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Skills Builder-MA
| Term | Definition |
|---|---|
| accessible services | Efforts to make primary care accessible by minimizing wait times to see a provider, as well as increasing office hours and after-hours access to providers using different methods (telephone, video and email). |
| capitation | A reimbursement method that pays health care providers a fixed prepayment for all necessary contracted services for each enrolled member. The capitated rate is typically paid monthly. The payment per pt remains the same, regardless of how many times a pt |
| comprehensive care | Care designed for the patients physical and mental health needs with a team-based approach. |
| coordinated care | Patient care that is coordinated across the health care system, such as any specialty care, hospitals, home health care, and community services that the patient has available or is using. |
| fee for service | Reimbursement method that pays claims based on a contracted fee schedule amount. The provider of service submits itemized claims w/ the cost determined by the provider. Adjusted amount is NOT the patient responsibility. |
| health care reimbursement | Payments received for health care services provided. |
| health coaching | Promotion of strategies aimed at improving overall health (ex: encourages a patient to begin a exercise program with the guidance of their provider). |
| managed care plans | Used by private and public insurance plans. This payment model uses administrative methods and clinical utilization review review to reduce health care costs. 3 types: HMO, PPO, POS |
| patient education | Information provided to patients specific to the needs of that patient, related to their specific disease, treatment or plan of care. |
| patient navigator | Individual that can work with the patient and providers to navigate the patient's care to help them better understand how to access and receive treatment if there are obstacles involved. Role is often filled by the medical assistant. |
| patient-centered medical home (PCMH) | A partnership between a patient and their care team in which total health is the focus, not just a single condition. A health care team consists of a provider (physician, NP, PA), CMAA, CCMA, nurses and pharmacists. |
| scope of practice | A specific set of standards that a medical professional may perform within the limits of the medical license, registration, and/or certification. |
| value-based plan | A reimbursement model also referred to as pay-for-performance. Offers incentives for providers who meet the program defined quality measures for preventive care services and management of chronic conditions. Includes cost incentives. |
| abandonment | Stopping care without providing an equally qualified substitute or not providing adequate time for a patient to find another provider. |
| abuse | Any action that potentially harms or injuries another person. |
| accreditation | Status for health care facilities that meet the standards of care and safety set forth by an agency. |
| assault | Causing another individual physical harm. |
| battery | Physical contact to another individual without their consent. |
| beneficence | A moral obligation to act in the best interest of others. |
| certification | Verification by an outside agency that an employee is following established guidelines and standards of care and providing the highest quality of care for their patients. |
| defamation of character | Hurting an individual's character or reputation by making dishonest statements regarding that individual. |
| discrimination | Biased or prejudicial treatment of individuals based on demographics (ex/ age, religion, race or sex). |
| emancipated minor | A person under 18 years of age who has legally been declared an adult by a court of law. |
| ethics | Set of principals that differentiate right and wrong. |
| justice | Fair distribution of benefit, risk, resources and cost to ensure equal treatment. |
| libel | Written, published false statements that damage an individual's reputation. |
| malfeasance | An intentional act that is wrongful and often illegal, usually resulting in high monetary penalties. |
| malpractice | Any treatment by an medical professional that does not follow the standards of care. |
| misfeasance | An act that is legal but not performed properly. |
| morals | Personal principles that guide behavior or judgement. |
| negligence | When a patient does not receive adequate and appropriate care, which leads to suffering and harm. |
| nonfeasance | A failure to act when there is a legal duty to do so, such as a provider finding a suspicious spot in a mammogram and doing nothing to further investigate or treat it, resulting in injury to the patient. |
| nonmaleficence | A commitment not to cause harm. |
| Occupational Health and Safety Administration (OSHA) | Agency that creates regulations that employers must follow for employees to remain safe while working. |
| res ipsa loquitur | "The thing that speaks for itself," meaning that the fault of the provider is obvious by their actions. |
| respondeat superior | "Let the master answer", doctrine of law that holds the employer vicariously liable for acts of an employee. |
| subpoena duces tecum | A requirement to bring requested documentation to the court of law when appearing for the summons. |
| tort | "Wrong," or a harmful act committed by one individual to another. |
| adjudication | The claims process of the payor paying or denying claims submitted after comparing them to the coverage or policy benefit requirements. |
| adjustment | A correction resulting in a credit issued. |
| after-visit summary | Information that includes follow-up appointments, provider orders, instructions, educational resources, and financial account information. |
| charge capture | Process of assigning procedure codes for claims. |
| copayment | A set amount determined by the plan/payer that the patients pays for specified services, usually office visits and emergency department visits. |
| downtime | Time when the computer system is not functional and other processes must temporarily suffice. |
| electronic medical record (EMR) | Record in a medical practice or clinic to document the patient's demographic information, care, progress and treatment. |
| electronic remittance advice (ERA) | The payer's response to the organization's claim. It includes specific details regarding billed versus allowed amounts, required contractual adjustments and patient responsibility amounts. |
| practice management program (PMP) | Software used to electronically manage administrative functions, such as scheduling appointments, integrating patient documentation from EHR's, coding, billing and revenue cycle tasks such as running aging reports and managing accounts receivable. |
| preauthorization | Approval of insurance coverage and necessity of services prior to the patient receiving them. |
| real-time adjudication (RTA) | A tool that allows for a submission of the coded visit to the insurance company by participating providers for reimbursement decisions by third-party payers while the patient is present. |
| decoding | When a receiver validates that they understand a message. |
| Erik Erikson | Psychologist who developed the concepts of stages of life based on a person's age. |
