Medical Billing

9 Most Commonly Used Terms In Medical Billing


Medical billing and coding require the use of various terms to make work easier. Professional billers and coders undertake a course to learn these terms as part of their career. This explains why you can’t trust in-house billers who might lack the appropriate knowledge of these terms. For a smooth process, here is a list of top terms used by billers from a professional agency.

Health Maintenance Organization (HMO)

This agency controls health costs through spreading of risks and stringent management methods to allow medical intervention where necessary. The HMO uses a patient’s primary care physician to permit non-urgent medical intervention. This requires a patient to get permission to see a subspecialist with a recommendation from the primary physician.

Non-adherence makes the HMO not liable for claims the subspecialist submits. The primary care physician only refers to a subspecialist in the HMO network offering a lower contracted rate for services. This lowers medical costs on the platform.

Health Insurance Portability and Accountability Act (HIPAA)

This law was passed in 1996 to enhance the healthcare services scope. It also aims at establishing regulations to secure health records from unauthorized parties. The best medical billing companies in Houston undertake all processes in adherence to this law. HIPAA regulations also set specific requirements for clearinghouses, medical providers, and other organizations handling patient protected health information. Among the regulations in this law is patients’ access to their own medical records.

Centers for Medicare and Medicaid Services (CMS)

Formerly known as Health Care Financing Administration (HCFA), it is a federal entity managing and administering healthcare cover through HIPAA, Medicaid, Medicare, and other branches of medicine. The CMS handles the provision and enrollment of healthcare providers to Americans. This body has influence and a great degree of power in the health care service.

In-Network (INN)

Medical service providers create a contracted rate with the insurance carrier depending on the type of insurance coverage. The health insurance carrier might offer services as a health maintenance organization or point of service. Regardless of the situation, the service provider with a contract is presumed to be “in-network.” The patient can go to a physician in the network to lower a significant portion of the medical service cost. A service provider is paid lower than the market rate according to the contract to make medical costs cheaper.

Out-Of-Network (OON)

An OON physician is not contracted by the patient’s insurance company. The physician is paid less or greater than the physician on the network depending on the patient and contract with the insurer. An out of network physician is not listed among those for insurance providers to consider. However, this physician is bound by the contract between the patient and health service provider. The OON physician can receive higher pay but the patient contributes a bigger portion for the medical services offered.

Personal Injury Protection (PIP)

This regards auto insurance concerning a state’s no-fault insurance system. All states utilizing this system make it essential for health coverage and other payments. Other states have the PIP considered after Worker’s Compensation. However, most states consider PIP essential with a limited amount of money that usually exhausts before a patient reaches maximum medical improvement.

Point of Service (POS)

This health plan includes the HMO model and the preferred provider network. It requires a patient choosing a subspecialist without permission from their primary care physician. However, the patient should choose a specialist within the POS network to avoid losing cover for the visit. The specialist should have a lower rate contracted to that in the market for services provided. This lowers costs across the network. The point of service plan gives patients the freedom to determine accessibility to medical care without insurance company interference.

Preferred Provider Organization (PPO)

This health insurance plan offers patients better control over their choice of physician. The PPO has a list of physicians in the network and insurance provider contracted rate. Other physicians are presumed out of network. This plan covers a percentage for each provider regardless of whether they are in-network or not. In-network providers have a contracted rate to lower the patients’ medical budget. Providers out of network have a higher market rate and cost patients more. Additionally, the PPO incentivizes patients to use physicians on the network through lower or no deductibles for well-care visits.

Workers’ Compensation (WC)

Every state has a worker’s compensation system run through an administrative agency. The WC fulfills the U.S. Department of Labor’s initiative to see employees covered for lost wages and medical costs after work-related injuries. The workers’ compensation plays a significant role whenever a worker is injured on the job. This depends on state buy usually covers physical injuries, psychiatric injuries, and chronic stress-related injuries.

In summary

Understanding the medical billing process is an essential aspect of managing a medical practice. Equally important is enlisting the services of a professional medical billing agency to handle billing tasks.

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