Genetic Counseling, Insurance, and Medical Billing

This set of vocabulary flashcards covers essential insurance terminology, payor types, billing models, and the roles of genetic counselors in managing healthcare resources.

Premium

The cost for a particular policy, often paid in part by an employer, that functions as a 'subscription' for health coverage.

Deductible

The financial responsibility of members before their insurance plan starts contributing; this amount restarts every calendar year.

Max Out-of-Pocket

The maximum financial responsibility of a member for the calendar year, after which insurance covers medically necessary costs at $100\%$.

Medicaid

A government payory for low-income adults and children, pregnant and postpartum women, the elderly, and individuals with disabilities; it is funded jointly by state and federal programs.

Medicare

A federally funded and administered program for persons over age $65$ and individuals under $65$ with certain disabilities or health concerns.

Tricare

A federally funded payor for active-duty and reserve members, retirees, and their families.

Fully Insured

A commercial payor type where the insurance company takes the risk and groups are pooled so that risk is shared across all members.

Self-Insured

A commercial payor type where the employer or group takes the risk and benefits are administered through an Administrative Service Only (ASO) agreement.

Analytic Validity

A measure of how well a test predicts the presence or absence of a particular genetic change; it answers if the test works in the lab.

Clinical Validity

A measure of how well a genetic change relates to the presence, absence, or risk of a specific disease; it answers if the test works in the clinic for the target population.

Clinical Utility

A measure of how well a test informs the treatment, management, or prevention of disease; it addresses the 'so what?' of the testing.

Insurance/Third-Party Billing

A model where claims are sent to a payor for adjudication, with benefits based on available resources, medical necessity, and group eligibility.

Institutional/Client Billing

A model where claims are sent to the ordering practice, which may then bill the patient or insurance; sometimes involves health plans paying a flat rate per member per month.

Inpatient Billing

A model where all services are rolled into a daily maximum charge for rendered care, rather than being billed as individual fees.

CPT Codes

Current Procedural Terminology codes that explain 'what you did' (e.g., 96040 for genetic counseling).

ICD-10 Codes

Diagnosis codes used to explain 'why you did it' or why a service is medically indicated (e.g., C50 for breast cancer).

Fraud

The purposeful misrepresentation of provided services for personal gain.

Waste

The performance of unnecessary or inappropriate medical procedures.

Abuse

Taking advantage of a covered service beyond what is medically indicated.

Utilization Management

A role for genetic counselors in managed care involving the processing of authorizations and appeals.