| feedback | Information relayed to the message sender regarding how the message was received and interpreted. |
| objective | Information that can be observed or measured. |
| subjective | Information gathered from what a patient communicates. |
| therapeutic communication | Interaction between a patient and a medical professional focused on improving the physical and emotional well-being of the patient. |
| clarification | Getting additional details or perspective to ensure understanding. |
| restatement | Confirmation of the information by repeating it back in your own words. |
| summarizing | Briefly describing the speakers' intention and need. |
| precertification | A request to determine if a service is covered by the patient's policy and what the reimbursement would be. |
| Referral | An order from a provider for a patient to see a specialist or to obtain specific medical services. |
| Assignment of Benefits | Gives the organization permission to directly bill the patient's insurance company for services rendered. |
| audit log | A trail of entries made in the electronic record. |
| Authorization for Disclosure | Specifies who may receive information. |
| eligibility | Coverage for services. |
| Notice of Privacy Practices | Explains how PHI is protected, used and disclosed. |
| preauthorization | An approval to render services. |
| referral | Seeking services outside the realm of the primary care provider. |
| demographic information | Record in a medical practice or clinic to document the patient's demographic information, care, progress and treatment. |
| established patients | Received same provider services within the last three years. |
| matrix | A matrix is the designed timeframe for appointments based on the method of appointment durations. |
| new patients | The initial patient appointment or the first encounter after a three-year absence from the organization. |
| batch journal | Also referred to as a daily report or day sheet. Allows for check-and-balance auditing to ensure accuracy in the amount charged and the amount received. |
| coinsurance | The percentage of the allowed amount the patient will pay once the deductible is met. |
| deductible | The amount that must be paid before benefits are paid by the insurance. |
| guarantor | The person who has agreed to take financial responsibility for the patent account. |
| accounts payable | Any financial obligations the organization must pay to operate. |
| accounts receivable | Any financial compensation the organization receives. |
| add-on codes | Codes that provide more information on services that are added to the primary procedure and cannot be billed alone. |
| aging accounts | Accounts that re delinquent due to patient nonpayment. |
| bundled codes | Codes that are grouped together when more than one procedure or service is provided. |
| concurrent care | Similar care provided by more than one physician at the same time. |
| consultation | Care provided or discussed with another physician at the request of the primary physician. |
| counseling | Part of the evaluation and management process without a complete history and physical. |
| CPT codes | Current Procedural Terminology codes that identify medical services and procedures performed by a provider. |
| CPT symbols | Symbols used within the Current Procedural Terminology manual to provide repetitive information that is needed without adding extra pages. |
| critical care | Care provided to unstable, critically ill patients with constant bedside attention needed. |
| diagnosis codes | International Classification of Disease, 10th revision, Clinical Modification (ICD-10-CM) codes based on the provider's diagnosis (why the patient is in need of medical services). |
| downcoding | Reimbursement from the insurance payer based on a code level lower than the CPT code submitted. |
| Evaluation and Management codes | Codes organized according to the place and type of service provided to the patient and further categorized by the patient status. |
| HCPCS codes | Healthcare Common Procedure Coding System codes that identify supplies and procedures not described by CPT codes. |
| medical necessity | Reasonable and appropriate services based on clinical standards per CMS and the OIG. |
| modifiers | Characters appended to CPT and HCPCS codes to describe a circumstance that code description does not include. |
| unbundling | Breaking apart a bundled code into individual CPT codes to obtain a higher reimbursement. This is an illegal and unethical practice. |
| upcoding | Coding procedures at a higher level than performed to receive higher reimbursement. This is an illegal and unethical practice. |
| acuity | Codes that identify the severity of the condition. |
| clean claim | A correctly completed standardized claim that does not have any errors and can be processed by the third-party payer. |
| edits | A notification in the PMS that a code should be reviewed. |
| laterality | Codes that identify the side of the body affected. |
| modifiers | Additional characters added on to a CPT or HCPCS code that provide additional information. |
| practice management systems (PMS) | Software used in health care facilities to manage operations. |
| adjusted | Reviewed and paid based on the insured's plan details. |
| allowed amounts | The maximum amount the payer will reimburse for each service according to the patient's policy |
| contractual adjustments | The amount of the patient's balance the provider must adjust or write off. |
| denied claims | A claim unpaid and returned by a third-party payer because of beneficiary identification errors, coding errors, a diagnosis that does not support medical necessity of the service, duplicate claim, coverage issues, or other patient coverage issues. |
| electronic remittance advice (eRA) | The electronic remittance advice is the payer’s response to the organization's claim. It includes specific details regarding billed versus allowed amounts, required contractual adjustments, and patient responsibility amounts. |
| patient responsibility amounts | The amount the patient is responsible for paying after any third-party payer. |
| body mechanics | Exercises or movements designed to improve posture and coordination and prevent injury. |
| disaster management | Process of preparing for and responding to potential disasters. |
| equipment | Items that are used for a particular purpose and used multiple times that may require regular service. |
| inventory supply log | Form that tracks the amount of inventory the office has and can be used to predict anticipated amounts needed based on the history. |
| par level or threshold | Minimum amount of inventory an office will have on the shelf before placing another order. |
| preventive maintenance | Performing regularly scheduled maintenance activities to help prevent unexpected failures. |
| quality control | System of maintaining standards in manufactured products by testing a sample against the specification. |
| supplies | Short-term, expendable assets that are consumed. |
| supply chain | A relationship between a company and its suppliers to produce and distribute a specific product to buyers. |
Created by:
Danielle Mulhern
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