nha exam ccma : insurance and codes

third-party payer

health plan (insurance companies)

first party payer

patient

second party payer

healthcare provider

deductible

amount of money a pt must pay out of pocket before insurance begins paying (ex: $1000, once pt reaches 1k, then insurance company will start paying)

copayment

set amount of money paid at the time of service before services rendered

coinsurance

policyholder and insure company share cost of services; 80:20

assignment of benefits

form signed by patient to allow the provider to be paid directly by the insurance company (pt takes step pack)

participating provider

providers that agree to write off the diff. between that amount charged and the allowed amount by the insurance company

allowed amount

max amount insurance company pays for a service/pdt

ex: 1500 MRI (amt charged by provider to insurance), allowed amt = 1000 so insurance company pays 1000 and provider writes of 500

advanced beneficiary notice

form provided to patient when the provider believes medicare will not cover services. pt would be responsible for payments not covered by medicare

explanation of benefits

statement from insurance company outlining amount billed, amounts allowed, amounts applied to deductible, coinsurance, copays

preauthorization

the process of contacting the insurance plan to see if a procedure is covered under pt's insurance plan

govt health plans

medicare: covers pts 65+

- PART A: hospitalization

- PART B: routine med office visits and outpatient services

- PART C: optional additional coverage offered by priv companies

- PART D: medications

medicaid

offered to low income and mentally indigent through cost sharing (government)

tricare

covers active military personnel and dependants

CHAMPVA

covers surviving spouses and dependent children of veterans who have died under service

CHIP

provides lowcost health coverage to children in families that earn too much to qualify for medicaid

workers compensation

work related injuries, pt doesn't pay any fees

managed care health plans

provides healthcare for payments through a network of providers and hospitals (using participating providers)

HMO

contracts w providers and hospitals to provide preventative and acute care (less than ppo)

- requires referrals for specialists

- needs preauthorization

- need pcp

PPO

more flexible

- no referral

- in-network providers (cost less)

- out-of-network

fee-for-service

amt charged controlled by physician

amt paid controlled by insurance

pay-for-performance

compensates providers only if certain measures met for quality/efficiency

capitation

assigned a per member per month payment based on age, race, sex, lifestyle, med history

insurance claim

request for coverage or compensation for expenses related to a covered event, such as an accident, illness, or damage to property. The insurance provider evaluates the claim and provides compensation if it is covered under the policy

insurance claims process

physician's office involves obtaining patient information, verifying insurance coverage, delivering services, and preparing and submitting healthcare claims.

coordination of benefits

prevents duplication of payment

- primary insurance pays first

- second plan pays the deductible and copayment after the primary insurance has processed claim

bday rule

determines primary insurance

- person born earliest in year

CMS 1500 form

the standard form used by health-care providers to bill for services, including disease state management services

account balance

total balance

- debit = negative (charges)

- credit = positive (payments)

accounts receivable

money owed to the provider to the provider for services rendered

accounts payable

debt incurred but not paid; supplies/utilities

guarantor

a person who agrees to pay a debt if the primary debtor does not

international classification of diseases (ICD 10)

maintained by WHO to track morbidity and mortality rates

- translates pt diagnoses into codes

- 3-7 characters

- first: alphabetical

- 2/3 = numeric

- 4/7 = alphabetical or numeric

- need chief complaint, ROS, pt exam, proper documentation

tabular list

diagnosis codes organized in numerical order -- final code

CPT (current procedural terminology)

used to document procedures and services in outpt settings

5 digit numerical

explains what services were provided

- code MUST link w diagnosis

modifiers

help further describe procedure code w/o changing definition

E/M codes

evaluation and management codes

- use of CPT codes range from 99202 to 99499

CPT/HCPCS

healthcare common procedure coding

- level ii codes designed to represent non physician services

downcoding

reimbursement on lower code level than submitted

- lack of documentation

upcoding

reimbursement on a higher code level than submitted

- fraudulent

NPI

unique ID numbers for covered health care providers