Insurance and Billing

Medicare

A federal program for people 65+ years old

CMS-1500

Standard claim form used for outpatient reimbursement

Superbill

Term used for an encounter form in the physician's office

ABN

Advanced Beneficiary Notice. Form signed by Medicare patients prior to receiving covered services that may be denied by Medicare. Patients sign this and realize they may be responsible for noncovered services.

Medicaid

Federal program for low-income persons

Tricare

U.S. government health insurance plan for all military personnel

Workers Compensation

Health insurance plan providing treatment for workers injured on the job

PPO (Preferred Provider Organization)

Health insurance that makes it easier to see out-of-network doctors.

Release of Information (ROI)

A form signed by a patient or health care facility that allows for copying and releasing patient information.

Patient's Bill of Rights

A list of guarantees for those receiving medical care.

CLIA

Clinical Laboratory Improvement Amendments; the law that regulates human testing.

HIPAA (Health Insurance Portability and Accountability Act)

A federal law that sets standards for protecting the privacy of patients' health information (PHI).

Joint Commission

A not-for-profit organization that evaluates and accredits healthcare facilities.

OSHA

Occupational Safety and Health Administration.

Quality Control

The strategy for minimizing errors by managing each stage of production.

Chain of Custody

The documented and unbroken transfer of evidence.

Fraud

Wrongful or criminal deception intended to result in financial or personal gain.

Battery

Intentional unauthorized physical contact with another person.

Assault

Threat or attempt to injure another person.

Negligence

Careless neglect, often resulting in injury.

Report

A collection of writing that carries information to be shared with someone else.

Tort

A wrongful act or infringement of a right (other than under contract) leading to civil legal liability.

Invasion of Privacy

Revealing personal information about an individual without their consent.

Implied Consent

Type of consent in which a patient who is unable to give consent is treated under the legal assumption that they would want treatment.

Informed Consent

Permission given after the patient has been informed of the risks, benefits, and alternatives of a procedure.

Written Consent

Consent documented in writing explaining diagnostic findings, prescribed treatment, and expected results.

Problem-Oriented Medical Record (POMR)

Medical record consisting of a database, problem list, care plan, and progress notes.

Account Balance

The amount in an account.

Debit

Negative entry or withdrawal.

Credit

Positive entry or payment.

ICD-10-CM

International Classification of Diseases, 10th Revision, Clinical Modification; 3–7 character diagnosis codes.

ICD-10-PCS

International Classification of Diseases, 10th Revision, Procedure Coding System used for inpatient procedures.

CPT

Current Procedural Terminology; codes for medical procedures and services, five digits.

HCPCS

Healthcare Common Procedure Coding System; codes for supplies, equipment, and services not included in CPT, 5 digits.

Regular

3–10 business days.

Urgent

24 hours.

Stat

Immediately; ASAP.

NPI

National Provider Identifier.

Accounts Receivable

Money owed to a business for services provided; owed to you.

Accounts Payable

Debts owed by a business that have not yet been paid; owed by you.

Assets

Property or resources owned by a person or business.

Liabilities

Debts or financial obligations.

Preauthorization

Approval from an insurance company before certain medical services or procedures are performed to verify coverage and medical necessity.

Precertification

The process of obtaining insurance approval before certain services or procedures; verifies insurance coverage.

Adjudication

The process by which an insurance company reviews a claim, determines coverage, calculates payment, and decides patient and provider responsibility.

Allowed Amount

The maximum amount a third-party payer will pay for a particular procedure or service

Copayment

An amount of money paid by the patient at the time of medical service

Coinsurance

The policyholder and the insurance company share the cost of covered losses in a specified ratio (e.g., 80:20)

Deductible

A specific amount the patient must pay out of pocket before the insurance carrier begins paying

Explanation of Benefits (EOB)

A statement from the insurance carrier describing what services were paid, denied, or reduced in payment

Participating Provider (PAR)

A provider who agrees to write off the difference between the amount charged and the approved fee established by the insurer

Managed Care

A system of health care that provides services through a defined network of providers in return for preset payments

Direct billing

An arrangement allowing a provider to submit insurance claims directly to the insurance carrier electronically

Clearinghouse submission

A method of submitting insurance claims through specialized software that forwards claims to multiple insurance carriers

Third-party payer

An insurance company that pays health care providers for covered medical services provided to the insured patient

Usual, Customary, and Reasonable (UCR)

A method used by insurance carriers to establish provider payments based on the fees charged by similar providers in the area

Premium

The amount paid regularly (usually monthly) to an insurance company to maintain health insurance coverage

Auditing

The process of checking claims to ensure they are complete.

Reviewing

The process of checking diagnosis and procedure codes to ensure the provider is reimbursed correctly.

Unbundling

The process in which codes are separated out to bill for procedures separately.

Abstracting

The process of reviewing a patient's medical record to determine what diagnosis and procedure codes should be used for billing purposes.

Financial Obligation Form

Form where the patient promises to pay for any medical services, copays, coinsurance, or deductibles that are not covered or are denied by their insurance company.