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Account– Your charges for a medical visit.
Account Number– Number youre given by your doctor or hospital for a medical visit.
Actual Charge– The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount an insurance plan approves.
Adjustment- The portion of your bill that your doctor or hospital has agreed not to charge you.
Admission Date (Admit Date)– Date you were admitted for treatment.
Admission Hour– Hour when you were admitted for inpatient or outpatient care.
Admitting Diagnosis– Words that your doctor uses to describe your condition.
Advance Beneficiary Notice (ABN)– A notice the hospital or doctor gives you before you retreated, telling you that Medicare will not pay for some treatment or services. The notice is given to you so that you may decide whether to have the treatment and how to pay for it.
Advance Directive (Healthcare)– Written ahead of time, a health care advance directive is a written document that says how you want medical decisions to be made if you lose the ability to make decisions for yourself. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.
All-inclusive Rate- Payment covering all services during your hospital stay.
Ambulatory Payment Classifications (APC)– A Medicare payment system that classifies outpatient services so Medicare can pay all hospitals the same amount.
Ambulatory Care– All types of health services that do not require an overnight hospital stay.
Ambulatory Surgery- Outpatient surgery or surgery that does not require an overnight hospital stay.
Amount Charged- how much your doctor or hospital bills you.
Amount Paid-The dollar amount that you paid for your doctor or hospital visit.
Amount Not Covered- What your insurance company does not pay. It includes deductibles, co- insurances, and charges for non-covered services.
Amount Payable by Plan– How much your insurer pays for your treatment, minus any deductibles, coinsurance, or charges for non-covered services.
Ancillary Service– Services you need beyond room and board charges, such as laboratory tests, therapy, surgery and the like.
Anesthesia– Drugs given to you during surgery to eliminate or reduce surgical procedure pain.
Appeal- A process by which you, your doctor, or your hospital can object to your health plan when you disagree with the health plans decision to not pay for your care.
Applied to Deductible– Portion of your bill, as defined by your insurance company, that you owe your doctor or hospital.
Assignment– An agreement you sign that allows your insurance to pay the doctor or hospital directly.
Assignment of Benefits– When insurance payments are sent directly to your doctor or hospital.
Attending Physician Name– The doctor who certifies that you need treatment and is responsible for your care.
Authorization Number– A number stating that your treatment has been approved by your insurance plan. Also called a Certification Number or Prior-Authorization Number.
Balance Bill- How much doctors and hospitals charge you after your health plan, insurance company, or Medicare have paid its approved amount.
Beneficiary– Person covered by health insurance.
Beneficiary Eligibility Verification– A way for doctors and hospitals to get information about whether you have insurance coverage.
Beneficiary Liability– A statement that you are responsible for some treatments or charges.
Benefit – The amount your insurance company pays for medical services.
Bill/Invoice/Statement- Printed summary of your medical bill.
Cardiology Charges– Charges for heart procedures. Examples are heart catheterization and stress testing.
Case Management- A way to help you get the care you need, especially when you need pre- authorized care from several services. Usually a nurse helps arrange for your care.
Centers for Medicare and Medicaid (CMS)-The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.*
CHAMPUS– Insurance linked to military service, also known as TriCare.
Charity Care– Free or reduced-fee care for patients who have financial hardship.
Claim– Your medical bill that is sent to an insurance company for processing.
Claim Number– A number given to a medical service.
Clean Claim– A claim that does not have to be investigated by insurance companies before they process it.
Clinic- An area in a hospital or separate building that treats regularly scheduled or walk-in patients for non-emergency care.
COBRA Insurance– Health insurance that you can buy when you lose your job. It is generally more expensive than insurance provided through your job but less expensive than insurance purchased on your own when you are unemployed.
Coding of Claims– Translating diagnoses and procedures in your medical record into numbers that computers can understand.
Coinsurance- The cost sharing part of your bill that you have to pay.
Coinsurance Days (Medicare)– Hospital Inpatient Medicare coverage from day 61 to day 90 of continuous hospitalization. You are responsible for paying for part of those days. After the 90th day, you enter your “Lifetime Reserve Days.”
Collection Agency – A business that collects money for unpaid bills.
