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IHMO Ch 12 Key Term
| Question | Answer |
|---|---|
| Advance beneficiary notice of noncoverage (ABN) | An agreement given to the patient to read and sign before rendering a service if the participating physician thinks that it may be denied for payment because of medical necessity or limitation of liability by Medicare. |
| Approved charges | A fee that Medicare decides the medical service is worth, which may or may not be the same as the actual amount billed. The patient may or may not be responsible for the difference. |
| Assignment | A transfer, after an event insured against, or an individual's legal right to collect an amount payable under an insurance contract. |
| Benefit period | A period of time during which payments for Medicare inpatient hospital benefits are available. |
| Centers for Medicare and Medicaid Services (CMS) | CMS divides responsibilities among three divisions: the Center for Medicare Management, the Center for Beneficiary Choices, and the Center for Medicaid and State Operations. |
| Correct coding initiative (CCI) | Federal legislation that attempts to eliminate unbundling or other inappropriate reporting of procedural codes for professional medical services rendered to patients. |
| Crossover claim | A bill for services rendered to a patient receiving benefits simultaneously from Medicare and Medicaid or from Medicare and a Medigap plan. |
| Diagnostic cost groups (DCGs) | A system of Medicare reimbursement for HMOs with risk contracts in which enrollees are classified into various DCGs on the basis of each beneficiary's prior 12-month hospitalization history. |
| Disabled | Individuals younger than 65 years of age who have been entitled to disability benefits under the Social Security Act or the Railroad Retirement system for at least 24 months are considered disabled and are entitled to Medicare. |
| End-stage renal disease (ESRD) | Individuals who have chronic kidney disease requiring dialysis or kidney transplant are considered to have ESRD. |
| formulary | List of drugs that a health insurance plan covers as a benefit. |
| Hospice | A public agency or private organization primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill patients and their families in their own homes or in a homelike center. |
| Hospital insurance | Known as Medicare Part A. A program providing basic protection against the costs of hospital and related after-hospital services for individuals eligible under the Medicare program. |
| Intermediate care facilities (ICFs) | Institutions furnishing health-related care and services to individuals who do not require the degree of care provided by acute care hospitals or nursing facilities. |
| Limiting charge | A percentage limit on fees, specified by legislation, that nonparticipating physicians may bill Medicare beneficiaries above the fee schedule amount. |
| Medical necessity | The performance of services and procedures that are consistent with the diagnosis in accordance with standards of good medical practice, performed at the proper level, and provided in the most appropriate setting. |
| Medicare | A nationwide health insurance program for persons age 65 years of age and older and certain disabled or blind persons regardless of income, administered by HCFA. |
| Medicare administrative contractor (MAC) | Insurance carrier that receives and processes claims from physicians and other suppliers of service for Medicare Part B. |
| Medicare/Medicaid (Medi-Medi) | Refers to an individual who receives medical or disability benefits from both Medicare and Medicaid programs; sometimes referred to as a Medi-Medi case or a crossover. |
| Medicare Part A | Hospital benefits of a nationwide health insurance program for persons age 65 years of age and older and certain disabled individuals regardless of income, administered by CMS. Medicare Part B |
| Medicare Part C | Plans may include health maintenance organizations, fee-for-service plans, provider-sponsored organizations, religious fraternal benefit societies, and Medicare medical savings accounts. |
| Medicare Part D | Stand-alone prescription drug plan, presented by insurance and other private companies that offer drug coverage that meets the standards established by Medicare. |
| Medicare Secondary Payer (MSP) | The primary insurance plan of a Medicare beneficiary that must pay for any medical care or services first before Medicare is sent a claim. |
| Medicare Summary Notice (MSN) | A document received by the patient explaining amount charged, Medicare approved, deductible, and coinsurance for medical services rendered. |
| Medigap (MG) | A specialized supplemental insurance policy devised for the Medicare beneficiary that covers the deductible and copayment amounts typically not covered under the main Medicare policy written by a nongovernmental third-party payer. |
| National alphanumeric codes | Alphanumeric codes developed by HCFA. |
| Nonparticipating physician (nonpar) | A provider who does not have a signed agreement with Medicare and has an option about assignment. |
