The Lingo
The patient is first; the PT is second; and the insurer is third.
What is party?
Allows patients more flexibility to choose healthcare providers they may prefer but there is no guarantee of 100% coverage.
What is a PPO?
A mixture of standardized numbers and letters that indicate a specific diagnosis used for billing.
ICD-10 codes
A government healthcare system accessible to members of the armed service and their families.
What is Tricare?
An insurance company refusal to pay for services rendered?
What is denial?
Considered the payor that makes payment for services under an insurance policy.
What is the insurer?
Insurance made available to its employees and includes a variety of benefits and services and often requires payment of a deductible or co-pay.
What is private insurance?
A series of 5 numbers used for indicating the service provided for the purpose of reimbursement.
What is a CPT code?
A government insurance plan that provides coverage for inpatient care, SNFs and hospice.
What is Medicare Plan A?
Requires state Medicare/Medicaid agencies to create Health Insurance Marketplaces to give the uninsured access to health insurance.
What the ACA or Obamacare?
Payment by the first or third party to the second party for services rendered.
What is reimbursement?
A system used by hospitals and other large healthcare agencies to control the cost of services. Only patients enrolled within their network / plan are seen. There is a monthly payment received for services that have been provided to those enrolled.
What is a MCO (managed care organization)?
Therapeutic exercise, neuromuscular re-education, and therapeutic exercises are examples of this category of CPT codes.
What are timed (or time based) codes?
A government insurance plan that provides coverage for outpatient care and covers for other plans that have been exhausted or denied.
What is Medicare part B?
A qualification process that determines if a patient may use their benefits based on certain factors.
What is eligibility?
A PT service is provided to a patient and the payment is made for that specific service either by the patient or the insurer.
What is fee-for-service?
A third party payer that contracts with a network of clinicians providing a variety of medical disciplines for a prepaid amount in efforts to reduce expenditures. A PCP is often used as the gait keeper before other specialists can be seen.
What is an HMO?
The range of CPT codes within which PT procedural codes are utilized.
What is 97000?
A government program that provides coverage for non-elderly low-income parents.
What is Medicaid?
A fixed payment the patient must pay, usually when using private insurance, despite the costs covered by the insurance company or services provided.
What is a copayment?
A healthcare provider is paid a fixed amount each month proportionate to the number of patients treated during that time period.
What is capitation?
A patient accessible account provided by insurance companies to save funds that can only be used for the payment of medical services and products.
What is an HSA OR FSA? (health savings account / flexible spending account)
Used by insurance companies to identify the PT who is billing.
What is an NPI?
A payment system that assigns a score to SNF patients and determines the amount of reimbursement that case will be awarded based on 5 parameters.
What is a PDPM (Patient-driven payment model)?
A limitation of the number of visits allowed due to an approval process that occurs before treatment is started.
What is Authorization?