CIMO CH 1 The Medical Billing Cycle

policyholder
a person who buys an insurance plan; the insured
heath plan
a plan, program, or organization that provides health benefits
premium
the periodic amount of money the insured pays to a health plan for insurance coverage
payer
private or government organization that insures or pays for health care on the behalf of beneficiaries
deductible
amount due before benefits start
fee-for-service
health plan that repays the policyholder for covered medical expenses
coinsurance
part of charges that an insured person must pay for health care services after payment of the deductible amount
managed care
a type of insurance in which the carrier is responsible for both the financing and the delivery of health care
capitation
advance payment to a provider that covers each plan member’s health care services for a certain period of time
preferred provider organization (PPO)
managed care network of health care providers who agree to perform services for plan members at discounted fees
health maintenance organization (HMO)
a managed health care system in which providers agree to offer health care to the organization’s members for fixed periodic payments from the plan
copayment
a small fixed fee paid by the patient at the time of an office visit
consumer-driven health plan (CDHP)
a type of managed care in which a high-deductible/low-premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses, up to the deductible amount
patient information form
form that includes a patient’s personal, employment, and insurance data needed to complete an insurance claim
documentation
a record of health care encounters between the physician and the patient, created by the provider
encounter form
a list of the procedures and charges for a patient’s visit
electronic health record (EHR)
a computerized lifelong health care record for an individual that incorporates data from providers who treat the individual
practice management program (PMP
a software program that automates many of the administrative and financial tasks in a medical practice
diagnosis
physician’s opinion of the nature of the patient’s illness or injury
medical record
a chronological record of a patient’s medical history and care that includes information that the patient provides, as well as the physician’s assessment, diagnosis, and treatment plan
procedure
medical treatment provided by a physician or other health care provider
coding
the process of assigning standardized codes to diagnoses and procedures
diagnosis code
a standardized value that represents a patient’s illness, signs, and symptoms
procedure code
a code that identifies a medical service
modifier
a two-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service
encounter form
a list of the procedures and charges for a patient’s visit
practice management program (PMP)
a software program that automates many of the administrative and financial tasks required to run a medical practice
medical coder
a person who analyzes and codes patient diagnoses, procedures, and symptoms
medical necessity
treatment provided by a physician to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and provided in accordance with generally accepted standards of medical practice
adjudication
series of steps that determine whether a claim should be paid
remittance advice (RA)
an explanation of benefits transmitted electronically by a payer to a provider
explanation of benefits (EOB)
paper document from a payer that shows how the amount of a benefit was determined
statement
a list of all services performed for a patient, along with the charges for each service
billing cycle
regular schedule of sending statements to patients
accounting cycle
the flow of financial transactions in a business
accounts receivable (AR)
monies that are flowing into a business
Medicare
federal health plan that covers persons aged sixty-five and over, disabilities and end stage renal disease (ESRD) and dependent widows
Medicaid
Federal/state program for low incomes who cannot afford medical care. Qualifications and benefits vary by state.
TRICARE
Government plan that covers dependants of active-duty members of the uniformed services, and retired military personal.
CHAMPVA
The Civilian Health and Medical Program of the Veterans Administration is for veterans with permanent service-related disabilities and their dependents.
Workers’ compensation
Covers job-related illnesses or injuries, benefits vary according to state law.