power of attorney (DPA)
authorizes a person to make medical decisions for a patient when the patient is unable to do so
69
do - not - resuscitate (DNR)
prevents efforts to resuscitate those who have exhibited the signs of death; doesn't go into effect until the person is permanently unconscious without realistic hope of recovery
70
advance medical directives
instructions people give to others regarding their medical wishes in case they are unable to
71
fetal homicide laws
laws that make causing the death of a fetus a crime separate and independent from any crime committed against the woman carrying the fetus
72
etiquette
the proper form of social interaction in a given culture or community
73
affordable care act (ACA)
signed into law by president Barak Obama in 2010; makes health insurance coverage mandatory
74
ethical theories
attempt to systemize, defend, and recommend concepts of right and wrong behavior
75
ethics v. law
while moral obligation focuses on an individuals conscience - legal obligations are enforced by the states power w/o regard to conscience
76
meta ethics
a branch of ethical theory that considers the origin and meaning of ethical principles
77
normative ethics
involves determining the moral standards that regulate right and wrong conduct
3 theories
- virtue theory
- duty theory
- consequentialist theory
78
roe v. wade
in 1973, in a landmark decision regarding abortion, the US Supreme Court in roe v. wade applied the right to privacy to abortion
79
amniocentesis
a medical technique used to test DNA in amniotic fluid; allows physicians to identify genetic abnormalities before birth
80
negative eugenics
limits or discourages reproduction by those considered genetically inferior
81
eugenics
a science that deals with "improving" hereditary qualities
82
positive eugenics
encourages reproduction by those considered genetically superior
83
methods on conception
test tube fertilization artificial insemmination
84
medical paternalism
takes away patient autonomy and gives the power to medical personnel or the government for societys benefit
85
patient autonomy
requires that the patient give informed consent prior to the start of any medical treatment
86
formulary
a list of approved drugs from which doctors must prescribe to have insurance cover the pharmaceuticals
87
doctor-patient privilege
a relationship in which a patients medical history, conditions, and related info can't be made known without the patients consent
88
medical record
document that includes a patients history, condition, diagnostic & therapeutic treatment and the results of treatment
89
author of a medical record
the provider who has created the data that appear in the record
90
age of maturity
when a person becomes an adult
91
certificate of destruction
documents that records were properly destroyed in the ordinary course of business
92
substituted consent
an authorized person makes a decision for a person who is unable to do so
93
legal basis for confidentiality
the right of privacy derived from the U.S. constitution, statues, and the common law
94
accounts receivable (AR)
payments that hospitals receive from third party payers for providing healthcare services
95
CMS-1500 claim form
standard insurance claim form used to report outpatient services to insurance companies
96
coordination of benefits (COB)
also known as crossover; group policy provision that helps determine the primary carrier in situations in which an insured party is covered by more than one policy, thus preventing the insured from receiving claims overpayments
97
explanation of benefits (EOB)
statement sent to a participant in a health plan as well as the healthcare provider that lists services, amounts paid by the plan, and total amount billed to the patient
98
fiscal intermediaries (FI)
insurance companies contracted by the government to process claims for government insurance programs, such as medicare parts A & B
99
remittance advice
communication from third party payer to payee that provides a detailed accounting of payments and healthcare services provided
100
revenue codes
UB-92 payment codes for healthcare services or items
101
UB-92 claim form
also known as the CMS-1450 form; standardizes the processing of billing for hospital inpatient and outpatient services
102
reimbursement
the way that healthcare providers are paid for providing medial services
103
healthcare providers
doctors, hospitals, and healthcare facilities
104
medical coding
the process of assigning codes to certain pieces of information in the health record
105
preventable health threats
illnesses that can be prevented before they occur by routine physical examinations and immunizations
106
third-party payers
responsible for providing an insurance arrangement that provides benefits in the form of healthcare services
107
fee-for-service reimbursement
healthcare provider receives reimbursement based on the amount that they charge for service
108
covered medical expenses
medical expenses that are listed in the benefits section of the insurance policy as being reimbursable by the insurance company
109
chargemaster
a list of healthcare supplies and services with specific charges assigned for each supply and service
110
facility fee
fee paid to hospital for services provided
111
service fee
fee paid to physicians for services provided, such as medical consultation and surgery
112
skilled nursing facility
a facility designed to treat medicare-eligible patients
113
outcome and assessment information set (OASIS)
a dataset used in home healthcare for patient assessments to help monitor and improve the outcomes of home healthcare
114
CMS
centers for medicare and medicaid services' professional, universal health claim form; used by providers of outpatient health services to bill their fees to health carriers (or third-party payers)
115
CMS-1450
institutional claim form used by hospitals to receive payment from third-party payers; also known as the UB-04 or the uniform bill
116
medicare carriers
private companies that have a contract with medicare to process medicare part B bills for physicians and medical suppliers
117
audit trails
information maintained on coding reviews and the actions needed for improvement
118
upcoding
assigning codes that aren't supported by the information in the patients health record
119
unbundling
breaking down codes that are normally assigned as a set into separate codes for the purpose of obtaining higher reimbursement
120
coinsurance
provision stating that the insured and the insurer will share all losses covered by the policy in porportion agreed upon in advance; for example, an 80-20 policy means that the insurer pays 80 percent and insured pays 20 percent of expenses
121
copayment
an arrangement in which the covered person pays a specified amount for various services and the healthcare provider pays the remainder. copayment is usually paid at service.