Consent (for treatment)- An agreement you sign that gives your permission to receive medical services or treatment from doctors or hospitals.
Contractual Adjustment- A part of your bill that your doctor or hospital must write off (not charge you) because of billing agreements with your insurance company.
Coordination of Benefits (COB)– A way to decide which insurance company is responsible for payment if you have more than one insurance plan.
Co-payment– A cost sharing part of your bill that is your responsibility to pay. Also known as co-pay.
Coronary Care– Routine charges for care you receive in a heart center because you need more care than you can get in a regular medical unit.
Covered Benefit– A health service or item that is included in your health plan, and that is paid for either partially or fully.
Covered Days– Days that your insurance company pays for in full or in part.
CPT Codes– A coding system used to describe what treatment or services were given to you by your doctor.
CT Scan– A type of X-ray of the head or body; usually done in a hospitals x-ray department.
Date of Bill– The date the bill for your services is prepared. It is not the same as the date of service.
Date of Service (DOS)– The date(s) when you were treated.
Days– The total number of days that you are being charged for the hospitals services.
Deductible– How much cost sharing that you must pay for medical services often before your insurance company starts to pay.
Description of Services- Tells what your doctor or hospital did for you.
Diagnosis Code– A code used for billing that describes your illness.
Diagnosis-Related Groups (DRGs)- A payment system for hospital bills. This system categorizes illnesses and medical procedures into groups for which hospitals are paid a fixed amount for each admission.
Discharge Hour- Hour when you were discharged.
Discount– Dollar amount taken off your bill, usually because of a contract with your hospital or doctor and your insurance company.
Drugs/Self Administered– Drugs that do not require doctors or nurses to help you when you take them. You may be charged for these. You will need to check with your doctor or hospital.
Due from Insurance– How much money is due from your insurance company.
Due from Patient– How much you owe your doctor or hospital.
Durable Medical Equipment (DME)– Medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home.
EEG– Equipment or medical procedure that measures electricity in the brain.
EKG/ECG– Equipment or medical procedure that measures how your heart works, and your doctors reading of the results.
Eligible Payment Amount– Those medical services that an insurance company pays for.
Emergency Care– Care given for a medical emergency when you believe that your health is in serious danger when every second counts.
Emergency Room– A special part of a hospital that treats patients with emergency or urgent medical problems.
Estimated Insurance– Estimated cost paid by your insurance company.
Enrollee– A person who is covered by health insurance.
Estimated Amount Due– How much the doctor or hospital estimates you or your insurance company owes.
Explanation of Benefits (EOB/EOMB)- The notice you receive from your insurance company after getting medical services from a doctor or hospital. It tells you what was billed, the payment amount approved by your insurance, the amount paid, and what you have to pay.
External Cause of Injury Code– A code describing a place or item that may have caused injuries, poisoning, or health problems.
Federal Tax ID Number– A number assigned by the federal government to doctors and hospitals for tax purposes.
Financial Responsibility– How much of your bill you have to pay.
Fiscal Intermediary (FI)– A Medicare agent that processes Medicare claims.
Fraud and Abuse– Fraud: To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Abuse: Payment for items or services that are billed by mistake by providers, but should not be paid for by the insurance plan. This is not the same as fraud.
Guarantor– Someone who has agreed to pay the bill.
HCFA 1500 Billing Form (CMS)– A form used by doctors to file insurance claims for medical services.
HCPC Codes– A coding system used to describe what treatment or services were given to you by your doctor.
Health Care Financing Administration (HCFA)– Former name of the government agency now called the Centers for Medicare & Medicaid Services.
Healthcare Provider– Someone who provides medical services, such as doctors, hospitals, or laboratories. This term should not be confused with insurance companies that “provide” insurance.
Health Insurance– Coverage that pays benefits for sickness or injury. It includes insurance for accidents, medical expenses, disabilities, or accidental death and dismemberment.
Health Maintenance Organization (HMO)– An insurance plan that pays for preventive and other medical services provided by a specific group of participating providers.
HIPAA– Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of your health information.
Home Health Agency– An agency that treats patients in their homes.
Hospice – Group that offers inpatient, outpatient, and home healthcare for terminally ill patients.
Hospital Inpatient Prospective Payment System (PPS)– A federal system that pays a fixed fee for inpatient care.
