- Chapter 1 - Key Terms

gucetowo's version from 2015-07-01 00:38


Question Answer
accounts payable (AP) A practice's operating expenses
accounts receivable (AR)Monies owed to a medical practice
adjudicationHealth plans process of examing clains and determining benefits
benefitsHealth plan payments for covered services
catpitationA fixed prepayment covering provider's services for a plan memeber for a specified period
cash flowMovement of monies into or out of a business
certificationRecognition of a superior level of skill by an official organization
coinsurancePortion of chargesan insured person must pay for healthcare
complianceactions that satisfy official requirements
consumer driven health plan (CDHP)Medical insurance that combines a high-deductible health plan with a medical savings plan
copaymentAmount a beneficiary must pay at the time of a healthcare encounter
covered Servicesmedical procedures and treatments that are included as benefits in a health plan
deductibleAmount the insured must pay for healthcare services before a healthplans payment begins
diagnosis codeNumber assigned to a diagnosis
electronic health record (EHR)computerized lifelong helathcare record for an individual that incorporates data from all sources
ethicsstandards of conduct based on moral principles
etiquettestandards of professional behavior
excluded servicesServices not covered in a medical insurance contract
fee-for-servicepayment method based on provider charges
cealthcare Claime-transaction or a paper document filed to receive benefits
health information technology (HIT)Computer information sustems that record, store, and manage patient information
health maintenance organization (HMO)managed healthcare sustem in which providers offer helathcare to memebers for fixed periodic payments
health planIndividual or group plan that provides or pays for medical care
indemnity planHelath plan that offers protection from loss
managed careSustem combining the financing and deliver of healthcare services
managed care organization (MCO)Organization offering a managed healthcare plan
medical billing cycleSteps that lead to a maximum appropriate, timely payment for a patients' medical services
medical coderStaff member woth specialized training who handles diagnostic and procedural coding
medical insuranceFinancial plan that covers the cost of hospital and medical care
medical insruance specialistStaff member who handles billing, checks insurance, and processes payments
medical necessityPayment criterion that requires medical treatment to be appropriate and provided in accorndance with generally accepted standards
networkA group of healthcare providers, including physicians and hospitals, who sign a contract with a healthplan to provide services to plan members
non-covered servicesMedical procedures that are not included in a plands benefits
out-of-networkProvider that does not have a participation agreement with a plan
participationContractual agrreement to provide medical services to a payer's policyholders
paitent ledgerRecprd of a patient's financial transactions
Patient Protection and Affordable Care Act (ACA)Health system reform legislation that introduced significant benefits for patients
payerHelath plan or program
per member per month (PMPM)Periodic capotated prospective payment to a provider that covers only services listed on the schedule of benefits
PM/EHRSoftware combining both a PMP and an EHR into a single product
policy holderPerson who buys an insurance plan
practice management program (PMP)Account software used for scheduling appointments, billing, and financial record keeping
preauthorizationPrior authorization from a payer for services to be provided
preexisting conditionIllness or disorder that existed before the insruance coverage became effective
preferred provider organization (PPO)Managed care organization in which a network of providers supplies discounted treatment for plan members
premiumMoney the insured [aus tp a health pland for a policy
preventive medical servicesCare provided to keep patients healthy or prevent illness
primary care physician (PCP)Physician in a health maintenance organization who directs all aspects of a patients care
procedure codeCode that identifies medical treatment or diagnostic services
professionalismActing for the good of the public and the medical practice
providerPerson or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business
referralTrasnfer of patient care from one physician to another
revenue cylce management (RCM)The process of making sure sufficient monies flow in the practice to pay the practice's bills
schedule of benefitsList of medical expenses covered by a health plan
self-funded (self-insured) health planOrganization pays for health insirance directly and sets up a fund from which to pay
third party payerPrivate or government organization that insures or pays for healthcare on behalf of beneficiaries
out-of-pocketExpenses the insured must pay prior to benefits