Legal Issues 2

Define the term allowable charge?

This is the dollar amount considered by a health insurance company to be a reasonable charge for medical services or supplies based on the rates in your area.

Define the term beneficiary?

The person, people, or entity designated to receive the death benefits from a life insurance policy or annuity contract

Define the term coinsurance?

The amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.

Define the term copayment?

One of the ways you share in your medical costs. You pay a flat fee for certain medical expenses (e.g., $10 for every visit to the doctor), while your insurance company pays the rest.

Define the term claim?

A form sent to the insurance company requesting payment for covered medical expenses

Define the term customary fees?

The average fee charged for a specified service or procedure in a defined geographical area

Define the term deductible?

The amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.

Define the term dependent?

Any individual, either spouse or child, that is covered by the primary insured member's plan.

Define the term exclusion?

Any specific situation, condition, or treatment that a health insurance plan does not cover.

Define the term explanation of benefits?

The health insurance company's written explanation of how a medical claim was paid. It contains detailed information about what the company paid and what portion of the costs you are responsible for.

Define the term health maintenance organization (HMO)?

A health care financing and delivery system that provides comprehensive health care services for enrollees in a particular geographic area. HMOs require the use of specific, in-network plan providers.

Define the term health savings account (HSA)?

A personal savings account that allows participants to pay for medical expenses with pre-tax dollars. HSAs are designed to complement a special type of health insurance called an HSA-qualified high-deductible health plan (HDHP). HDHPs typically offer lower monthly premiums than traditional health plans. With an HSA-qualified HDHP, members can take the money they save on premiums and invest it in the HSA to pay for future qualified medical expenses.

Define the term In-network provider (in panel)?

A health care professional, hospital, or pharmacy that is part of a health plan's network of preferred providers. You will generally pay less for services received from in-network providers because they have negotiated a discount for their services in exchange for the insurance company sending more patients their way.

Define the term Medicaid?

A health insurance program created in 1965 that provides health benefits to low-income individuals who cannot afford Medicare or other commercial plans. Medicaid is funded by the federal and state governments, and managed by the states.

Define the term Medicare?

The federal health insurance program that provides health benefits to Americans age 65 and older. Signed into law on July 30, 1965, the program was first available to beneficiaries on July 1, 1966 and later expanded to include disabled people under 65 and people with certain medical conditions. Medicare has two parts; Part A, which covers hospital services, and Part B, which covers doctor services, part C which gives choice of healthcare plans, and part D which is the prescription plan .

Define the term network (panel)?

The group of doctors, hospitals, and other health care providers that insurance companies contract with to provide services at discounted rates. You will generally pay less for services received from providers in your network.

Define the term out-of-network provider?

A health care professional, hospital, or pharmacy that is not part of a health plan's network of preferred providers. You will generally pay more for services received from out-of-network providers.

Define the term out-of-pocket maximum?

The most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year.

Define the term preferred provider organization (PPO)?

A health insurance plan that offers greater freedom of choice than HMO (health maintenance organization) plans. Members of PPOs are free to receive care from both in-network or out-of-network (non-preferred) providers, but will receive the highest level of benefits when they use providers inside the network.

Define the term premium?

The amount you or your employer pays each month in exchange for insurance coverage.

Define the term provider?

Any person (i.e., doctor, nurse, dentist) or institution (i.e., hospital or clinic) that provides medical care.

Define the term third-party administrator?

Is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity.[1] This can be viewed as "outsourcing" the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the insurance or the company itself. Often, in the case of insurance claims, a TPA handles the claims processing for an employer that self-insures its employees. Thus, the employer is acting as an insurance company and underwrites the risk.

Define the term Affordable Care Act (Obamacare)?

The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name "Affordable Care Act" is used to refer to the final, amended version of the law.

Identify new benefits, rights, and protections offered under Obamacare

Letting young adults stay on their parents' plan until 26

Stopping insurance companies from denying you coverage or charging you more based on health status

Stopping insurance companies from dropping you when you are sick or if you make an honest mistake on your application

Preventing gender discrimination

Stopping insurance companies from imposing unjustified rate hikes

Doing away with life-time and annual dollar limits

Giving you the right to a rapid appeal of insurance company decisions

Expanding coverage to tens of millions by subsidizing health insurance costs through the Health Insurance Marketplaces (HealthCare.Gov and the state-run Marketplaces)

Expanding Medicaid to millions in states that chose to expand the program

Providing tax breaks to small businesses for offering health insurance to their employees

Requiring large businesses to insure employees

Requiring all insurers to cover people with pre-existing conditions

Making CHIP easier for kids to get

Improving Medicare for seniors

Ensuring all plans cover minimum benefits like limits on cost sharing and ten essential benefits including free preventive care, OB-GYN services with no referrals, free birth control, and coverage for emergency room visits out-of-network.

Define the term accident insurance?

Low cost plan to cover unfortunate happenings that take place on private property or in workplace. Protects against financial loss from medical and hospital bills and provides for additional protection for institution above regular policy

Define the term professional Liability Insurance?

A supplemental policy that covers the insured against claims of negligence

Define the term litigious?

Inclined to dispute or disagree; argumentative. Prone to go to law to settle disputes

Define the term International Classification of Diseases (ICD-10) code?

A 5 digit code that specifies injury/condition that is being treated

Define the term Current Procedural Terminology (CPT) code?

A 5 digit code what treatment is being provided

Define the term National Provider Identifier (NPI)?

Government issued identification number for individual health care providers and organizations

- Initial evaluation, including plan of treatment and goals

- Appropriate Pt medical Hx

- Pt examination results

- Functional assessment

- Type of Tx and body parts to be treated

- Expected frequency and # of Tx's

- Prognosis

- Functional, measurable, and time-based goals

- Precautions and contraindications

- A statement that the Tx plan and goals were discussed and understood by the Pt and/or guardian

- Daily Tx records

- A record of changes in physical status, physician orders or TX plans or goals

- Weekly progress notes, especially on goals

- Copy of notes to or from the referring Dr.

- A Rx or other state-mandated documentation from a Dr.

List 15 focus points about documentation that a healthcare provider should use when billing for and receiving reimbursements?