Medical Billing Terminology - F, G & H

F

Fee for Service: This refers to a type of health insurance wherein the provider is paid for every service they perform. People with fee-for-service plans typically can choose whatever hospitals and physicians they want to receive care in exchange for higher deductibles and co-pays.

Fee Schedule: A document that outlines the costs associated for each medical service designated by a CPT code.

Financial Responsibility: Whoever owes the healthcare provider money has financial responsibility for the services rendered. Insurance companies or patients themselves may be financially responsible for the costs associated with care, and these responsibilities are typically outlined in a healthcare plan contract.

Fiscal Intermediary (FI): The name for Medicare representatives who process Medicare claims.

Formulary: A table or list provided by an insurance carrier that explains what prescription drugs are covered under their health plans.

Fraud: Providers, patients, or insurance companies may be found fraudulent if they are deliberately achieving their ends through misrepresentation, dishonesty, and general illegal activity. Medical billing specialists who deliberately enter incorrect or misleading information on claims may be charged with fraud.

G

Group Health Plan (GPH): A plan provided by an employer to provide healthcare options to a large group of employees.

Group Name: The name of the group, insurance carrier, or insurance plan that covers a patient.

Group Number: A number given to a patient by their insurance carrier that identifies the group or plan under which they are covered.

Guarantor: The party paying for an insurance plan who is not the patient. Parents, for example, would be the guarantors for their children’s health insurance.

H

Healthcare Financing Administration: The former name for what is now the CMS.

Healthcare Financing Administration Common Procedure Coding System (HCPCS): HCPCS is a three-tier coding system used to explain services, devices, and diagnoses administered in the healthcare system. Medical billing specialists utilize codes in the HCPCS on a daily basis to file claims.

Healthcare Insurance: This is insurance offered to a group or an individual to cover costs associated with medical care and treatment. Those covered by healthcare insurance typically must pay a premium for their plans in addition to various co-pays and/or deductibles.

Healthcare Provider: These are the entities that offer healthcare services to patients, including hospitals, physicians, and private clinics, hospices, nursing homes, and other healthcare facilities.

Healthcare Reform Act: The major healthcare legislation passed in 2010 designed to make healthcare accessible and less expensive for more Americans.

Health Insurance Claim: The unique number ascribed to an individual to identify them as a beneficiary of Medicare.

Health Insurance Portability and Accountability Act (HIPAA): HIPAA was a law passed in 1996 with an aim to improve the scope of healthcare services and establish regulations for securing healthcare records from unwanted parties.

Health Maintenance Organization (HMO): HMOs are networks of healthcare providers that offer healthcare plans to people for medical services exclusively in their network.

Hospice: This refers to medical care and treatment for persons who are terminally ill.

HIPAA Understand the basics

HIPAA is the acronym for the Health Insurance Portability and Accountability Act. Although HIPAA covers many things, physicians typically are most concerned with HIPAA’s Administrative Simplification provisions, and particularly the Privacy, Security and Breach Notification requirements. Since it was originally enacted, HIPAA has been amended and expanded several times as a result of new laws and regulations. The most sweeping change resulted from the Health Information Technology for Economic and Clinical Health Act (HITECH), enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA).

This toolkit provides an overview of the HIPAA Privacy, Security and Breach Notification Rules with which almost all physicians must comply. At their core, these rules simply implement longstanding physician commitments to protect the confidentiality of their patients’ medical information and maintain open physician-patient communications. However, the specificity of the requirements goes well beyond traditional, self-evident obligations, and violations can result in serious penalties. Thus, physicians need to understand these rules and participate in a formal compliance plan designed to ensure all the requirements are met.   Physicians should also note that HIPAA is considered a “floor,” meaning, states may have requirements that go above and beyond what the federal government requires.  This toolkit is focused on the federal mandates.

In a nutshell, these three core compliance areas include:  

1.  The Privacy Rule 

The Privacy Rule restricts covered entities’ and business associates’ use and disclosure of an individual’s "protected health information" (PHI). Physicians who transmit PHI electronically in a HIPAA Standard Transaction, such as by filing electronic claims or checking eligibility electronically even if they are using a third party such as a billing service or a clearinghouse, are “covered entities,” and bound by HIPAA.  “Business associates” include those persons and companies that physicians hire to help their practice and that have access to their patients’ PHI, such as billing services, attorneys, accountants and consultants. "Protected health information" means individually identifiable information that is held or transmitted by a covered entity or business associate in any form or media—whether electronic, paper,or oral, that relates to the past, present, or future physical or mental health of an individual, health care services, or payment for health care. The Privacy Rule also provides for “individual rights” such as a patient’s right to access their PHI, restrict disclosures, request amendments or an accounting of disclosures and their right to complain without retaliation.