STANDARD INDUSTRY TERMINOLOGY
Accept Assignment
When billing medical services, the provider may indicate on the claim form that they have an authorization from the patient allowing payment from the insurance company to be sent directly to the provider’s billing office. Checks will be issued directly to the provider. In the example of Medicare, Accepting Assignment is an arrangement between the provider and Medicare which allows the provider to be reimbursed at slightly higher rates than providers who are not enrolled with Medicare.
Access
Patients' ability to obtain necessary health services.
Acute Care
Health care provided to treat conditions that are short term and episodic in nature.
Aftercare
The amount of time usually specified by insurance carriers during which the patient
receives free services following hospitalization or rehabilitation.
- AKA- Global Care or Free Aftercare
Aging
A method the software uses to keep track of the age of various balances that is owed to
a practice. The aging is separated by 30-day buckets.
Ambulatory Care
Health services rendered in a hospital outpatient facility, a clinic, or a physician's office; often synonymous with the term outpatient care.
Ancillary Services
Supplemental services provided with medical or hospital care.
Approved/Allowed amount
Amount an insurance carrier will allow/approve for a billed medical procedure. Insurance carriers will sometimes limit their coverage to a portion of the approved/allowed amount (i.e. a carrier might pay only 80% of the allowed amount, with the remaining 20% due from the patient or subsequent carrier). Typically these amounts vary on an annual basis.
- AKA – Reasonable and Customary
Benefit Assignment
A method under which an insured person requests that his/her benefits, under an insurance claim, be paid directly to a designated physician or hospital.
Capitation
A payment plan for health care providers. Under it, a managed-care health organization pays a doctor or other provider a fixed amount to care for a patient for a specific period of time -regardless of the actual cost of treatment or quantity of services provided. It is the payment of a per capita amount for a defined package of health care services. A specific dollar amount per member is paid to providers or organizations of providers.
Carrier
Insurance company, prepayment plan or government agency that, under a health insurance or prepayment program, administers claims submitted for or by its beneficiaries and, in certain cases, directly provides services.
Chargeback
A practice management term used to describe a negative (debit, positive) payment listed on a bulk remittance from an insurance company. Larger insurance plans will “take back” a previous payment for various reasons (duplicate payment, error on first payment, patient not covered by the plan at the time of service). This type of “chargeback” affects the total amount of the paid claims (check amount) by this “chargeback” amount.
- AKA - Take Back, Recoup or Auto-refund
Charges
The dollar amount charged by a provider for service rendered.
- AKA – Fee Schedule
Chart
A hard copy folder of the patient’s record kept in the office (or possibly off site for inactive patients).
Claims
Claims are bills that providers turn in to insurance carriers for health care services (“charges” rendered to patients. A claim can be printed on paper or can be sent to the carrier electronically.
CMS Claim Form
In July 2001, the Health Care Financing Administration (HCFA) became the Centers for Medicare & Medicaid Services (CMS). Because of this name change, the prefix of form numbers that had been "HCFA" have changed to "CMS." Visit www.cms.hhs.gov/forms for more information. The CMS-1500 form and instructions are used by non-institutional providers and suppliers.
Coordination of Benefits (COB)
A typical insurance provision whereby responsibility for primary payment for medical services is allocated among carriers when a person is covered by more than one employer-sponsored coverage. This coordination prevents duplicate reimbursement for the same medical services. This generally requires that payment of benefits from the 1st carrier must be received before the claim can be submitted to the 2nd carrier (or 3rd carrier, if applicable).
Co-insurance
Refers to money that an individual is required to pay for services, after a deductible has been paid. Often represented as a percentage.
Concurrent Review
Monitoring of the medical treatment and progress toward the recovery once a patient is admitted to a hospital to assure timely deliver of services and to confirm the necessity of continued inpatient care. This monitoring is under the direction of medical professionals.
Co-payment
A predetermined (flat) fee that an individual pays for health care services at the time the health care service is rendered
Credentialing
The process used by managed care companies to examine and verify the medical qualifications of health-care providers before accepting them into the network.