Incremental Nursing Charge– Charges for nursing services added to basic room and board charges.
Inpatient (IP)– Patients who stay overnight in the hospital.
Insurance Company Name– Name of the company that your claim will be sent to.
Insured Group Name– Name of the group or insurance plan that insures you, usually an employer.
Insured Group Number– A number that your insurance company uses to identify the group under which you are insured.
Insured’s Name (Beneficiary)– The name of the insured person.
Intensive Care– Medical or surgical care unit in a hospital that provides care for patients who need more care than a general medical or surgical unit can give.
Internal Control Number (ICN)– A number assigned to your bill by your insurance company or their agent.
International Classification of Diseases, 9th Edition (ICD-9-CM)– A coding system used to describe what treatment or services your doctor gave to you.
IV Therapy– Treatment provided by giving intravenous solutions or drugs.
Labor and Delivery Room– A unit of a hospital where babies are born.
Laboratory – Charges for blood tests and tests on body tissue samples, such as biopsies.
Lifetime Reserve Days (Medicare)- Under Medicare, you have a lifetime reserve of 60 more days of inpatient services after you use the first 90 benefit days. You must pay a fixed amount or each day of service.
Long-Term Care- Care received in a nursing home. Medicare does not pay for long-term care unless you need skilled nursing or special rehabilitation.
Mailer/Summary of Account- A monthly summary of services (and charges?) mailed to the person who pays the bill.
Managed Care– An insurance plan that requires patients to see doctors and hospitals that have a contract with the managed care company, except in the case of medical emergencies or urgently needed care if you are out of the plans service area.
Medicaid– A state administered, federal and state funded insurance plan for low-income people who have limited or no insurance.
Medical Record Number– The number assigned by your doctor or hospital that identifies your individual medical record.
Medical/Surgical Supplies– Special supplies, such as materials used to repair a wound or instruments used for your care.
Medicare– A health insurance program for people age 65 and older. Medicare covers some people under age 65 who have disabilities or end-stage renal disease (ESRD).
Medicare + Choice– A Medicare HMO insurance plan that pays for preventive and other healthcare from designated doctors and hospitals.
Medicare Approved– Medical services for which Medicare normally pays.
Medicare Assignment– Doctors and hospitals who have accepted Medicare patients and agreed not to charge them more than Medicare has approved.
Medicare Number– Every person covered under Medicare is assigned a number and issued a card for identification to providers.
Medicare Paid– The amount of your bill that Medicare paid.
Medicare Paid Provider– The amount of your bill that Medicare paid to your doctor or hospital.
Medicare Part A– Usually referred to as Hospital Insurance, it helps pay for inpatient care in hospitals and hospices, as well as some skilled nursing costs.
Medicare Part B– Helps pay for doctor services, outpatient care, and other medical services not paid for by Medicare Part A.
Medicare Summary Notice (MSN)– The notice you receive from Medicare after getting services from your doctor or hospital. It tells you what was billed to Medicare, Medicare’s approved payment, the amount Medicare paid, and what you have to pay. Also called an Explanation of Medicare Benefits (EOMB).
Medigap– Medicare Supplement Insurance that pays for some services not covered by Medicare A or B, including deductible and coinsurance amounts.
Co-pay– Agreed amount of the charges for medical services that patients or guarantors must pay.
MRI- A type of X-ray; magnetic resonance brain or body images, usually done in a hospitals x-ray department.
Network– A group of doctors, hospitals, pharmacies, and other health care experts hired by a health plan to take care of its members.
Non-Covered Charges– Charges for medical services denied or excluded by your insurance. You may be billed for these charges. Non-Participating Provider- A doctor, hospital, or other healthcare provider that is not part of an insurance plans doctor or hospital network.
Nursery– Nursing care charges for newborn babies.
Observation– Type of service used by doctors and hospitals to decide whether you need inpatient hospital care or whether you can recover at home or in an outpatient area. Usually charged by the hour.
Oncology– Charges for treating cancer and related diseases.
Operating Room– A hospital or clinic area where surgeries are done.
Other Room and Board– Any extra charges that cannot be included in routine room and board charges.
