Medical billing and coding latest version graded A+

Medical billing and coding latest version graded A+ Medical Insurance Financial plan (the payer) that covers the cost of hospital and medical care Policyholder Person who buys an insurance plan; the insured, subscriber, or guarantor Health Plan Individual or group plan that provides or pays for the cost of medical care Benefits What a health plan pays for services covered in an insurance policy; listed in the schedule of benefits. Medical Necessity Reasonable services of provider (doctor or facility) consistent with professional medical standards. Covered Services Determined as being medically necessary and both reasonable and consistent with the standards for the diagnosis or treatment of injury or illness. Non-covered Services Medical procedures not covered in a plans benefits. Individual Health Plan (I H P) contract between individual and the plan known as direct pay. Group Health Plan (G H P) contract between an employer or organization and the plan, the group members are insured as "subscribers". Disability Insurance Replaces income lost because the insured cannot work Workers' Compensation Insurance Provides benefits for an insured injured on the job Indemnity Insurance Payment method is fee-for-service based on the contract's schedule of benefits,fee is paid AFTER the patient receives services from the physician. Managed care A system that combines the financing and the delivery of appropriate, cost- effective health care services to its members. Premium Periodic payment the patient is required to make to keep the policy in effect. Deductible Amount that the insured pays on covered services before benefits begin. Coinsurance Percentage of each claim that the insured pays; states the health plan's percentage of the charge, followed by the insured's percentage. Health Maintenance Organizations (HMOs) A manged health care system in which providers agree to offer healthcare to the organization's members for fixed periodic payments from the plan. capitation Method a fixed prepayment made to the medical provider for all necessary contracted services provided to each patient who is a plan member no matter how much medical care is received during the determined time period. Per member per month, (PMPM) (per member per month): The "capitated rate" Capitation this amount is paid to the health care provider based on the schedule of benefits, no matter how much medical care is received during the determined time period. Point of Service Plan (PPO) Combines features of both HMOs and PPOs Also called an "open access HMO "Allows members to see providers in or out of HMO's network Members pay more for out-of-network providers. Preferred Provider Organizations (PPO) A managed care organization structured as a network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge. PPOs control the cost of health care by: Directing patients' choices of providers Controlling use of services Requiring preauthorization for services Requiring Cost-sharing Consumer-Driven Health Plans (CDHP) Combine two elements: A health plan, usually a PPO, that has a high deductible (such as $1,000) and low premiums A special "savings account" that is used to pay medical bills before the deductible has been met Cost containment plan based on consumerism: Idea that patients who pay for health care services become more careful consumers. Private Payers Have contracts with businesses to provide benefits for their employees...better rates self-funded health plans The organization "insures itself" a company creates its own insurance plan for its employees, rather than using a carrier; the plan assumes payment risk, contracts with physicians,