Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
87 Cards in this Set
- Front
- Back
|
The amount the physician chatges for services
|
Actual Charge
|
|
|
the term for processing payment of a claim
|
adjuducate
|
|
|
Person who reviews the claim to determine payment
|
adjudicator
|
|
|
the amount set by the carrier as the reimbursement amount
|
Allowed charge
|
|
|
Request that money be paid directly to the physician for services rendered on a given claim
|
Assignment
|
|
|
A reference source publushed by the AMA as a means to describe services rendered to a patient
|
CPT-4
|
|
|
A form of prepayment in which a provider agress to furnish services to members of a particular insurance program for a fixed fee
|
Capitation
|
|
|
the coordination and integration of a plan design through a patient care coordinator
|
Case Management
|
|
|
A government sponsored program providing hospital and medical services to active duty, retired personnel, and their eligible dependents
|
CHAMPUS or Tricare
|
|
|
Portion of cost for covered services that is patient's responsibility either by a fixed amount or percentage
|
Copay
|
|
|
CHAMPUS
|
civilian health and medical program of uniformed services
|
|
|
statement from insurance that shows what was allowed and written off
|
Explanation of benefits/ explanation of medicare benefits
|
|
|
the federal agency monitors medicare programs
|
CMS
|
|
|
A coding system designed by HCFA to report patient services that incorporates CPT-4 and alphanumerical codes
|
HCPCS
|
|
|
a health care program providing services for its members by contract agreement with specific physicians, hospitals, and labs
|
HMO
|
|
|
the source of diagnosis coding required by insurance carriers and government agencies
|
ICD9-CM
|
|
|
Traditional insurance programs referred to as fee for service programs
|
Indemnity
|
|
|
a method for preapproving all elective admissions, surgeries, and other services as required by insurance carriers
|
Precertification
|
|
|
A special insurance program offering patients higher reimbursement by using physicians, hospitals, and labs within a network
|
PPO
|
|
|
Sartorius
|
Origin: Anterior superior iliac spine
Insertion: Medial surface of tibia near tibial tuberosity Action: Flexion at knee; flexion and lateral rotation at hip Nerve: Femoral |
|
|
the charge most frequently used, in a specific area by physicians, based on speciality
|
Preveiling charge
|
|
|
a physician in a speciality area other than primary care who provides specialized care to the patient
|
Specialist
|
|
|
the reimbursement method that establishes a maximum fee an insurance company will pay for services
|
UCR (usual customary and reasonable)
|
|
|
the process of assessing medical care services to assure quality, medical necessity, and appropriateness of treatment
|
Utilization Review
|
|
|
A plan arranged by an employer or special interest group for the benefit of members and their eligible dependents
|
Group Health Plan
|
|
|
A plan issued to an individual (usually high premiums)
|
Individual health plan
|
|
|
a plan where by services are rendered by physicians or facilities who elect to participate in a set program for services
|
Prepay health care program
|
|
|
1. ascertaining the usual fee a dr charges to the majority of patients for a particular service
2. reviewing the geographic location of the practice and speciality of physician. 3. reviewing complications or unusual circumstances of services |
UCR Payment Factors
|
|
|
The amount a doctor charges the majority of their patients for a particular service
|
Usual fee
|
|
|
The range amount of fees charged by doctors of similar training and speciality when executng the same service
|
customary fee
|
|
|
the fee that meets the requirement of usual and customary fees or is justified considering the special circumstances of the service of the particular case in question
|
reasonable fee
|
|
|
determines the maximum amount of payment to be made by a carrier for a specific service, most HMO and PPO programs have
|
Fee schedules
|
|
|
incorporate the use of unit counts applied to a specific code in order to determine payment factors , takes into account time, skills, and overhead expense of the physician as required by each service
|
Relative Value studies
|
|
|
pertains to inpatient hospital services, nursing homes, and home health care services (BCBS)
|
Blue Cross
|
|
|
The portion of patient's insurance providing financial assistance with outpatient costs for services, physician charges, etc
(BCBS) |
Blue Shield
|
|
|
the provider is not obligated to file ins or to write off the difference of the actual charge and the allowed charge, they may collect in full from the patient at the time service is rendered
(BCBS) |
indemity
|
|
|
a special contract whereby the provider agrees to see BS patietnts, file the ins to BS on behalf of the patient, and wait for payment from BS before collecting from the patient
|
UCR provider
|
|
|
