Advance Beneficiary Notice (ABN)
A form provided to the patient when the provider believes Medicare will probably not pay for services received
Allowed Amount
The maximum amount a third-party payer will pay for a particular procedure or service
Copayment
a small fixed fee paid by the patient at the time of an office visit
Coinsurance
a provision under which both the insured and the insurer share the covered losses, typically 80:20
deductible
specific amount of money a patient must pay out of pocket before the insurance carrier begins paying
Explanation of Benefits
a form created by the insurance company to explain what charges were covered, denied, or need more documentation based on the claims submitted by the physician's office
Participating provider (PAR)
Providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer
Medicare
A federal program of health insurance for persons 65 years of age and older by Part A (hospitalization) or Part B (routine medical office visits)
Tricare
U.S. government health insurance plan for all military personnel
CHAMPVA
covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities
Medicaid
provides health insurance to the medically indigent population through a cost-sharing program between federal and state governments for those who meet specific eligibility criteria
Managed Care
is an umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals
CMS-1500 form
Standard insurance form used by all government and most commercial insurance payers.
33 blocks
divided into three section
CMS-1500 Section 1
Carrier Block: contains the address of the insurance carrier and is located at the top of the form
CMS-1500 Section 2
Patient/insured section: contains information about the patient or insured; includes boxes 1-13
CMS-1500 Section 3
Physician/Supplier Section: contains information about the physician or supplier: boxes 14-33
Supine Position
Dorsal Recumbent Position
Sims' Position
Knee-elbow position
Fowler's Position
Lithotomy Position
Epidural Injection
epidural space of the spine
Intra-arterial Injection
injection into an artery (to break up clots)
Intra-articular Injection
injection into joint space
Intradermal Injection
Skin of the upper chest, forearms, upper pack. 5-15º angle
intramuscular injection
deltoid, vastus lateralis, ventrogluteal muscles
Intraosseous Injection
Bone marrow
Intraperitoneal Injection
within the peritoneal cavity
Intrapleural Injection
pleural space (lungs)
Intrathecal Injection
Subarachnoid space (brain)
Fat soluble vitamins
A, D, E, K
Water Soluble vitamins
B1, B2, B3, B6, Folate, B12, Pantothenic acid, biotin, C.
Erikson's stages of psychosocial development
trust vs. mistrust
autonomy vs. shame and doubt
initiative vs. guilt
industry vs. inferiority
identity vs. role confusion
intimacy vs. isolation
generativity vs. stagnation
integrity vs. despair
Grief Cycle
denial, anger, bargaining, depression, acceptance
Sagittal Plane
divides body into left and right
Coronal Plane
divides body into front and back
Transverse Plane
horizontal division of the body into upper and lower portions
Right Upper Quadrant (RUQ)
Right lobe of liver, gallbladder, right kidney, portions of stomach, small and large intestine
Left Upper Quadrant (LUQ)
Left lobe of liver, stomach, pancreas, left kidney, spleen, portions of large intestine
Right Lower Quadrant (RLQ)
cecum, appendix, right ovary and tube, right ureter, right spermatic cord
Left Lower Quadrant (LLQ)
contains parts of the small and large intestines, left ovary, left fallopian tube, left ureter
Epigastric Region
located above the stomach
Umbilical Region
hypogastric region
Right Hypochondriac Region
right lateral region just below the ribs
Left Hypochondriac Region
left upper region below the rib cartilage
Right lumbar Region
right middle region near the waist
Left Lumbar Region
Right Iliac Region
Left Iliac Region
Chain of Infection
infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host
Wheezing
Difficult breathing with a high-pitched whistling or sighing sound during expiration
Rales
Crackles; wet crackling noise in lungs
Rhonchi
loud rumbling sounds heard on auscultation of bronchi obstructed by sputum
kg -> lbs
1 kg = 2.2 lbs
Trendelenburg position
Intradermal needle gauge
27-28
Intradermal Needle Length
3/8 in
Subcutaneous Needle Gauge
25-26
Subcutaneous Needle Length
1/2 to 5/8 inch
Intramuscular Needle gauge
20-23
Intramuscular Needle Length
1-3 inches
Smaller
the higher the needle gauge number, the ___ the diameter
Precertification
A process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure.
EMR
electronic medical record
suffix
word ending
prefix
a syllable or word that comes before a root word to change its meaning
Pancreas
digestion and endocrine
Thymus
endocrine and immune
Upcoding
A fraudulent practice in which provider services are billed for higher procedural codes than were actually performed, resulting in a higher payment.
Usual Fee
Fee for a service or procedure that is charged by a provider for most patients under typical circumstances.
Customary fee
fee typically charged for a service in a particular geographic area
Reasonable Fee
The generally accepted fee a physician charges for an exceptionally difficult or complicated service. A charge is considered reasonable if it is deemed acceptable after peer review even if it does not meet the criteria for a customary fee or prevailing charges.
Capitation
System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan.
Phantom Billing
Billing for services not performed
Who do you report to for Fraud?
Office of Civil Rights (OCR)
Who do you report to for unsecured HPI?
Secretary of Health and Human Services
What is the difference between eHPI and HPI? Who governs both?
HHS
U.S. Department of Health and Human Services
U.S. Department of Health and Human Services
provide essential services, including health care for low-income families, programs for older adults, and child services
CMS
Centers for Medicare and Medicaid Services
OSHA
Occupational Safety and Health Administration
Red Cross
An international organization dedicated to the medical care of the sick or wounded in wars and natural disasters
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