Out-of-Network Provider– A doctor or other healthcare provider who is not part of an insurance plan’s doctor or hospital network. Same as non-participating provider.
Out-of-Pocket Costs– Costs you must pay because Medicare or other insurance does not cover them.
Outpatient (OP)– Patient who does not need to stay overnight in a hospital. Outpatient services include lab tests, x-rays, and some surgeries.
Outpatient Service– A service you receive in one day at a hospital or clinic without staying overnight.
Over-the-Counter Drug– Drugs not needing a prescription that you buy at a pharmacy or drug store.
Paid to Provider- Amount the insurance company pays your medical provider.
Paid to You– Amount the insurance company pays you or your guarantor.
Participating Provider– A doctor or hospital that agrees to accept your insurance payment for covered services as payment in full, minus your deductibles, co-pays and coinsurance amounts.
Patient Amount Due– The amount charged by your doctor or hospital that you have to pay.
Patient Type– A way to classify patients–outpatient, inpatient, etc.
Pay This Amount -How much of your bill you have to pay.
Per Diem– Charged or paid by the day.
Pharmacy Charges– Cost of drugs given under a pharmacists direction.
Physical Therapy– Treatment of diseases or injuries by exercise, heat, light, and/or massage.
Physician– Person licensed to practice medicine.
Physician Extenders– Also called mid-level service providers. Physician extenders include licensed nurse practitioners and/or licensed physician assistants. They coordinate patient care under a doctors supervision.
Physician Office– Your doctors office.
Physician Practice– A group of doctors, nurses, and physician assistants who work together.
Physician Practice Management– Non-physician staff hired to manage the business aspects of a physician practice. These staff include billing staff, medical records staff, receptionists, lab and X-ray technicians, human resources staff, and accounting staff.
Point-of-Service Plan (POS)– An insurance plan that allows you to choose doctors and hospitals without having to first get a referral from your primary care doctor.
Policy Number– A number that your insurance company gives you to identify your contract.
Pre-Admission Approval or Certification– An agreement by your insurance company to pay for your medical treatment.
Pre-Existing Condition– A health condition or medical problem that you already have before you sign up to receive insurance. Some health insurers may not pay for health conditions you already have.
Prepayments– Money you pay before getting medical care; also referred to as preadmission deposits.
Prevailing Charge– A billing charge that is commonly made by doctors in a specific region or community. Your insurance company determines this charge.
Primary Care Network (PCN)– A group of doctors serving as primary care doctors.
Primary Care Physician (PCP)– A doctor whose practice is devoted to internal medicine, family/general practice, or pediatrics. Some insurance companies consider Obstetrician/gynecologists primary care physicians.
Primary Insurance Company– The insurance company responsible for paying your claim first. If you have another insurance company, it is referred to as the Secondary Insurance Company.
Private Room (Deluxe)– A more expensive hospital room than those available to other patients. You may have to pay extra for this type of room if it is not a medical necessity.
Procedure Code (CPT Code)– A code given to medical and surgical procedures and treatments.
Prospective Payment System (PPS)– A Medicare system that pays hospitals a set amount for covered diagnostic or treatment services.
Provider Contract Discount– A part of your bill that your doctor or hospital must write off (not charge you) because of billing agreements with your insurance company.
Provider Name, Address, and Phone #– Name and address of the doctor or hospital submitting your bill.
Psychiatric/Psychological Treatments– Nursing care and other services for emotionally disturbed patients, including patients admitted for inpatient care and those admitted for outpatient treatment.
Radiology– X-rays used to identify and diagnose medical problems.
Reasonable and Customary (R & C)– Billing charges that insurers believe are appropriate for services throughout a region or community.
Recovery Room– A special room where you are taken after surgery to recover before being sent home or to your hospital room.
Referral- Approval needed for care beyond that provided by your primary care doctor or hospital. For example, managed care plans usually require referrals from your primary care doctor to see specialists or for special procedures.
Release of Information- A signed statement from patients or guarantors that allows doctors and hospitals to release medical information so that insurance companies can pay claims.
Renal Dialysis– Removal of wastes from the blood. Normally the kidneys would remove these wastes if they were functioning properly.
Respiratory Therapy– Giving oxygen and drugs through breathing, as well as other therapies that measure inhaled and exhaled gases and blood samples.
