Billing Basics
What does “EOB” stand for in medical billing?
Explanation of Benefits
What is a “deductible”?
The amount a patient pays before insurance starts covering costs
What does “HIPAA” stand for?
Health Insurance Portability and Accountability Act.
Reimbursement for income lost as a result of a temporary or permanent illness or injury.
What is Disability Insurance
What is a “co-pay”?
A fixed amount a patient pays for a service.
In billing, what does “POS” mean?
Place of Service.
What does “pre-authorization” mean?
Approval from the insurer before certain services are provided.
Why is it important to follow HIPAA?
To protect patient privacy and avoid penalties.
federal health insurance program, authorized by Congress and administered by CMS, for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease (ESRD).
Medicare
Define “reimbursement” in billing.
Payment from insurance for services provided.
Who is responsible for billing patient co-pays?
The provider’s billing office.
What is a “network” in health insurance?
A group of providers contracted with an insurance plan
Define “fraud” in billing.
Intentionally submitting incorrect claims to receive payment.
cost-sharing program between the federal and state governments to provide health care services to Americans with low incomes.
Medicaid
What is an “adjustment” on a bill?
A reduction in the billed amount based on insurance agreements.
What is the purpose of a claim form?
To submit details of services provided for reimbursement.
Define “out-of-pocket maximum.
The most a patient pays in a year before insurance covers 100%.
What is “upcoding”?
Billing for a higher-cost service than was provided.
Are available through employers and entities (e.g., labor unions) that offer health insurance coverage for small groups (up to 50 employees), large groups (more than 100 employees), and association health plans
Group Health Plans
What’s an “allowed amount”?
The maximum an insurance plan will pay for a service.
Define "Superbill
A document listing rendered services and codes for insurance submission.
What is “coordination of benefits”?
Determining primary and secondary insurance coverage.
What organization investigates Medicare fraud?
Office of Inspector General (OIG).
Helps cover inpatient hospital care, skilled nursing facility care, hospice care, and home health care;
Medicare Part A
What is a “write-off”?
The portion of a bill a provider agrees not to charge.