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Please also check the
insurance billing manual updates and the
blog for more information.
Glossary of Insurance Terms (F- O)Fee schedule – listing of established allowances set by the insurance companies; maximum allowable charge for specific medical services. Also: the set fees or prices of the health care provider. It is important to have a fee schedule in written form. Functional Goals Functional Outcomes Functional Outcomes Reporting Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists” by Diana L. Thompson for her interpretation of these terms. Gatekeeper – AKA primary care physician (PCP)- Co-ordinates medical care in a managed care system. Health Care Decision Counseling- Services, sometimes provided by insurance companies or employers, that help individuals weigh the benefits, risks and costs of medical tests and treatments. Unlike case management, health care decision counseling is non-judgmental. The goal of health care decision counseling is to help individuals make more informed choices about their health and medical care needs, and to help them make decisions that are right for the individual's unique set of circumstances. HCFA – Health Care Financing Administration – Department of Health and Human Services division that oversees federal health care regulations such as Medicare, Medicaid. HCFA 1500 - Health Care Financing Administration (HCFA) claim forms that are most widely accepted by insurance companies. Health Maintenance Organizations (HMO's)- Health Maintenance Organizations represent "pre-paid" or "capitated" insurance plan in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided, Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs vary in design. Depending on the type of the HMO, services may be provided in a central facility, or in a physician's own office. ICD-code- International Classification of Disease code – a code that indicates what the diagnosis or condition is that the patient is being treated for. This is provided by the referring physician or health care provider. ICD-9 indicates the 9th edition. ICD –10 indicates the 10th edition. Codes are revised with each edition. Indemnity Health Plan- Indemnity health insurance plans are also called "fee-for-service." These are the types of plans that primarily existed before the rise of HMOs, IPAs and PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of health care services, and the insurance company (or self-insured employer) pays the other percentage. For example, an individual might pay 20 percent for services and the insurance company pays 80 percent. The fees for services are defined by the providers and vary from physician to physician. Indemnity health plans offer individuals the freedom to choose their health care professionals. Independent Practice Associations- IPAs are similar to HMOs, except that individuals receive care in a physician's own office, rather than in an HMO facility. Independent Medical Exam (IME) –examination of the client and their records by an independent party. In a personal injury case, the adjuster will usually call for an IME when they are determining if the service is reasonable and necessary. The insurance company pays for the exam. The doctor must be the same kind of provider as the PCP. In general, when this exam is called for you can expect the benefits to be terminated. It is advisable that the client consult with the attorney before going to an IME and when the benefits are terminated.
Insured- the person who is the policyholder. This may not necessarily be the owner and it may not always be the injured party. The insured may be a spouse, dependent or a passenger. Interim Report – A re-evaluation of the clients’ condition that can be requested by the lawyer, insurance company or doctor. Labor and Industry (L&I) or worker’s compensation – Insurance Plan that covers workers on the job. Each state has different rules and regulations. Lien – filing a claim against the settlement to secure payment for your services. Find out who you need to file this with by contacting the county court. Medically necessity- services such as massage therapy that may be need to for treatment of the condition or illness. In order to bill insurance companies, the work you do must be medically necessary. The injury or illness must be diagnosed by a physician. Each company has their own definition of medically necessity. Managed Care- A medical delivery system that attempts to manage the quality and cost of medical services that individuals receive. Most managed care systems offer HMOs and PPOs that individuals are encouraged to use for their health care services. Some managed care plans attempt to improve health quality, by emphasizing prevention of disease. Maximum Dollar Limit- The maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period. Maximum dollar limits vary greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year. Mediation – Method of Alternate Dispute Resolution in which the mediator acts as a liaison between the insurance company and the injured party to agree on a settlement. The mediator is paid by the parties requesting a mediation. You may be asked to appear at a mediation. Modalities – for the purpose of insurance billing a modality uses mechanical devices or other methods to assist in the treatment; such as hot or cold packs, paraffin baths, infrared treatments. Modalities are also a term used to describe the many different types of techniques of massage and bodywork. Different modalities are Reiki, Trigger point therapy, myofascial release, structural integration (there are literally hundreds). Narrative Report – summary of client’s injuries, treatments given, and progress usually in a letter format. Often required for settlement. Out-Of-Plan/out of network- This phrase usually refers to physicians, hospitals or other health care providers who are considered non-participants in an insurance plan (usually an HMO or PPO). Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by an individual's insurance company.
Please also check the
insurance billing manual updates and the
blog for more information.
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