Saturday, 12 August 2017

Medical Terms

Plan 
A benefit your employer, union or other group sponsor provides to you to pay for your health care services. 

Preauthorization 
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. 

Preferred Provider 
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more. 

Premium 
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. 

Prescription Drug Coverage 
Health insurance or plan that helps pay for prescription drugs and medications.

Prescription Drugs
 Drugs and medications that by law require a prescription. 

Primary Care Physician 
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient

Primary Care Provider 
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services. 

Provider 
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law

Reconstructive Surgery 
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions. 

Rehabilitation Services 
Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Skilled Nursing Care 
Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home. 

Monday, 7 August 2017

Glossary of Health Coverage and Medical Terms

Excluded Services 
Health care services that your health insurance or plan doesn’t pay for or cover. 

Grievance 
A complaint that you communicate to your health insurer or plan. 

Habilitation Services 
Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. 

Health Insurance 
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

Home Health Care 
Health care services a person receives at home. 

Hospice Services 
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization 
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Hospital Outpatient Care 
Care in a hospital that usually doesn’t require an overnight stay.

Tuesday, 1 August 2017

Health Coverage and Medical Terms

Allowed Amount 
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. 

Appeal 
A request for your health insurer or plan to review a decision or a grievance again.

Balance Billing 
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. 

Co-insurance 
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Complications of Pregnancy 
Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren’t complications of pregnancy. 

Co-payment 
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. 

Thursday, 27 July 2017

Using Health Information Technology

Medical assistants use health information technology (HIT)— computer hardware and software information systems that record, store, and manage patient information—in almost all physician practices. 

Practice Management Programs 
A good example of HIT is practice management programs (PMPs), specialized accounting software programs used in almost all medical offices for tracking charges for patients’ services and treatments, billing insurance companies and patients, recording payments, and collecting overdue accounts. Most programs also have the ability to schedule patient appointments. Since PMPs can send information electronically, rather than just on paper, cash flow is improved because physicians receive payment in less time than when they send in paper claims and wait for checks to arrive in the mail.

Practice management programs facilitate the day-to-day financial operations of a medical practice. Before PMPs became so universally used, manual accounting systems logged all of this information by hand, a time-consuming and cumbersome process. Now PMPs automate that work, so staff members can work more efficiently and in a timely manner. 

 Not all medical offices use the same PMP, but most programs operate in a similar manner. Initially, the program is prepared for use by entering basic facts about the practice. Often a computer consultant or an accountant helps set up these records. Information about many aspects of the business is entered, including:

  Patient data Information about each patient, such as name, address, contact numbers, and insurance coverage.
 Provider data Information about each provider, including facts about providers, referring providers, and outside providers such as labs, radiology, and ambulatory surgery centers. 
 Health plan data Details about the companies that insure the practice’s patients. 
 Transaction data The dates of patients’ past visits along with records of their illness and treatments, as well as payments collected. 

Once the initial setup and data entry are complete, the PMP is ready to be used to accomplish many of the daily tasks of a medical practice.

Electronic Health Records  
Another HIT application is rapidly becoming critical in physician practices: electronic health records, or EHRs. While patients’ financial records have been electronic for over a decade, clinical records—the documentation of a patient’s health entered by doctors, nurses, and other health care professionals—until recently, have been stored in paper charts. An electronic health record (EHR) is a computerized lifelong health care record for an individual that incorporates data from all sources that provide treatment for the individual. EHR systems are set up to gather patients’ clinical information using the computer rather than paper. Most EHR systems are designed to exchange information with—“to talk to”—the PMP and to cut out the need for many paper forms.

Sunday, 23 July 2017

Following Procedures

Medical administrative work requires following a set of procedures. Some procedures involve administrative duties, such as entering data, updating patients’ records, and billing insurance companies. Other procedures are done to comply with government regulations, such as keeping computer files secure from unauthorized viewing. In most offices, policy and procedure manuals are available that describe how to perform major duties.

For most procedures, medical assistants work in teams with both licensed medical professionals and other administrative staff members. Providers include physicians and nurses as well as physician assistants (PAs), nurse-practitioners (NPs), clinical social workers, physical therapists, occupational therapists, audiologists, and clinical psychologists. Administrative staff may be headed by an office manager, practice manager, or practice administrator to whom medical assistants, patient services representatives or receptionists, and billing, insurance, and collections specialists report. 

Communicating with Physicians and Patients  
Communication skills are as important as knowing about specific forms and regulations. Using a pleasant tone, a friendly attitude, and a helpful manner when gathering information increases patient satisfaction. Having interpersonal skills enhances the billing and reimbursement process by establishing professional, courteous relationships with people of different backgrounds and communication styles. Patients may need help with their questions about insurance reimbursement and the health care claim process. Patients also need assistance when problems with payments arise. Effective communicators have the skill of empathy; their actions convey that they understand the feelings of others.

Equally important are effective communications with physicians, other professional staff members, and all members of the administrative team. Conversations must be brief and to the point, showing that the speaker values the provider’s time. People are more likely to listen when the speaker is smiling and has an interested expression, so speakers should be aware of their facial expressions and should maintain moderate eye contact. In addition, good listening skills are important.  

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