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Insurance Billing Manual Glossary Of Terms (P-Z)
Please also check the
insurance billing manual updates and the
blog for more information.
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.
Please also check the
insurance billing manual updates and the
blog for more information.
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