Vocab

Question 1

define ACCEPT ASSIGNMENT

Answer 1

provider agrees to accept insurer’s payment as payment in full for services provided

Question 2

define ADVANCE BENEFICIARY NOTICE (ABN)

Answer 2

doc used to notify Medicare beneficiary that is either unlikely Medicare will pay/certain Medicare will not pay for service

Question 3

define AFFORDABLE CARE ACT (ACA)

Answer 3

law signed by Obama in 2010 to lower costs, expand Medicaid, and make insurance more accessible

Question 4

define ALLOWED AMOUNT

Answer 4

max amount insurer will pay for any service

Question 5

define ASSINMENT OF BENEFITS

Answer 5

authorization by signature of pt for payment to be made directly by insurance to provider for insurance

Question 6

define BENEFICIARY

Answer 6

person entitled to benefits of insurance policy (generally Medicare)

Question 7

define BIRTHDAY RULE

Answer 7

way to identify primary responsibility in insurance coverage when kids are covered by more than 1 parent; primary coverage is parent with earlier birthday

Question 8

define CAPITATION

Answer 8

provider paid fixed amount per member per month for each pt who is member of particular insurance organization regardless of whether services were provided

Question 9

define CARRIER

Answer 9

company that sells insurance

Question 10

define CMS-1500

Answer 10

standard claim form designated by Centers for Medicare & Medicaid services to bill third party/Medicare FFS

Question 11

define COINSURANCE

Answer 11

percent pt is responsible for paying for each service after deductible has been met

Question 12

define CONVERSION FACTOR

Answer 12

dollar amount that coverts RVUs into fee

Question 13

define COORDINATION OF BENEFITS (COB)

Answer 13

aka dual coverage; when both spouses have insurance, policy provision limits to 1 insurer being primary & no more than 100% of cost covered to avoid duplication of payment

Question 14

define COPAYMENT

Answer 14

specified amount insured must pay toward charge for services

Question 15

define DEDUCTIBLE

Answer 15

amount to be paid before insurance will pay

Question 16

define DEPENDENT

Answer 16

person covered under subscriber’s insurance policy

Question 17

define DIAGNOSIS-RELATED GROUPS (DRGs)

Answer 17

method of determining reimbursement from medical insurance according to diagnosis on prospective basis

Question 18

define EXCLUSIVE PROVIDER ORGANIZATION (EPO)

Answer 18

like HMOs where pt must use provider network & no partial coverage for out of network care

Question 19

define EXPLANATION OF BENEFITS (EOB)

Answer 19

printed description of benefits provided by insurer to beneficiary; explanation to pt about how insurance claim from provider was paid on their behalf

Question 20

define FEE-FOR-SERVICE (FFS)

Answer 20

payment for each service provided, individual can choose to pay high premiums for flexibility of providers

Question 21

define FLEXIBLE SPENDING ARRANGEMENT (FSA)

Answer 21

aka: cafeteria plan; use it or lose it plan where pretax funds from employee/sometimes employer set aside for use in payment of medical services & supplies not covered by insurance and only able to be used for qualified expenses

Question 22

aka: FSA

Answer 22

cafeteria plan

Question 23

what are qualified expenses according to FSA

Answer 23

expenses specified in plan that would generally qualify for medical & dental expenses deduction explained in IRS publication 502

Question 24

define GATEKEEPER

Answer 24

PCP who coordinates pt referrals & hospital admissions

Question 25

define GEOGRAPHIC PRACTICE COST INDEX (GPC)

Answer 25

index/number multiplied to each of RSRVS components to adjust for geographical cost differences to generate different payment amounts depending on provider's practice, urban/suburban area, state/part of state, etc

Question 26

define HEALTH MAINTENANCE ORGANIZATIONS (HMOs)

Answer 26

type of managed care operation group insurance entitling members to services provided by participating hospitals, clinics, & providers

Question 27

define HEALTH REIMBURSEMENT ARRANGEMENT (HSA)

Answer 27

pays for medical expenses and can be paired w/standard or high deductible plan; only employer can contribute

Question 28

define HEALTH SAVINGS ACCOUNT (HSA)

Answer 28

tax-sheltered savings account w/contributions from employer & employee which can be used to pay for medical expenses

Question 29

define INDEMNITY-TYPE INSURANCE

Answer 29

insurance w/least amount of structural guidelines for pts to follow, pts able to see provider of choice w/o having to deal with network or other managed care guidelines

Question 30

define INDEPENDENT PRACTICE ASSOCIATIONS (IPA)

Answer 30

association of independent physicians/other organizations that contracts independent physicians in their own office w/own staff & provides services to managed care organizations on negotiated per capita rate/flat retrainer fee/negotiated fee-for-service basis

Question 31

aka: independent practice associations

Answer 31

individual practice associations

Question 32

define MEDICARE

Answer 32

federal program for providing health care coverage for individuals over age of 65 or disabled

Question 33

define MEDICARE ADVANTAGE

Answer 33

part C segment of Medicare that enables beneficiaries to select managed care plan as primary coverage

Question 34

define MEDICAID

Answer 34

joint funding program by federal & state (except AZ) governments for medical care of low income pts on public assistance

Question 35

define MEDIGAP

Answer 35

private insurance to supplement medicare benefits for payment of deductible, copay, & coinsurance

Question 36

define PREAUTHORIZATION

Answer 36

prior approval of insurance coverage & necessity of procedure

Question 37

define PRECERTIFICATION

Answer 37

obtaining plan approval for services prior to pt receiving them under pt's insurance contract

Question 38

define PREDETERMINATION

Answer 38

refers to discovery of max amount of money carrier will pay for primary surgery, consultation service, post-op care, etc

Question 39

define PREFERRED PROVIDER ORGANIZATION (PPO)

Answer 39

organization of physicians who network together to offer discounts to purchasers of healthcare insurance

Question 40

define PRIMARY

Answer 40

occurring 1st in time

Question 41

define QUALITY ASSURANCE

Answer 41

inclusive policies, procedures, & practices as standards for reliable lab results including documentation, calibration, maintenance of all equipment, quality control, proficiency testing, & training

Question 42

define SECONDARY

Answer 42

one step removed from first

Question 43

define SUBSCRIBER

Answer 43

person who has been insured (insured policyholder)

Question 44

define THIRD-PARTY REIMBURSEMENT

Answer 44

indicates payment of services rendered by someone other than pt (gen. fed & state agencies, insurance companies, & worker's comp)

Question 45

define THIRD-PARTY LIABILITY (TPL)

Answer 45

refers to legal obligation of 3rd parties (eg. certain individuals/entities/insurers/programs) to pay part/all expenditures for medical assistance furnished under state plan

Question 46

define TRIC ARE FOR LIFE

Answer 46

medicare wraparound coverage for tri-care eligible beneficiaries who have Medicare part a & B

Question 47

define UTILIZATION MANAGEMENT (REVIEW)

Answer 47

includes preauthorization, precertification, predetermination, concurrent review, & discharge planning

Question 48

define WAIVERS

Answer 48

document outlining services not covered by insurance & cost associated w/services. signature means pt understands & will pay out of pocket