CHAP 7 MAA

insured

The person who takes out the insurance policy; purchases an insurance policy from a company or arrange coverage

premium

The rate charged to the policyholder for the insurance policy; usually paid on a regular basis.

Third-Party Payer

in the case of a policy with an insurance company, in which the insurance company agrees to carry the risk of paying for those services; entity other than patient or provider that pay on behalf of the patient.

Coordination of Benefits

If a patient has two or more insurances policies, not all of them should pay 100% percent of the insurance so one insurance carrier is named the primary. This coordinates how much different insurance carriers will pay if more than one applies to the claim.

Birthday Rule

If both parents have insurance over a child, the insurance of the oldest parent / earlier birthday is used.

Fee for Service

made by insurance carrier after the patient has received medical services

Capitation

payment made in advance

Indemnity Plans

under most, the insurance company reimburses medical costs on a fee-for-service basis. Conditions before reimbursement is made: 1. Policy premium payment is up-to-date 2. Deductible is paid 3. Coinsurance has been taken into account

Managed Care Plans

health insurance structure types

Health Maintenance Organizations (HMOs)

attempt to control costs by: restricting patients’ choice of providers, requiting cost sharing, requiring pre-authorization/pre-certification for services, controlling access to services.

Preferred Provider Organizations (PPOs)

contracts to perform services for PPO members at specified rates; generally lower fee charged to regular patients; gives the insured a list of PPO providers from which to receive healthcare at PPO rates

Point of Services (POS)

combinations of HMO and PPO

Consumer-Driven Health Plans (CDHP)

has a higher deductible but lower monthly premium; lets consumers use pre-tax dollars from a savings account to pay for qualified healthcare

Flexible Spending Account (FSA)

Pre-tax monies are deposited into a FSA account to be used for eligible medical expenses; “use-or-lose” account

Health Reimbursement Account (HRA)

Life FSA except any monies remaining at the end of the coverage period can roller over and accumulate; only employers contribute to the HRA

Health savings Account (HSA)

Similar to HRA except that any taxpayer (not just employer) can contribute to the HSA

Accountable Care Organization (ACOs)

brings together a network of providers to provide patient care while minimizing unnecessary spending; Providers within ACO coordinate patient care and eliminate duplicated procedures and medication; members share in financial savings by the insurance plan if they can show evidence of meeting quality measurement standards.

Medicare + ABCD

federal health plan that provides insurance to citizens 65+, disabilities, and spouses of entitled individuals. A. Hospital Insurance B. Medical Insurance C. Medicare Advantage D. Prescription Drug Coverage

TRICARE (formerly CHAMPUS)

The Department of Defense’s health insurance plan for military personnel and their families.

CHAMPVA

government health insurance program covering the expenses of the families of veterans with total, permanent, service-connected disabilities.

Participating (PAR) Provider

a physician who joins an insurance plan is a participating (PAR) provider in that plan; agrees to the insurance plan members according to the plans rules and payment schedules

Nonparticipating (nonPAR) Provider

a physician that chooses not to join a particular insurance plan; doesn't have to obey the rules or follow the payment schedule of that plan but also don’t receive any benefits of participation;

Fee Schdeule

contracts that set fees negotiated between insurance companies and physician. In Medicare the Centers for Medicare and Medicaid Services is responsible for setting up the terms of the plan, referred as Medicare Fee Schedule (MFS)

Diagnostic Coding

codes for reporting what is wrong with the patient or what brought the patient to see the physician. ICD-10

Procedural Coding

codes for reporting each procedure and service the physician peformed in treating the patient. CPT Codes

Current Procedural Terminology (CPT)

codes used for procedures

Tabular List

ICD-10 Code listed alphanumeric-ly of all diseases and injuries organized by body systems or conditions