Date of Service
The date the patient is actually seen by the doctor.
Deductible
The amount that the health care plan dictates as being the patient’s out-of-pocket liability toward their own medical care, before the health care plan will begin payment.
Diagnosis Codes
The code used to recognize a disease or condition by its outward signs and symptoms. ICD-9 (International Statistical Classification of Diseases 9th edition) codes are commonly used to report the reason for service as a diagnosis.
Discharge planning
A health plans medical personnel working with the attending physician and hospital staff to assess alternatives to hospitalization, evaluate appropriate settings for care, and arrange for the patients discharge, including planning for subsequent care at home or in a skilled-nursing facility.
Discounted-Fee-for-Service
A financial reimbursement system whereby a provider agrees to provide services on a fee-for-service basis, but with the fees discounted by a certain percentage from the usual charges.
Durable Medical Equipment (DME)
Medical equipment that can stand repeated use. Examples: crutches, wheelchairs,
oxygen equipment, etc. Medicare has different claim filing requirements for DME procedures.
Explanation of Benefits/Explanation of Medical Benefits (EOB/EOMB)
The insurance company's written explanation to a claim, showing what they paid and what the client must pay. EOBs are always sent to subscribers and may also be sent to the provider of service, depending on benefit assignment.
Encounter Form
An in-office form that lists specific and/or specialty medical services provided by the
physician.
- AKA - Superbill, Fee Slip, Routing Slip, Charge Ticket, Ticket
Gatekeeper
A primary care physician in a managed-care environment who is responsible for managing the patient’s overall care and who must authorize all specialists referrals. In most health maintenance organizations (HMO’s), the specialist care is not covered by Insurance if the primary care physician does not approve it.
HIPAA
A Federal law passed in 1996 that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care. Full name is "The Health Insurance Portability and Accountability Act of 1996."
Health Maintenance Organization (HMO)
One of the ways medical care is provided. The HMO contracts with physicians to serve as primary care physicians. Physicians in the HMO provide health care to the members for a fixed (capitated) fee or for a discounted rate. Delivery of health care is managed by each member’s primary care physician, who personally performs the care or refers the patient to a specialist.
Indemnity Health Plans
Traditional health insurance, sometimes called “fee-for-service” insurance. Patient’s may choose any physician or hospital, and the insurance company will reimburse a certain percentage of costs, usually after the patient pays an annual deductible.
Long-Term Care
The provision of health, personal and social services to individuals who lack some functional capacity. Care is provided on a long-term basis in institutions or at home with a skilled level of care rather than an acute level.
Managed Care
A general term representing a coordinated approach to the design, financing and delivery of healthcare which balances price and uses controls to deliver high-quality, cost-effective health care. The focus of managed care plans is on preventive health care. HMOs are a common form of managed care.
Medicaid
A federal program created by Title XIX-Medical Assistance, a 1966 amendment to the Social Security Act, administered by states, that provides health care benefits to indigent and medically indigent persons.
Medicare
A federal program, created by Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits primarily to persons over the age of 65 and others eligible for Social Security benefits. Medicare has 2 parts: Part A to cover inpatient care and Part B to cover professional services and outpatient care.
Medigap
Medigap insurance is offered by private insurance companies, not the government. It is not the same as Medicare or Medicaid. These policies are designed to pay for some of the costs that Medicare does not cover. Medigap carriers are assigned a unique ID that can be reported on the Medicare claim, allowing Medicare to forward the balance of the claim automatically to the Medigap carrier.
Management Service Organization (MSO)
A centralized Practice Management Group providing billing and financial services to multiple Physician Groups
Network
In healthcare industry, network can mean groups of physicians, hospitals and other health-care providers working with the health plan to offer care at negotiated rates.
Occupational Health
A grouping of health care services that encompasses the general health and wellness of employees, routine physical examinations, compliance with government regulations (OSHA) that relate to employee safety, and treatment of work-related injuries or illnesses.
