Health Law and Ethics
Restricting and maintaining security of patients information
Confidentiality
Prior Approval
Pre-Authorization
Person eligible to receive healthcare benefits
Beneficiary
An encounter form in the physicians office
Superbill
Health Insurance company that provides coverage, such as BC/BS is called what?
Third-Party-Payer
Assigning Lower level codes than documented in the record
Downcoding
Final choice being made by someone with NO judicial powers
Arbitration
Provider accepts pre-established payments for providing health care services to enrollees over a period of time
Capitation
Letter signed by a provider explaining why claim should be reconsidered for payment
Appeal
Assigning an ICD-10 code that doesn't match a record to illegally increase reimbursement
Upcoding
Judicial dispute resolution process in which as appeal board makes a final determination
Adjudication
Percentage patient pays for covered services after deductible and copayment have been met
Deductible
Person responsible for paying health care fees
Guarantor
Insurance claim or flat file used to bill institutional services, such as services performed in hospitals
UB-04
Individuals entitled to Medicare and eligible for some type of Medicaid benefits
Dual Eligible
Legal action to recover a debt
Litigation
!!Double Points!!
A list of predetermined payments for health care services provided to patient
Fee Schedule
Submitting multiple CPT codes when 1 code should be submitted
Unbundling
A correctly completed standardized claim
Clean Claim
!!Double Points!!
Determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan
The Birthday Rule
Time permitted by state to submit a medical malpractice lawsuit
Statue of Limitations
Health care services determined by state that a NP and PA can perform
Scope of Practice
Single-payer system owned by government and operates health care facilities
Socialized Medicine
Performs centralized claims processing for providers and health plans
Clearinghouse
Provider receives reimbursement directly from patient
Assignment of Benefits