Responsible Party– The person(s) responsible for paying your hospital bill–usually referred to as the guarantor.
Revenue Code– A billing code used to name a specific room, service (X-ray, laboratory), or billing sum.
Room and Board Private– Routine charges for a room with one bed.
Room and Board Semiprivate– Routine charges for a room with two beds.
Same-Day Surgery– Outpatient surgery.
Secondary Insurance– Extra insurance that may pay some charges not paid by your primary insurance company. Whether payment is made depends on your insurance benefits, your coverage, and your benefit coordination.
Service Area– Geographic area where your insurance plan enrolls members. In an HMO, it is also the area served by your doctor network and hospitals.
Service Begin Date– The date your medical services or treatment began.
Service Code– A code describing medical services you received.
Service End Date– The date your medical services or treatment ended.
Skilled Nursing Facility– An inpatient facility in which patients who do not need acute care are given nursing care or other therapy.
Source of Admission– The source of your admission referral, transfer, emergency room, etc.
Specialist- A doctor who specializes in treating certain parts of the body or specific medical conditions. For example, cardiologists only treat patients with heart problems.
Statement Covers Period– The date your services or treatment begin and end.
Submitter ID-Identification number (ID) that identifies doctors and hospitals who bill by computers. Doctors and hospitals get an ID from each insurance company to whom they send claims using the computer.
Supplemental Insurance Company– An additional insurance policy that handles claims for deductible and coinsurance reimbursement.
Swing Bed– Bed for a patient who receives skilled nursing care in a non-skilled nursing facility.
Total Charges– Total cost of your medical services.
Type of Admission– The reason for your admission, such as emergency, urgent, elective, etc.
Type of Bill– A bill that shows what type of care is being billed, such as hospital inpatient, hospital outpatient, skilled nursing care, etc.
UB-92– A form used by hospitals to file insurance claims for medical services.
Units of Service– Measures of medical services, such as the number of hospital days, miles, pints of blood, kidney dialysis treatments, etc.
Utilization Review (UR)– Hospital staff who work with doctors to determine whether you can get care at a lower cost or as an outpatient.
You May be Billed– A phrase used by your insurance company informing you that your doctor or hospital may bill some charges directly to you.
Buck-Slip- A form given to patients to gather identification, contract, insurance, and various health-related information
Release of Information (ROI) – Patient gives all the information regarding his/her insurance, employment details and residential information. This note is called ROI.
Promissory note-The Provider signs promissory note and he assures to patient that all his/her information will be used only for billing purpose and this information will not be given to any other source.
Assignment of Benefits– A patient assigns all his benefits to the provider that he/she should receive from the insurance company for the service rendered by the provider. This is called Assignment of Benefits.
Encounter- When a patient meets the provider for healthcare services and each visit is called as Encounter. Episodic billing- For each and every visit of patient for healthcare service is recorded as new account and this is called Episodic Billing.
Provider– A Physician who renders service to a patient is called as Provider.
Participating provider– A provider who participate with the insurance company is called participating provider. A participating provider claims are processed within approximately 14 days of receipt of claims. Participating providers claims are given priority than the non-participating providers.
Non-Participating provider– A Provider who does not participate with the insurance company is called as non-participating provider. Non-participating provider claims are processed within approximately 27 days of receipt of claims.
Referring Physician– A Physician who refers the patient to a specialist is called as referring physician.
PIN (Provider Identification Number)– PIN is the Individual provider number issued by the local Medicare carrier. This number helps the provider in receiving the reimbursement for claims filed to Medicare carrier. The format of PIN is unique and varies from carrier to carrier. PINs are the numbers the physicians use to receive reimbursements/bill for services.
UPIN- UPIN is Unique Physician Identification Number. It is allotted to all Medicare providers. It is issued by CMS (Center for Medicare and Medicaid Services). The format of UPIN is 6 alphanumeric (3 alphas and 3 digits). In the absence of UPIN number, a surrogate UPIN number is given to the physician. The format of surrogate UPIN is RES000 or OTH000 UPINs are never used for billing purpose and are used only when a referring/ordering physician requests a service
Super Bill– A bill sent over a series of bills is a called super bill. Also known as an encounter form, route slip or fee slip. This is a paper charge capture tool used to document coding for a specific patient visit. It is a printed form with patient information at the top, and a subset of the provider’s/practice’s most commonly used ICD and/or CPT codes. The form travels with the patient through the clinic. Providers check off items when they see the patient, and the form then travels to the checkout desk or billing office where the codes are entered into the billing system.