eligible dependents of active duty members are entitled to benefits under this program as well as retired personnel and their eligible dependents, all eligible members have the same rate deductibles, but percentage of cover varies based on members duty status, ie active= 20% co pay, retired- 25% co pay; all hospital admissions require a nonavailabiltiy waiver from military facility before admission into a civilian hospital
|
CHAMPUS / Tri-care
|
|
|
area where have to report to certain area for medical care
|
catchment area
|
|
|
created in 1973 to provide medical benefits program for spouses and children of veterans with total, permanent, service connected disabilities or for the surviving dependents of veterans who die as a result of service connected disabilities
|
CHAMPVA
|
|
|
systems enrollees are "locked" into its provider network for a specified time in exchange for monthly premiums, for member= reduced out of pocket costs and nomial copayments for physician office visits, rx drugs, and hospitilizations
|
HMO
|
|
|
delivers health care services through physicians who are employees of HMO, purest form of managed care, physicians are devoted to the provision of services on a prepaid basis and compensated on a salary basis , not on number of services provided
|
staff HMO
|
|
|
predominately contracts with one independant multispeciality group practice to provide services to its members, physician group is paid on capitation basis to provide a specific set of services, physician group decides how the capitaiton payments are distributed to each physician in the group
|
Group HMO
|
|
|
the lower the total costs of services, the higher the profit, which is the exact opposite of the fee for service system, profit can be increased by: negotiating a relativiely high rate or 2. reducing practice costs through various efficiencies
|
Capitaiton
|
|
|
this is where the HMO contracts directly with physicians in independant practices and/or contracts with one or more associations that contain physicians in independant practices
|
Individual Practice Association
|
|
|
the HMO contracts with 2+ multispeciality physician groups to provide care for their members/enrollees, physician groups under the organizational form usually do not limit their practice solely to HMO members/enrollees
|
Network HMO
|
|
|
open ended HMO, newest form, the member can elect to use a non-participating provider and pay only a portion of the cost instead of 100%
|
Point of Service HMO
|
|
|
1. contracts are developed to provide care at a lower fee
2. patient usually responsible for a small copay of $5-$25 3. patient has a selected group of physicians from which they may seek care 4. providers have special contract agreements 5. must file ins claim forms, collect any deductible or copay, and write off differences 6. ins claims need to be filed within 60 days 7. all patient care is under the direction of a PCP 8. PCP is held to a monthly capitation for care (usually $5-6/ HMO patient regardless if seen or not) 7. PCP is not eligible tor receive any reimbursement other than capitaiton each month, except with special circumstances 8. if HMO makes a profit at the end of the year, each particiapting physician will receive a porion of monies within the incentive withhold pool |
General concepts of HMO
|
|
|
a business arrangement between a group or network of providers and payers where providers offer their health care services to PPO members/enrollees at discounted rates in exchange for increased business volume and quicker payments
|
PPO
|
|
|
1. pt has a choice of physicians
2. patient services are not overseen or directed by PCP 3. pt may decide whether or not to seek the care of a specialist without having to go through another physician first 4. if the patient sees a physician who is not a PPC, the patient still retains benefits for the services, but at a reduced rate |
PPO guidelines
|
|
|
a state funded assistance program created to help ease the burden and expense of quality of medical care for qualified patients, eligibility is a month to month requirement based on the income of the recipient
|
Medicaid
|
|
|
1. provider needs to sign a contract with in order to treat patients and receive reimbursement
2. claims should be submitted with the diagnosis code to the highest level of specificity 3. recieves funding from state and federal agencies 4. governed by CMS |
Guidelines for Medicaid
|
|
|
patient is both medicare and medicaid, recipients are usually under the old age security benefits (under 65), severely disabled, and/or blind
|
Medi-Medi
|
|
|
1. medicaid will not pay a claim unless the office accepts assignment on the medicare portion of the claim regardless of the provider's participation status in the medicare system
2. after medicare processes the claim it will automatically cross over to the medicaid carrier for payment |
Guidelines for Medi-Medi
|
|
|
insurance safegaurds employees who experience job related injuries, coverage enables the employee to receive compensation for loss wages, medical expenses, and permanent disability, premium or coverage payments, by law, are the responsibilty of the employer
|
Worker's Comp
|
|
|
Medical Services
Temporary disability Permanent disabiltiy survivor death benefits rehab benefits |
Workers' Comp will cover
|
|
|
wage earner
|
A
|
|
|
