Untitled Flashcards Set

Utilization review (UR)

An analysis to ensure services and procedures billed to a third-party payer are medically necessary.

Third-party administrator (TPA)

An administrator who processes claims for insurance.

Guarantor

The person responsible for paying the patient's medical bill.

Dependent

Spouse, children, or other individuals covered under a health care plan.

Group insurance

Insurance most commonly purchased through an employer, where the employer may pay part of the premium.

Individual insurance

A policy purchased by a person who agrees to pay the entire premium for health coverage.

Affordable Care Act (ACA)

Legislation that opened up more options for individuals to purchase insurance through a healthcare marketplace.

Health Care Savings Account (HSA)

Allows employees to save money through payroll deduction.

Fee-for-service

A type of insurance where providers are paid based on the services they provide.

Managed care

Controls costs by requiring physicians to adhere to specific rules for payment.

Health Maintenance Organization (HMO)

A managed care plan that focuses on preventive care and requires patients to choose a primary care physician.

Preferred Provider Organization (PPO)

A managed care plan that contracts with healthcare agencies to provide care at reduced rates without requiring referrals.

Exclusive Provider Organization (EPO)

Combines features of HMO and PPO, where out-of-network visits are not reimbursed.

Point of Service (POS)

Allows patients to choose a primary care physician and visit out-of-network specialists at a higher cost.

Accountable Care Organizations (ACOs)

Groups of providers coordinating care for patients to reduce unnecessary healthcare costs.

Medicaid

A public program for low-income individuals, funded by federal and state governments.

Children's Health Insurance Program (CHIP)

A low-cost insurance program for children in families with income too high for Medicaid.

Medicare

A federal program for people age 65 and older, and for younger individuals with disabilities.

Coordination of benefits (COB)

The process of coordinating policies for patients with multiple insurances.

Explanation of Benefits (EOB)

A statement that outlines the services paid by insurance.

Contractual adjustment

The difference between the amount billed and the maximum allowable charge.

Advance Beneficiary Notice of Noncoverage (ABN)

A notice given to a patient advising that Medicare may not cover certain services.

Referral

Authorization from a medical practice for a patient to receive specialized services.

UBO4

Form used for inpatient admissions and long-term care.

CMS 1500

Universal claim form used for outpatient services.

International Classification of Diseases (ICD-10)

The system used to classify patients' diagnoses or reasons for visits.

Current Procedural Terminology (CPT) codes

Codes that represent the procedures performed in response to a physician's diagnosis.

Downcoding

When a procedural code is reduced to its most basic form due to vagueness.

Electronic Medical Record (EMR)

A digital record limited to one practice.

Electronic Health Record (EHR)

A digital record that can be shared across multiple healthcare organizations.

Chief complaint

The main symptom or cause that brings the patient to see the doctor.

Safety Data Sheet (SDS)

Describes how to handle hazardous chemicals safely.