Procedure codes– Procedure codes a list of descriptive terms and identifying codes for reporting medical services and procedures that physicians perform. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, thereby serving as an effective means for reliable nationwide communication among physicians, patients, and third parties.
Bundled Procedures– When two or more procedures combined together is called as Bundled procedures.
Unbundled Procedures– A service which is considered part of the basic allowance of another procedure but which is billed separately to the Insurance. Insurance does not allow billing for incorrect unbundled services.
Diagnosis codes– ICD (International Classification of Disease) codes are developed by WHO (World Health Organization) and updated by AMA as per American medical requirements. ICD-9CM codes are updated by AMA. 9 is the version and CM is Clinical Modification. These codes are alphanumeric.
Modifiers– Modifiers are two digit/alphanumeric codes that are attached to the CPT codes. This code tells about any modifications done to the procedures or repeat of the same procedures on the same day. If a service is done twice a day then modifier should be attached to it or else insurance will deny the service.
Referral & Referral Authorization#– A PCP (Primary Care Physician) refers the patient to a specialists is called as Referral. The number given to authorize the referral is called Referral authorization#.
Pre-Certification/Pre-Authorization– A system whereby a provider must receive approval from a staff member of the health plan, such as the health plan Medical Director, before a member can receive certain health care services. It relates not only whether a service of procedure is covered but also to find out whether it is medically necessary.
Fee Schedule– The amount fixed by the insurance for each procedures is called Fee schedule.
Contract Maximum– Some insurance companies have a maximum payable amount on certain illness. The amount payable on a patients policy based on his/her contract is called Contract maximum.
Deductible- The subscriber has to pay fixed amount to the insurance company before insurance company start covering his/her healthcare services. This amount is called Deductible.
Billed Amount– This is the amount charged by the provider as a compensation of his/her services rendered to the patient.
Allowed Amount- Most insurance companies have a fixed payable amount for different services performed by the provider. This amount is fixed based on the cost of treatment, geographical location of the practice, etc. Insurance companies will only pay only their allowed amount.
Contractual Adjustment-When providers billed amount is more than the participating insurance companies allowed amount, the insurance companies will pay the allowed amount and the difference between billed and allowed is called contractual adjustment. The provider should not collect this amount from the patient as he/she is participating with the insurance. (Billed amount – Allowed amount
Balance Billing– When a provider is non-participating and the insurance company pays only the allowed amount, then the difference between the billed and allowed amount can be billed to patient or secondary insurance (if available). This is called as Balance billing. The Provider can adjust this amount due to professional courtesy and this adjustment is called as Write-off.
Co-Insurance– A primary insurance company calculates the allowed amount for the charges and makes a partial payment from the allowed amount. The difference between the allowed and paid amount is called Co-insurance. This amount can be billed to secondary insurance (if available) or to the patient. A provider needs to collect this amount from the patient (Allowed amount “ Paid amount = Co-insurance) Co-pay/Co-payment- When a patient contracts with the insurance company (like HMOs), an insurance company fixes the patient liability that he/she should pay to the provider during his every visit to the provider. This amount is called as Co-pay/Co-payment. In other words, it is also called as Time of service (TOS) payment.
Out of pocket expenses– Out of Pocket Expense normally refers to the payment made by the insured. Normally it refers to both Co-pay, Deductibles and any other payment by patient to the provider out his pocket. Offset- When an insurance company had paid in excess or wrong payment has been to the provider earlier. The insurance company will deduct this amount in the payment to the provider. This is called Offset.
Capitation– A Capitation is a fixed dollar amount per plan member per month paid to providers regardless of medical utilization. The payment structure shifts the financial risk from the insurance company to the physician or hospital accepting payment. Coordination of Benefits- This is a provision regulating payments to eliminate duplicate coverage when a claimant is covered by multiple health plans. An insurance company takes into account benefits payable by another carrier in determining its own liability.
