Week 1
is the amount paid to a healthcare provider for services provided to a patient.
reimbursement
are healthcare services for which the insurance company will pay as outlined in the healthcare plan.
Benefits or covered costs
established in 1935 to provide old-age benefits for workers, unemployment insurance, and aid to dependents and children with physical handicaps, was amended by Public Law 89-97 on July 30, 1965, to create the Medicare program
Social security act
charges, refers to the price assigned to a unit of medical or health service, such as a visit to a physician or a day in a hospital.
billed charges
s the regular set of tasks and activities that produces reimbursement (revenue)
revenue cycle
is an annual amount of money that the policyholder must pay before the health insurance plan will assume its share of liability for the remaining charges or covered expenses
deductible
is a national health insurance program that provides health services to elderly and other qualifying individuals.
Medicare
or allowable amount, is the amount that the third-party payer or insurance company will pay for a service.
allowable charges
is the supervision of all the administrative and clinical functions that contribute to the capture, management, and collection of patient service reimbursement.
Revenue cycle management
The contract that describes the conditions of the insurance policy is called a
certificate of insurance
the portion of Medicare that covers outpatient care services, is an optional and supplemental insurance package that beneficiaries may purchase.
Medicare Part B
and reimbursement are often used interchangeably; both refer to the amount paid to a healthcare provider for services provided to a patient.
payment
in general, is a system of reducing a person’s exposure to risk of loss by having another party, an insurance company, assume the risk.
insurance
are the health conditions, illnesses, injuries, diseases, or symptoms that the health insurance company will reimburse for treatment that attempts to maintain, control, or cure said conditions. In addition to covered conditions, the policy indicates healthcare services related to covered conditions and all other aspects of healthcare for which the healthcare plan will pay.
covered conditions
Medicare’s prescription drug benefit program, was created by the MMA of 2003.
Medicare Part D
s based on the actual resources expended to deliver the services and is finalized after the services are delivered.
retrospective reimbursement
is an insurance company or health agency that pays the physician, clinic, or other provider for the care or services rendered to the patient.
third party payer
as “services or supplies that are proper and needed for the diagnosis or treatment of your medical condition; are provided for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local area; and aren’t mainly for the convenience of you or your doctor”
medically necessary
is a period of expanded cost sharing based on prescription drug utilization and cost for Part D beneficiaries. This coverage gap is also referred to as the “donut hole.
coverage gap
is established prior to the healthcare delivery and does not change based on the costs of the actual services delivered to the patient.
prospective reimbursement