husband's number, used by wife, 62+
|
B
|
|
|
Widow
|
D
|
|
|
disabled adult
|
HAD
|
|
|
disabled child
|
C
|
|
|
uninsured and entitled only to health ins benefits
|
T
|
|
|
Id number is SS# (or husbands SS#)
sex of patient effective dates of coverage |
Medicare card
|
|
|
a federal health care insurance program under the direction of CMS, established in 1966 by an act of congress as a means to assist the elderly with the high cost of medical expenses
|
Medicare
|
|
|
1. persons 65+
2. under 65 w/ permanent kidney failure 3. under 65 and disabled |
Medicare eligibility requirements
|
|
|
Responsible for processing claims submitted to medicare
|
Highmark medicare services
|
|
|
benefits for hospital inpatient care, nursing homes, home health care, and hospice
$1132/ illness deductible 1-60 days= 100% covered (deductible only) 61-90 days= $283/day 91+ days= $565/ day |
Medicare Part A
|
|
|
outpatient services, recipient pays a monthly premium, yearly deductible ($162) to all outpatient services and a 20% copay, pt responsible for full amount of anything not covered
|
Medicare Part B
|
|
|
A= social security tax
B= half= general revenues half= individuals pays |
how medicare is funded
|
|
|
only other program recognized by the federal system, distinguished by other medicare numbers by id # (alpha first than id#)
|
RR medicare
|
|
|
1. pt has coverage under a group plan or has other coverage through a working spouse
2. if illness or injury results from an auto accident or 3rd party liability 3. black lung victim 4. veterans w/ cash card from VA 5. work related injuries which fall under workers comp |
when medicare can be secondary ins
|
|
|
1. medical doctors
2. dr of osteopathy 3. liscensed clinical psychologist 4. accredited clinical social worker 5. lab 6. OP hospital services 7. qualified ambulatory surgical centers |
Providers of Services
|
|
|
before filing a claim the office must either have the actual signature of the patient on the claim form or be estabilshed in the medicare system
|
Signature for Medicare Claims
|
|
|
the means devised by medicare to show allowed amounts of payment, based on contract agreement, and limiting charge factors established by medicare
|
Medicare profile
|
|
|
Files all Medicare claims for patient, accepts payments allowed by medicare, collects only copays and deductibles, and writes off amounts
|
Particiapting medicare provider
|
|
|
have contracts and file medicare claims, but may not accept so patient may be responsible for 100%
|
non participating medicare provider
|
|
|
1. receive a 4-5% higher reimbursement rate on allowed amount
2. receive payment for clean claims within 19 days of receipt at the medicare office 3. notice increase pt flow bc listed in directory disbursed by medicare 4. receive increased hospital referrals since hospitals are required to give the names of participating providers to recipients |
Participating Providers (medicare)
|
|
|
a special program available to medicare recipients to help the pt with costs incurred from medical expenditure over and above the medicare allowed amount,
Secondary insurances to cover copays, deductibles, and any additional expenses ie. Aetna BCBS |
Medigap
|
|
|
when medicare receives a claim with incomplete or incorrect info, the carrier will send a request to process the claim
help track violations due to charges, procedural or diagnostic coding each can carry a fine of up to $2000. |
ADR (additional documentation request/required)
|
|
|
Level 1= utilizes basic CPT-4 coding practices
Level 2= alphanumerical listing of codes developed by medicare when code description is vague or incomplete level 3= special codes developed by medicare whenever a description does not exist in CPT |
CPT levels
|
|
|
statements thate are designed to allow the provider to collect from the patient when services are disallowed by medicare based on frequency or type of services, if not signed by patient cannot collect money from
|
Medically unnecessary statement
|
|
|
1. medicare does not usually pay for this many visits or treatments
2. does not pay for this service 3. treatment has yet to be proved effective |
Reasons medicare may deny
|
|
|
standard unique identifier for health care providers adapted by HIPAA, 10 digit random #, permanent, will not change if have change in practice, location,speciality, etc
|
NPI
|
|
|
estabilshed in 1989, means to track and maintain a physician's profile and performance record regardless of location, must be present in boxes 17 and 17A of HCFA 1500 claim form to receive payment for consultations, labs, xrays, and adaptive equipment
|
UPIN (unique physician id #)
|
|
|
first appeared in 1989 as a means to identify the physician who actually performed the service in a clinical setting
|
CPIN (clinical physician ID #)
|
|
|
effective april 1, 1992 offices were required to use new HCFC 1500 claim form to report services provided to medicare recipients
|
Ins claim forms
|
|
|
Under the 6th, two offenses will be considered different if ….
|
Under the 6th, two offenses will be considered different if each requires proof of an additional element that the other crime does not require.
|
