Insurance, Coding, & Billing Terms

private insurance

provided by a person’s employer

primary insurance

insurance that is filed first and is the main insurance for a person

premium

the amount of money that a person pays for their insurance

self-insured

individual pays for their insurance (usually people who self employed

self-pay

people who have no coverage and would be expected to pay at the time of service

government plans

special programs by state and federal government that provides insurance for the elderly, indigent and for children

co-pay

a specified sum of money based on the patient’s insurance policy benefits due at the time of service

deductibles

a specific amount of money a patient must be out of pocket before the insurance carrier begins paying for services

Explanation of benefits

provided to the patient by the insurance company as a statement that details what services were paid, denied, or reduced in payment

co-insurance

a percentage of the total cost that an individual must contribute toward each service

Advance Beneficiary Notice

a form that a medicare patient will sign when the provider thinks medicare won’t pay for a specific service or item

medicare

patient’s 65 and older

tricare

authorizes dependents of military personnel to see civilian practitioners

CHAMPVA

covers surviving spouses and dependent children of veterans who died in service related disabilities

medicaid

health insurance to the medically indigent population through a cost sharing program between federal government and states. covers women of child bearing age and children

workers compensation

a state legislative law that protects employees against the cost of medical care resulting form a work-related injury

CHIP

offers low cost health coverage for children from birth through the age 18; designed for families who earn too much to qualify medicaid, but cannot afford to buy private health coverage

group policies

offered through an individual’s employer who will usually pay a portion of the premium and then deduct the remainder of the premium from the employees pay

individual policies

offered through an individuals employer who will usually pay a portion of the premium and then deduct the remainder of the premium from the employees pay

individual policies

insurance plans that an individual funds themselves. patients might pay the entire premium themselves if they are self employed

HMO

type of health insurance plan that usually limits coverage of care from doctors who work for or contract with the HMO

PPO

a medical care arrangement in which medical professionals and facilities provide services to subscribed clients at reduced rates

Health Savings Account

a savings account that can be used to pay for medical expenses; these funds are not taxed until the time of withdrawal

flexible spending account

this account is funded with pretax dollars by an employee

electronic claims

require all same information as paper based claim, but can be processed through a direct billing system or a clearinghouse vendor to scrub

chart review

consists of collection and clinical review of medical records to ensure that payment is only for services that meet all plan coverage and medical necessity requirements

problem focused

addresses an acute or chronic condition and documents history, exam, and medical decision making related to the condition

detailed

can be for an acute or chronic condition but requires a chief complaint; documents history, exam, diagnostic procedures, laboratory reports and can even conclude for planning in-office procedures

comprehensive history

includes evaluation and/or annual exam, addresses and assesses immediate needs and prepares patients to address any problems before they come up

referral

a document or form required by insurance companies that is used when a provider wants to send a patient to a specialist

participating provider

the provider and the insurance company have agreed between the amounts charged and approved and what will and will not be reimbursed

account balance

the total amount owed on an account

debit

an amount owed

accounts receivable

money owed to the provider

accounts payable

debits incurred and not yet paid

credit

a monetary balance in an individual’s favor

assets

the entire saleable property of a person, association, corporation or estate applicable or subject to the payments of debts

liabilities

amounts owed; debt

spreadsheets

used for reporting and the entering of information and the tracking of patient date, inventory and even personnel functions

network

a group of two or more computer systems that are connected together; you must take caution when accessing information from outside sources

microsoft word, excel, powerpoint and outlook

word processing programs that are commonly used to create and modify documents

data fields

a location where data is stored within a computer system

electronic medical record

there is a digital chart that is used in the facility

electronic health record

this includes the EMR and other information to be used between more than one facility