122
deductible
portion of an insured loss paid by the insured before they're entitled to benefits from the insurer
123
group health insurance
health insurance provided to a group, most often a group of employees, providing coverage in the form of lump-sum payment or periodic payments to compensate for income losses due to bodily injury, sickness, or disease as well as medical expenses
124
insured
party to an insurance arrangement who's secured against losses and provided benefits or services; this term is preferred to terms such as policy holder and policy owner
125
insurer
party to an insurance arrangement who undertakes to indemnify for losses, provide benefits, or render services. the term insurer is preferred to company or carrier. aka third party payer
126
major medical insurance
a type of health insurance that provides benefits up to a high limit for most types of medical expenses incurred, subject to a large deductible. these policies usually pay covered expenses whether an individual is in or out of the hospital
127
out-of-pocket expenses
amount not covered by insurance that the covered (or insured) person must pay out of their own pocket, such as coinsurance and a deductible; aka out of pocket costs
128
provider
any individual or group of individuals that provide a healthcare service (such as physicians or hospitals)
129
fee-for-service
the method by which a physician or provider bills for each service or visit instead of on a prepaid (that is, all-inclusive) basis. this was the initial way that patients received treatment, for which they usually paid cash.
130
managed care
a system of healthcare where the goal is to deliver quality, cost of effective healthcare through monitoring and recommending utilization and cost of services
131
prospective payment system (PPS)
a system wherein reimbursement is made to the provider based on a predetermined reimbursement level rather than on actual charges after the services have been provided
132
retrospective payment system
a system wherein reimbursement is made to providers after healthcare services have been given
133
usual, customary, and reasonable charges (UCR)
charges for healthcare services that are based on the physicians "usual" charge for the service, which is the "customary" amount that other physicians in the area charge, and a "reasonable" amount for the service performed
134
prepaid health plan
contract that covers specific medical expenses for individuals or groups
135
health insurance
protection against income losses for illness or injury, disability income, and accidental death or dismemberment
136
medical insurance
coverage for specific medical expenses
137
fee for service basis
healthcare providers receive payment for actual charges after healthcare services were provided
138
prospective basis
predetermined reimbursement level
139
premiums
regular, pre-established amounts paid by private insurance holders
140
government-sponsored healthcare programs
healthcare plans that are funded and administered by the federal or state government; examples include Medicare and Medicaid
141
medicare part A
hospital insurance coverage for those meeting medicare criteria
142
Medicare part B
supplemental insurance coverage for those meeting medicare criteria
143
inpatient hospital care
care for patients who are expected to remain in the hospital for at least 24 hours or more to receive care from a physician
144
long term care
care for persons with chronic disease or disabilities
145
skilled nursing facility (SNF) care
care including rehabilitation, 24 hour nursing coverage, and physical occupational, and speech therapies
146
hospice care
an organization that's primarily designed to provide pain relief symptom management and supportive services for the terminally ill and their families
147
out of pocket expenses
expenses that aren't covered by insurance
148
managed care plan
a collection of interdependent systems that integrate the delivery of healthcare services to a specific population
149
Health Maintenance organization (HMO)
a prepaid medical service plan that provides services to plan members
150
preferred provider organizations (PPO)
represent an organization of hospitals and physicians who, for a set fee, provide services to insurance company clients
151
accountable care organizations
groups of doctors, hospitals, and healthcare providers who organize into a group to provide care to medicare patients
