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Billing and Coding
Chapter 1 Terms
| Term | Definition |
|---|---|
| Accounts payable | The practice’s operating expenses, such as for overhead, salaries, supplies, and insurance. |
| Accounts Receivable | Monies owed to a medical practice by patients and third-party payers |
| Adjudication | the process followed by health plans to examine claims and determine benefits |
| Benefits | Payments for covered medical services for a specific period of time |
| Capitation | A fixed prepayment to a medical provider for all necessary contracted services provided to each patient who is a plan member. |
| Cash flow | The movement of money into or out of a business. |
| Certification | The process of earning a credential through a combination of education and experience followed by successful performance on a National Examination. |
| Coinsurance | The payer pays 80% of the covered amount and the patient pays 20% after the premiums and deductibles are paid. |
| Compliance | means actions that satisfy official requirements. In the area of coding, compliance involves following official guidelines when codes are assigned. |
| Consumer-Driven Health Plan (CDHP) | a type of medical insurance that combines a high deductible health plan with a medical savings plan that covers some out of pocket expenses. |
| copayment | an amount that a health plan requires a beneficiary to pay at the time of services for each health care encounter |
| Covered Services | Medical procedures and treatments that are included as benefits under an insured health plan |
| Deductible | the amount the insured pays on covered services before benefits begin must be met by insurance |
| Diagnosis Code | the number assigned to a diagnosis in the International Classification of Diseases. |
| Electronic Health Record (EHR) | a computerized life long health care record for individual that incorporates data from all sources that provide treatment for the individual. |
| Ethics | standards of behavior requiring truthfulness, honesty, and integrity |
| Etiquette | standards of professional behavior |
| Excluded Services | a service specified in a medical insurance contract that is not covered. |
| Fee-for-Service | a payment method based on provider charges |
| Healthcare Claim | an electronic transaction or a paper document filed with a health plan to receive payment |
| Health information Technology (HIT) | computer hardware and software information systems that record, store, and manage patient information |
| Health Maintenance Organization (HMO) | a managed healthcare system at which providers agree to offer health care to the organizations members for a fixed periodic payments from the plan. Usually members much received Medical services from the plans providers. |
| Health Plan | Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care; (an insurance company) |
| Indemnity Plan | the type of medical insurance that reimburses a policy holder for medical services under the term of its schedule of benefits. |
| Managed Care | System that combines the financing and the delivery of appropriate, cost-effective healthcare services to its members. |
| Managed Care Organization (MCO) | Organization offering some type of managed healthcare plan. |
| Medical Coder | Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records |
| Medical Insurance | a written policy stating the terms of an agreement between a policy holder and a health plan |
| Medical Insurance Specialist | medical office administrator staff member who handles billing, checks insurance and processes payment |
| Medical Necessity | payment criterion that requires medical treatments to be clinically appropriate provided in accordance with generally accepted standards of medical practice |
| Network | a group of healthcare providers including physicians and hospitals who sign a contract with a health plan to provide services to plan members. |
| Noncovered Services | medical procedures that are not included in a plan's benefits |
| Out-of-pocket | Description of the expenses the insured must pay before benefits begin. |
| Participation | Contractual agreement by a provider to provide medical services to a payer’s policyholders. |
| Patient ledger | Record of all charges, payments, and adjustments made on a particular patient’s account. |
| Payer | Health plan or program. |
| Per Member Per Month (PMPM) | Periodic capitated prospective payment to a provider who covers only services listed on the schedule of benefits. |
| PM/EHR | A software program that combines both a PMP and an EHR into a single product. |
| policy holder | Person who buys an insurance plan. |
| Practice Management Program (PMP) | Business software designed to organize and store a medical practice’s financial information; often includes scheduling, billing, and electronic medical records features. |
| Preauthorization | Prior authorization from a payer for services to be provided; if preauthorization is not received, the charge is usually not covered. |
| Preferred Provider Organization (PPO) | Managed care organization structured as a network of healthcare providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge. |
| Premium | Money the insured pays to a health plan for a healthcare policy. |
| Preventive Medical Services | Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests. |
| Primary Care Physician (PCP) | A physician in a health maintenance organization who directs all aspects of a patient’s care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper. |
| Procedure Code | Code that identifies medical treatment or diagnostic services. |
| Professionalism | For a medical insurance specialist, the quality of always acting for the good of the public and the medical practice being served. This includes acting with honor and integrity, being motivated to do one’s best, and maintaining a professional image. |
| Provider | Person/entity that supplies medical or health services and bills for the services in the normal course of business. They may be a professional member of the healthcare team, such as a physician, or a facility, such as a hospital or skilled nursing home. |
| Referral | Transfer of patient care from one physician to another. (Usually, a PCP will refer to a Specialty provider or for a procedure.) |
| Revenue Cycle | All administrative and clinical functions that help capture and collect patients’ payments for medical. |
| Schedule of Benefits | List of the medical expenses that a health plan covers. |
| Self-funded (self-insured)health plan | A company that creates its own insurance plan for its employees, rather than using a carrier; the plan assumes payment risk, contracts with physicians, and pays for claims from its fund. |
| third-party payer | A company that creates its own insurance plan for its employees, rather than using a carrier; the plan assumes payment risk, contracts with physicians, and pays for claims from its fund. |
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t_talks
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