| Nursing facility (NF) | A specially qualified facility that has the staff and equipment to provide skilled nursing care and related services that are medically necessary to a patient's recovery |
| Participating physician (par) | A physician who agrees to accept payment from Medicare (80% of the approved charges) plus payment from the patient (20% of approved charges) after the $100 deductible has been met. |
| Physician Quality Reporting Initiative (PQRI) | Voluntary pay-for-reporting program for providers who successfully report quality information related to services provided to patients under Medicare Part B. |
| Premium | The cost of insurance coverage paid annually, semiannually, or monthly to keep the policy in force. In the Medicare program, monthly fee that enrollees pay for Medicare Part B medical insurance. |
| Prospective payment system (PPS) | A method of payment for Medicare hospital insurance based on diagnosis-related groups (DRGs) (a fixed dollar amount for a principal diagnosis). |
| Quality improvement organization (QIO) program | A program that replaces the peer review organization (PRO) program and is designed to monitor and improve the usage and quality of care for Medicare beneficiaries. |
| Qui tam action | An action to recover a penalty brought on by an informer in a situation in which one portion of the recovery goes to the informer and the other portion to the state or government. |
| Reasonable fee | A charge is considered reasonable if it is deemed acceptable after peer review even though it does not meet the customary or prevailing criteria. |
| Relative value unit (RVU) | A monetary value assigned to each service on the basis of the amount of physician work, practice expenses, and cost of professional liability insurance. |
| Remittance advice (RA) | A document detailing services billed and describing payment determination issued to providers of the Medicare or Medicaid program; also known in some programs as an explanation of benefits. |
| Resource-based relative value scale (RBRVS) | A system that ranks physician services by units and provides a formula to determine a Medicare fee schedule. |
| Respite care | A short-term hospice inpatient stay for a terminally ill patient to give temporary relief to the person who regularly assists with home care of a patient. |
| Supplemental Security Income (SSI) | A program of income support for low-income aged, blind, and disabled persons established by Title XVI of the Social Security Act. |
| Supplementary medical insurance (SMI) | Part B—medical benefits of Medicare program. |
| Volume performance standard (VPS) | The desired growth rate for spending on Medicare Part B physician services, set each year by Congress. |
| Whistleblowers | Informants who report physicians suspected of defrauding the federal government. |
| ABN | advance beneficiary notice |
| CAP | claims assistance professional |
| CCI | Correct Coding Initiative |
| CLIA | Clinical Laboratory Improvement Amendments |
| CMS | Centers for Medicare and Medicaid Services |
| COBRA | Consolidated Omnibus Budget Reconciliation Act |
| DC | doctor of chiropractic |
| DCGs | diagnostic cost groups |
| DEFRA | Deficit Reduction Act |
| DME | durable medical equipment |
| EGHP | employee group health plan |
| ERA | electronic remittance advice |
| ESRD | end-stage renal disease |
| GPCIs | geographic practice cost indices |
| ICFs | intermediate care facilities |
| ICU | intensive care unit |
| LCD | local coverage decision |
| LGHP | large group health plan |
| LMRP | local medical review policy |
| MAAC | maximum allowable actual charge |
| MAC | Medicare administrative contractor |
| MCO | managed care organization |
| Medi-Medi | Medicare/Medicaid |
| MG | Medigap |
| MMA | Medicare Prescription Drug Improvement and Modernization Act |
| MSA | medical savings account |
| MSN | Medicare summary notice |
| MSP | Medicare Secondary Payer |
| NCDs | national coverage determinations |
| NEMB | Notice of Exclusions from Medicare Benefits |
| NF | nursing facility |
| Nonpar | nonparticipating provider or physician |
| OASDI | Old Age, Survivors, and Disability Insurance |
| OBRA | Omnibus Budget Reconciliation Act |
| OCNA | other carrier name and address key |
| Par | participating provider |
| PAYERID | payer identification |
| PFFS | private fee-for-service plan |
| PIN | provider identification number |
| PPS | prospective payment system |
| PQRI | physician quality reporting initiative |
| PRO | peer review organization or professional review organization |
| PSO | provider-sponsored organization |
| QIO | Quality Improvement Organization program |
| RA | remittance advice |
| RBRVS | resource-based relative value scale |
| RFBS | religious fraternal benefit society |
| RVU | relative value unit |
| SMI | supplementary medical insurance |
| SOF | signature on file |
| SSI | Supplemental Security Income |
| TEFRA | Tax Equity and Fiscal Responsibility Act |
| VPS | volume performance standard |
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