Health Insurance and Reimbursement

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