Glossary of Insurance billing terms
(A - E)
Advocacy-
Any activity done to help a person or group to get something the person or group
needs or wants.
Adjuster – the insurance representative
assigned to the clients case, who reviews and authorizes or denies payment.
The adjuster is also known as the claim manager. Not all companies have
assigned adjusters.
Affidavit – A written statement made under
oath. You may be asked to make or sign an affidavit that describes the
treatment and condition of the client. Accurate chart notes are necessary
to make statements to be used in an affidavit.
Affinity Plan or Network – a type of
insurance contract that requires providers to offer their services at a
discounted fee.
Allowable Fee – the maximum amount that
each insurance company will pay. This is usually based on the Usual,
Customary and Reasonable Fee (UCR), but not always. They will only pay
this amount no matter what you charge. If you are contracted with a
provider network, you are may be unable to charge the difference to your client.
Ancillary-
that which assists in the treatment of a service: massage is ancillary to
chiropractic treatments.
Arbitration – An alternative to going to
court for dispute resolution. Clients’ who are seeking a settlement from
an insurance company and don’t want to go to court can pay for arbitration
services. The arbitrators are usually lawyers or retired judges. You may
be asked to appear at an arbitration on behalf of the client. You can
charge the client for your appearance at an arbitration. Be prepared to
speak about the clients’ condition and how it has improved from your work and
what is the clients’ current state of health in relation to their injuries.
Assessment – the assessment (A) section of
the SOAP chart records: the process of assessment involves interpreting the
subjective and objective findings to make conclusions about the clients’
condition. This is also making a diagnosis, which massage therapists are
not licensed to make. Since we aren’t allowed to diagnose, this is
to report the immediate results of the session (functional outcomes).
Assignment of Benefits- line 13 on the
HCFA form; When a client authorizes the provider to be paid directly for their
services.
Authorization – to verify benefits and get
approval from the insurance company to treat the client. Even if you get a
verbal authorization, it does not guarantee that you will be paid. It is
advised that you start all claims by making a call to authorize or verify
benefits.
Benefit -
Amount payable by the insurance company to a claimant, assignee, or beneficiary
when the insured suffers a loss.
Bodily Injury Insurance – Type of auto
insurance that covers someone who is at-fault for bodily injuries that they have
caused to others in an accident. It is paid in a lump sum for any future
health care, pain and suffering, lost wages and permanent impairment or
disability.
Bundling –
process of combining two or more health care procedures into one CPT code.
I used to be able to charge for hot/cold packs, but they have now been bundled
into the CPT code for therapeutic massage (97124).
Capitation-
Capitation represents a set dollar limit that you or
your employer pay to a health maintenance organization (HMO), regardless of how
much you use (or don't use) the services offered by the health maintenance
providers. (Providers is a term used for health professionals who provide care.
Usually providers refer to doctors or hospitals. Sometimes the term also refers
to nurse practitioners, chiropractors and other health professionals who offer
specialized services.)
Claim- A
request by an individual (or his or her provider) to an individual's insurance
company for the insurance company to pay for services obtained from a health
care professional.
Clean Claim – A claim submitted to an
insurance company that is complete and accurate. An insurance company
won’t pay the bill unless the claim is “clean”. Some common errors include
incorrect codes, incorrect patient information and anything else that the
insurance company feels like at the time.
Co-Insurance-
Co-insurance refers to money that an individual is required to pay for services,
after a deductible has been paid. In some health care plans, co-insurance is
called "co-payment." Co-insurance is often specified by a percentage. For
example, the employee pays 20 percent toward the changes for a service and the
employer or insurance company pays 80 percent.
Co-Payment- Co-payment is a
predetermined (flat) fee that an individual pays for health care services, in
addition to what the insurance covers. For example, some HMOs require a $10
"co-payment" for each office visit, regardless of the type or level of services
provided during the visit. Co-payments are not usually specified by percentages.
Complementary and Alternative Medicine (CAM) – A term used to describe
massage therapy, acupuncture and other non-traditional healing methods.
Con current care- If the client visits two
health care providers that bill for the same service on any given day, the
procedures are considered to be duplicate and will not be allowed (paid).For
example: a client gets a massage and visits the physical therapist on the same
day and they both bill 97140 – one of the providers will not get paid.
Conversion Factor – Conversion factors
take into consideration geographical variations, inflation and variations in
medical expenses. The conversion factors are then applied to the Relative
Value Unit (RVU) to determine a price close to the usual, customary and
reasonable charges. See also Relative Value Unit.
CPT code
(Current Procedural Terminology) – 5 digit code indicating the
procedure that you are performing on the client set up by the Physicians Current
Procedural Terminology coding system and published by the American Medical
Association.
Deductible-The
amount an individual must pay for health care expenses before insurance (or a
self-insured company) covers the costs. Often, insurance plans are based on
yearly deductible amounts.
Denial Of Claim-
Refusal by an insurance company to honor a request by an individual (or his or
her provider) to pay for health care services obtained from a health care
professional.
Deposition – form of discovery or inquiry
in which attorney has the right to ask questions of the providers to obtain
information that will be relevant for settling the case. You may be asked
to provide such information on any case you work on.
Diagnosis – the providing physician must
provide a diagnosis and identify what disease, symptoms or illness a client has.
Massage Therapists are not allowed to diagnose.
Diagnosis Code - A code determined
by the World Health Organization for each specific diagnosis. Also known
as an International classification of Diseases (ICD –9). The 9 refers to
the 9th
edition. Published annually by the Health Care Financing Administration (HCFA).
For a list of ICD-9 codes, see the appendix.
WE ARE NOT ALLOWED TO ASSIGN THESE CODES! ICD-9 codes should be supplied
by the physician. I am supplying the codes so that you can know what the
diagnosis is when the physician only supplies the code and not the written
diagnosis.
Disability – A person who is unable to
work part or full time.
Disability Insurance – Private insurance
that covers a person who is disabled until they are able to go back to work.
Electronic Claim –
bills sent electronically through FAX or
computer to the insurance company.
Exclusions -
Medical services that are not covered by an individual's insurance policy.
Explanation of Benefits (EOB) – an
explanation of services issued to providers and patients telling them what has
been paid, what is owing, how much the co-pay is, what has not and why not and
for what dates of service.
Employer self- insured plans – Insurance
programs set up by companies for their employees by themselves rather than with
a commercial insurance carrier. They often contract with a commercial
insurance company to be the administrators. Companies who are self-insured
usually do not have to abide by the same rules for coverage. Self insured
companies here in WA State do not have to enforce the “Every Category Law” that
allows massage therapists to become providers for HMO’s and PPO’s.
Evaluation and Management Codes (E&M codes)
– CPT codes that cover evaluating and managing a clients’ case. It is
questionable as to whether or not massage therapists are allowed to use these
codes. Ask the claims manager or adjuster if you are allowed to use this code.
ERISA- Employee Retirement Insurance Security Act:
Federal Act that regulates self-insured employers. They do not recognize
massage therapists at this time.