Denials– Refusal of payment from insurance company due to the reasons stated by insurance
Rejection– When an insurance company denies a claim stating that info provided in the claim is not sufficient to process the claim, for which the patient or guarantor is responsible (which can be collected only from them) is called the Rejection by Insurance. E.g. Incorrect Ins ID#, Wrong Ins, etc.
Reviews– When an insurance company denies a claim stating that it needs additional info for processing, which can be obtained from the Providers or billing office can be defined as Review. Wrong Procedure or Diag Code, Invalid or Incomplete info on claim etc are some of the examples for review.
Crossover– A situation whereby gaps in coverage for the medical expenses for a Medicare Beneficiary are forwarded by the Medicare contractor to the Patients Medigap insurer for payment. Medigap crossovers occur only if correct Medigap information is completed on the Medicare claim form and if the patient has previously signed a Medigap crossover authorization form through a participating Medicare provider. Crossover takes place only in case of Medicare, Medicaid and Medigap Plans.
Transaction Control Number (TCN)– It is a number automated by the system while automatic crossover. If a claim is resubmitted then we need to provide the old TCN and the insurance will again provide a new TCN for the resubmitted claim. Normally, it has to be resubmitted within 2 weeks.
Stop-Loss Clause– Patient fixes his/her liability on deductibles and co-pay/co-insurance beyond which insurance has to pay 100% reimbursement. This is called stop-loss clause.
Catastrophic Limit– For services with co-payments or coinsurance, this is the maximum amount out-of-pocket charges you have to pay in a calendar year. Separate limits are usually applied on a per person and per family basis.
Up Coding– A potentially fraudulent activity, which involves claims, submitted to Insurances for non-covered/non-chargeable services, supplies, or equipment in a way that makes it appear that Insurance covered services were rendered. This term is used to describe the deliberate manipulation of CPT codes for increased payment. Intentional up coding is when a physician selects one level of service code for all visits with an attitude that it evens out.
Down Coding– Down coding occurs when the coding system used on a claim submitted to an insurance carrier does not match the coding system used by the company receiving the claim. The computer system converts the code submitted to the closest code in use, but the payment generated may be less than if the claim was not down coded.
E Codes– E Codes are supplementary classification of coding in which you look for external causes of injury rather than disease. The use of an E code after the primary or secondary diagnosis tells the insurance carrier what caused the injury.
V Codes– V codes are used when a person who is not currently sick encounters health services for some specific purpose, such as to act as a donor of an organ, receive vaccination, seek consultation regarding family planning, allergies etc., V codes are also a supplementary classification of coding.
Hospice – A hospice is a public agency or private organization that is primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill people and their families.
Respite Care– It is a short-term inpatient stay that may be necessary for the terminally ill patient to give temporary relief to the person who regularly assists with home care. Inpatient respite care is limited to stays of not more than 5 consecutive days for each respite period. Normally associated with Hospice care, respite care is a benefit to family members of a patient whereby the family is provided with a break or respite from caring for the patient. The patient is confined to a nursing home for needed care for a short period of time.
Skilled Nursing Facility– An institution or a distinct part of an institution, which has in effect a transfer agreement with one or more hospitals and is primarily, engaged in providing inpatient skilled nursing care or rehabilitation services. Provides skilled nursing care, continuous 24-hour nursing service, and maintains daily medical records for each patient. It must be licensed under all applicable state and local laws. It must be approved for payment of Medicare benefits or be qualified to receive that approval if so requested. It does not include any home or facility used primarily for rest, educational care, treatment of mental or nervous disorders or a facility for the aged which furnishes primarily custodial care, including training in routines of daily living. Licensed institution primarily engaged in the provision of skilled nursing care.
Skilled Nursing Care-Daily nursing and rehabilitative care that is performed only by or under the supervision of skilled professional or technical personnel. Skilled care includes administering medication, medical diagnosis and minor surgery. Custodial Care -Care provided primarily to meet the personal needs of the member. This includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administered, or any other care that does not require the continuing services of medical personnel. Custodial Care- care, which is designed chiefly to help a person with his or her activities of daily living.
