Insurance Billing Manual Glossary Of Terms
(P-Z)
Palliative Care
– Maintenance massage.
Pending
Claim – claim sent to insurance company
and is being held for any number of reasons such as incorrect codes, forms not
completed.
Personal Injury Protection
(PIP) – a component of auto insurance that pays the medical bills directly
before the case is settled. They will deal with getting the money from the
responsible party later.
Preferred
Provider Organizations (PPO)- You or
your employer receive discounted rates if you use doctors from a pre-selected
group. If you use a physician outside the PPO plan, you must pay more for the
medical care.
Prescriptions-
formal referrals from appropriate health care providers that include the
diagnosis, the diagnosis code, the treatment plan. A prescription is necessary
to prove medical necessity.
Primary Care Provider (PCP)-
A health care professional (usually a physician) who is responsible for
monitoring an individual's overall health care needs. Typically, a PCP serves as
a "quarterback" for an individual's medical care, referring the individual to
more specialized physicians for specialist care.
Progress Report /Progress
Notes – system of charting a clients’ progress and condition. These are
usually in the form of SOAP notes, but you can use
whatever works for you.
There are hundreds of methods of reporting: interim reports, narrative reports.
Provider -
Provider is a term used for health professionals who
provide health care services. Sometimes, the term refers only to physicians.
Often, however, the term also refers to other health care professionals such as
hospitals, nurse practitioners, chiropractors, physical therapists, massage
therapists and others offering specialized health care services.
Reasonable and Customary Fees-
The average fee charged by a particular type of health care practitioner within
a geographic area. The term is often referred to by insurance companies as the
amount of money they will approve for a specific test or procedure. If the fees
are higher than the approved amount, the individual receiving the service is
responsible for paying the difference. Sometimes, however, if an individual
questions his or her physician about the fee, the provider will reduce the
charge to the amount that the insurance company has defined as reasonable and
customary.
Relative Value Unit (RVU)- assigned value
of a CPT code that is relative to the actual costs of providing a procedure.
Each insurance company takes each value and then multiplies it by the conversion
factor for each specific region to determine an allowable fee or price for each
code.
Resource Based Relative Value Scale (RBRVS)
– system developed at Harvard University to assess health care providers work,
overhead costs and malpractice risk for each CPT code.
Third Party Payment – Money paid by
someone other than the person receiving the services or the primary provider,
such as the insurance company of the person who is at fault for a motor vehicle
accident.
Usual, Customary and Reasonable (UCR) or Covered
Expenses-Set by the insurance
companies to determine what to pay for each CPT code: An amount customarily
charged for or covered for similar services and supplies which are medically
necessary, recommended by a doctor, or required for treatment. The UCR is
determined by services such as Medicode and published in the National Fee
Analyzer. When I contacted this company, they were unable to tell me exactly
how these fees were determined. I believe that the reason the UCR’s are so
high, is because that is what insurance companies will pay and massage
therapists are billing that amount only because that is what they can get from
that company.