Ordering Physician
The physician or other provider who specifically prescribes the health care service being rendered
Place of Service (POS)
Facility where services are rendered.
Precertification
The process for reviewing non-emergency inpatient consultations (as well as selected outpatient procedures) by comparison with established medical norms to determine appropriate setting and intensity of service.
Preferred Provider Organization (PPO)
A form of health insurance that provides high coverage with low copayments for patients who use physicians within the PPO network. Patient’s can choose to use other physicians, but their copayments are typically higher.
Primary Care
Routine health care and well-visit screening tests (such as pap smears, blood pressure checks) and the first level of care for disease, illness or injury.
Primary Care Physician (PCP)
The doctor a patient sees first for medical care, usually a physician who is in some sense a generalist such as a family or general practitioner, general internist, pediatrician or obstetrician/gynecologist.
Prior Authorization
Approval required by the insurance company for a primary care physician (PCP) to refer a patient to a specialist or ancillary care provider for certain medical services/diagnoses. Typically it is the responsibility of the PCP to obtain the referral authorization number/referral form for the patient prior to the patient’s appointment with the specialist. Obtaining a Prior authorization does not guarantee payment.
- AKA – Referral, Referral Authorization or Referral Number
Procedure Codes
The standard assignment of codes (obtainable in book or electronic media form) for medical services that uniquely identify services performed by the provider to a patient. Procedure codes are typically assigned a price and are billed to patients and insurance companies. Some insurance carriers maintain their own coding system similar, but not identical to either of the following:
CPT (Current Procedural Terminology) - The most commonly used coding system that represents procedures performed by a medical provider. These codes are generally made up of 5 numeric characters.
HCPCS (Health Care Procedure Coding System) – This is another type of coding system used to represent procedures performed by a medical provider. These codes are 5 digit alphanumeric codes with the first character being alpha and the remaining numeric.
Provider/Rendering Provider
A term used for health professionals who provide health care services, instead of those who receive, pay for it or regulate it. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services. These fall into 2 types:
Participating Provider
Also known as Par. A provider that has contracted with a carrier. The carrier sets the fees for what is reasonable and customary. The provider gets a percentage of the allowed amount as payment. The provider must write off the difference between what he charged/billed and the allowed amount from the carrier.
Non-Participating Provider
Also known as Non-Par. A provider that has not contracted with a carrier. The provider sets his own fees and can charge the patient the difference between what the insurance carrier pays and what the provider charge/billed out. No insurance write off is required.
Referring physician
The referring physician is usually the physician that referred the patient to the billing provider
Risk
The chance of possibility of loss. For example, physicians may be held at risk if hospitalization rates exceed agreed upon thresholds. Risk sharing is often used as a control mechanism in the HMO setting.
Risk Pool
A pool of money that is at risk for being used for defined expenses. Commonly, if the pool of money that is put at risk is not used by the end of the year, some, or all of it, is returned to those managing the risk.
Subscriber
The person who is responsible for payment or whose employment is the basis for
eligibility for membership in a health coverage. (owner of the insurance coverage)
- AKA – Policyholder
Type of Service Codes (TOS)
Insurance company codes given to like procedures to classify them into medical groupings (1-Medical Care, 5-Diagnostic Lab)
Unique Physician Identification Number (UPIN)
A Medicare-assigned, nationally recognized unique number that identifies a physician to Medicare.
Utilization Review/Utilization Management
Evaluation of the use of hospital services, including admission, length of stay and ancillary services, using objective clinical criteria. It includes a review of outpatient costs as well
Withhold
The portion of the monthly capitation payment or fee schedule amount to physicians withheld by an HMO until the end of the year or other time period to create an incentive for efficient care. The withhold is "at risk." If the physician (or group of physicians) exceeds utilization norms, he/she does not receive it. It serves as a financial incentive for lower utilization. The withhold can cover all services or be specific to hospital care, laboratory usage or specialty referrals.
Worker’s Compensation
Liability insurance typically provided by the patients employer often through a managed care plan or third party administrator to cover industrial/work related injuries.