Durable Medical Equipment-Equipment that can withstand repeated use, is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home. To be covered, durable medical equipment must be medically necessary and prescribed by a contracting physician for use in the home. Examples are oxygen equipment, wheelchairs, hospital beds, and other items that the insurance company determines are medically necessary, in accordance with Medicare laws, regulations and guidelines.
Home healthcare– If a patient is confined to his/her home and requires skilled care for an illness or injury, Medicare can pay for care provided by a home health agency. Your physician should provide the home health agency with a plan of treatment. The services may be provided either on part-time or intermittent bases, not full time.
Practice management– Providers office sends all patient info to biller. Receive patient information from provider, enter all patient information, Date of service, diagnosis, procedure codes and co-payments. Submit claims, enter EOBs (Explanation of Benefits), bill patients for co-pay, deductible, co-insurance, and denials that patient needs to fix (coverage terminated, student verification). Contact provider office for missing information. For example, insurance info, medical notes, referrals, resubmit corrected claims.
Filing claims– paper and electronic claim submissions, enter patients information such as demographics, insurance information, responsible party, and superbill which list date of service, diagnosis, procedure codes, and co-payments. Submit to insurance in a timely fashion, receive acceptance and rejection reports, fix rejections and resubmit.
Patient billing– submit paper and electronic bills, use bill flash for electronic statements, paper statements sent out in BILLING system, bill for co-insurance, co-payment, deductibles, no referral/authorization, students verification, insurance terminated prior to visit, invalid identification number. If no payment received after second notice (Final Notice) Decision the doctor for collections.
Credentialing– Keeping providers records up to date with the insurance company. Records include background, name, address, Tax ID, NPI, licenses, specialty, college degrees, diplomas. If provider moves to a different location, need to update with insurance. Providers are participating or non participating/ in-network or out-of-network.
Medical coding– codes formulated for every procedure and diagnosis. Codes submitted to insurance for financial reimbursement. Helps insurance companies see what procedures were done and judge them at a glance. Registration-getting a provider registered with an insurance company. Need providers name, address, Tax ID, NPI, diplomas, licenses, resume, specialty, background information.
A/R management or Follow-up– phone calls made to the insurance company to follow up on claims submitted for patients. Service aging, high risk report, insurance aging, patient aging, check claim status, claim paid or denied, check details, check date, check number, cleared date, if denied incorrectly, have it reprocessed, if denied correctly, get required info and resubmit, post notes in insurance narrative.
Denial management: submit claim– find out if claims are denied by performing a follow up or receiving a denied EOB. Call insurance for denial reason, invalid ID, name doesn't match the ID, needs referral, needs medical notes, procedure not covered with diagnosis submitted, insurance terminated, submitted too late (timely filing). Contact providers office for necessary info then resubmit corrected claim. If denial for timely filing, appeal with proof.
Electronic claims– Claims electronically, submit in a batch and get session number, claims are accepted or rejected, find out why claims were rejected and take necessary actions to fix and resubmit, commercial insurance claims submitted through MD-online, submit through Ivans for Medicare and BCBS claims.
Practice management consulting-Assisting the providers office in improving their performance. Provide advice on how to become more organized and efficient. Ensure the providers office collects co-payments and calls insurance before seeing patient to check eligibility, see if referral is required, if insurance is unfamiliar, make sure Dr. participates to avoid denials. Inform office to send claims to billing service in a timely fashion to avoid late filing.
Medical billing-Bill insurance companies and patients for office visits and procedures. Submit claims by entering all patient information, date of service, CPT codes, diagnosis codes and co-payments, perform a follow up, post EOBs, correct denials, send patient bills for any patient responsibility. Need to communicate with providers and office staff, insurance companies and patients. Lyte- Medical billing software, manage provider accounts, stores account information such as name, address, phone number, Tax ID, NPI, stores patients records, insurance carriers, gives ability to enter claims, transmit claims, to submit paper and electronic, reports, patient aging, insurance aging.
Electronic Medical Records (EMR)– stores patient records electronically rather then using paper charts. Stores patient demographics, insurance, procedures, diagnosis, medical notes, referrals, prescriptions. More organized than paper charts since it is stored in a more structured data record. Quicker and easier to retrieve information.
