Studied by 51 PeopleAdvance beneficiary notice (ABN)
Tags & Description
Advance beneficiary notice (ABN)
Form that is signed by a patient that she understands that Medicare will probably deny payment for a procedure. Patient understands that she will be responsible for the bill.
balance billing
patient will be responsible for paying what is left on the bill after insurance pays
assignment of benefits
Provider accepts what the insurance will pay for the procedure. If there is anything left on the bill after insurance payment, the provider is not allowed to send the balance bill to the patient.
capitation
managed care plan that pays certain amount to provider over time for caring for pt
Co-insurance
Requires the insured individual to pay a fixed percentage of the loss after the deductible has been paid. Usually insurance pays 80%, patient pays 20%
coordination of benefits
order in which multiple insurance companies pay (prevents double payments)
copayment/copay
pre-determined amount set by the insurance company that you pay for a service (example: $35 to see a doctor, $60 to be seen in an urgent care center)
deductible
amount pt pays before insurance begins paying
Current Procedural Terminology (CPT) codes
used to designate procedures and tests
dependent
spouse or children under insurance plan
diagnosis related groups (DRGs)
Groups of procedures or tests related directly to a diagnosis.
eligibility
pt meets the qualifications to be covered by the insurance
explanation of benefits (EOB)
describes the services billed and includes a breakdown of how the payment is determined (sent to pt)
health care savings account (HSA)
a benefit offered by some employers that allows employees to save money through payroll deduction to accounts that can only be used for medical care
independent practice association (IPA)
independent physicians contracted with health maintenance organization to provide services to members
Health Maintenance Organization (HMO)
insurance method that focuses on prevention of disease, must see providers from an approved list
Medicare
federally funded insurance for people 65+ or disabled
Medicare Part A
The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care.
Medicare Part B
The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.
Medicaid
A federal and state assistance program that pays for health care services for people who cannot afford them.
Medi-Medi claim
beneficiary with Medicare primary and Medicaid as secondary payment. AKA a crossover payment
medicare administrative contractors (MACs)
process claims from providers for services rendered for medicare beneficiary
pre-existing condition
medical problems existing before insurance plan's effective date
primary and secondary coverage
claim submitted to one insurance company and the balance submitted to a second insurance company
Centers for Medicare and Medicaid Services (CMS)
division of US Dept of Health and Human Services that regulates Medicare and Medicaid. Provides the standard language for services provided. (everyone uses same definition of a "simple" exam)
remittance advice (RA)
an explanation of benefits transmitted electronically by the insurance company to a provider to explain how much will be paid and why some parts of the claim are denied
usual, customary, reasonable (UCR)
usual cost of similar services in area
utilization review (UR)
determining whether the medical care provided to a patient is necessary according to preestablished criteria
International Classification of Diseases (ICD-10)
numeric codes to describe injuries, conditions, or diseases
nonsufficient funds (NSF)
a check's bank account did not contain enough money to cover the amount written on a check.
collections
The process of using all legal resources available to collect payment for past due patient account balances.
credit
record of a payment recieved; balance in one's favor on an account.
denial
insurance company says they will not pay for a claim
Advance beneficiary notice (ABN)
medicare may not cover certain services, pt responsible for bill
assignment of benefits
transfer pt legal rights to the provider to collect insurance $ / insurance payment for services will go straight to the provider instead of the patient
balance billing
billing patient for total, or total after insurance has paid their portion
capitation
managed care plan that pays certain amount to provider over time for caring for pt
coinsurance
agreed amount paid to provider by policy holder. Usually a percentage split such as 80/20 or 70/30
coordination of benefits
order in which multiple insurance companies pay (prevents double payments)
copayment/copay
A set amount of a medical cost that the patient pays. Patients may pay $45 for their office visit each time they go.
crossover claim
crosses over automatically from 1 coverage to another payment
current procedural terminology (CPT codes)
codes used by physicians to define services provided to the patient
deductible
amount pt pays before insurance begins paying
dependent
spouse or children under insurance plan
diagnosis related groups (DRGs)
categories used to determine reimbursements for medicare pt inpatient services
eligibility
pt meets the qualifications to be covered by the insurance
explanation of benefits (EOB)
statement that accompanies payment, includes date and services paid for
health care savings account (HSA)
offered by employer, take some money out of paycheck for medical use
independent practice association (IPA)
independent physicians contracted with health maintenance organization to provide services to members
Health Maintenance Organization (HMO)
wide range of services through contract with specific group at predetermined rates
healthcare common procedure coding
assigns alphabetic and numeric code to services and items
medicare
federally funded insurance for people 65+ or disabled
medicare A
Portion of Medicare that deals with hospital expenses
medicare B
physician fees, test, some immunization
medicaid
Federal and State funded for people with low incomes.
medi-medi claim
beneficiary with Medicare primary and medicaid as secondary payment. AKA crossover claim
medicare administrative contractors (MACs)
process claims from providers for services rendered for medicare beneficiary
pre-existing condition
medical problems existing before insurance plan's effective date
primary and secondary coverage
primary-1st company that is sent the claim. secondary-bill remainder of charges
centers for medicare and medicaid services (CMS)
mandate use of panels defined by AMA for national standardization of testing
plan maximum
highest amount paid by insurance
preferred provider organization (PPO)
contract with preferred healthcare provider
remittance advice (RA)
medicare administration contract showing payments/ explaining reimbursment
usual, customary, reasonable (UCR)
usual cost of similar services in area
utilization review (UR)
checks cases to make sure bill were medically necessary
coding
assignment of a number to verbal statement or description
nonsufficient funds (NSF)
no money, hot checks
collections
acquiring funds that are due
credit
record of a payment recieved; balance in one's favor on an account.
debit
a charge owed on an account
day sheet/ daily journal
a daily record listing all financial transactions and/or patients seen
denial
insurance company says they will not pay