B&C Chapter 4: The Revenue Cycle Flashcards
accept assignment
provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts).
accounts receivable
the amount owed to a business for services or goods provided.
accounts receivable aging report
shows the status (by date) of outstanding claims from each payer, as well as payments due from patients.
accounts receivable management
assists providers in the collection of appropriate reimbursement for services rendered; includes functions such as insurance verification/eligibility and preauthorization of services.
allowed charges
the maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy.
ANSI ASC X12N
an electronic format standard that uses a variable-length file format to process transactions for institutional, professional, dental, and drug claims.
appeal
documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment.
assignment of benefits
the provider receives reimbursement directly from the payer.
bad debt
accounts receivable that cannot be collected by the provider or a collection agency.
beneficiary
the person eligible to receive health care benefits.
birthday rule
determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.
case management
development of patient care plans to coordinate and provide care for complicated cases in a cost-effective manner.
charge description master (CDM)
see chargemaster.
chargemaster
document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility’s patient accounting system, and charges are automatically posted to the patient’s bill (UB-04).
chargemaster maintenance
process of updating and revising key elements of the chargemaster (or charge description master [CDM]) to ensure accurate reimbursement.
chargemaster team
team of representatives from a variety of departments who jointly share responsibility for updating and revising the chargemaster to ensure accuracy.
claims adjudication
comparing a claim to payer edits and the patient’s health plan benefits to verify that the required information is available to process the claim; the claim is not a duplicate; payer rules and procedures have been followed; and procedures performed or services provided are covered benefits.
claims adjustment reason code (CARC)
reason for denied claim as reported on the remittance advice or explanation of benefits.
claims attachment
medical report substantiating a medical condition.
claims denial
unpaid claim returned by third-party payers because of beneficiary identification errors, coding errors, diagnosis that does not support medical necessity of procedure/service, duplicate claims, global days of surgery E/M coverage issue, NCCI edits, and other patient coverage issues (e.g., procedure or service required preauthorization, procedure is not included in patient’s health plan contract, such as cosmetic surgery).
claims processing
sorting claims upon submission to collect and verify information about the patient and provider.
claims rejection
unpaid claim returned by third-party payers because it fails to meet certain data requirements, such as missing data (e.g., patient name, policy number); rejected claims can be corrected and resubmitted for processing.
claims submission
the transmission of claims data (electronically or manually) to payers or clearinghouses for processing.
clean claim
a correctly completed standardized claim (e.g., CMS-1500 claim).
clearinghouse
agency or organization that collects, processes, and distributes health care claims after editing and validating them to ensure that they are error-free, reformatting them to the payer’s specifications, and submitting them electronically to the appropriate payer for further processing to generate reimbursement to the provider.
closed claim
claims for which all processing, including appeals, has been completed.
coinsurance
also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
common data file
abstract of all recent claims filed on each patient.
concurrent review
review for medical necessity of tests and procedures ordered during an inpatient hospitalization.
Consumer Credit Protection Act of 1968
was considered landmark legislation because it launched truth-in-lending disclosures that required creditors to communicate the cost of borrowing money in a common language so that consumers could figure out the charges, compare costs, and shop for the best credit deal.
coordination of benefits (COB)
provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other policies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim.
covered entity
private sector health plans (excluding certain small self-administered health plans), managed care organizations, ERISA-covered health benefit plans (Employee Retirement Income Security Act of 1974), and government health plans (including Medicare, Medicaid, Military Health System for active duty and civilian personnel; Veterans Health Administration, and Indian Health Service programs); all health care clearinghouses; and all health care providers that choose to submit or receive transactions electronically.
data analytics
tools and systems that are used to analyze clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.
data mining
extracting and analyzing data to identify patterns, whether predictable or unpredictable.
data warehouse
database that use reporting interfaces to consolidate multiple databases, allowing reports to be generated from a single request; data is accumulated from a wide range of sources within an organization and is used to guide management decisions.
day sheet
also called manual daily accounts receivable journal; chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day.
deductible
amount for which the patient is financially responsible before an insurance policy provides coverage.
delinquent account
see past due account.
delinquent claim
claim usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due.
delinquent claim cycle
advances through various aging periods (30 days, 60 days, 90 days, and so on), with practices typically focusing internal recovery efforts on older delinquent accounts (e.g., 120 days or more).
denied claim
claim returned to the provider by payers due to cording errors, missing information, and patient coverage issues
discharge planning
involves arranging appropriate health care services for the discharged patient (e.g., home health care).
downcoding
assigned lower-level codes than documented in the record.
electronic data interchange (EDI)
computer-to-computer exchange of data between provider and payer.
electronic flat file format
series of fixed-length records (e.g., 25 spaces for patient’s name) submitted to payers to bill for health care services.
electronic funds transfer (EFT)
system by which payers deposit funds to the provider’s account electronically.
Electronic Funds Transfer Act
established the rights, liabilities, and responsibilities of participants in electronic funds transfer systems.
Electronic Healthcare Network Accreditation Commission (EHNAC)
organization that accredits clearninghouses.
electronic media claim
see electronic flat file format.
electronic remittance advice (ERA)
remittance advice that is submitted to the provider electronically and contains the same information as a paper-based remittance advice; providers receive the ERA more quickly.
encounter form
financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter.
Equal Credit Opportunity Act
prohibits discrimination on the basis of race, color, religion, national origin, sex, marital status, age, receipt of public assistance, or good faith exercise of any rights under the Consumer Credit Protection Act.
Fair Credit and Charge Card Disclosure Act
amended the Truth in Lending Act, requiring credit and charge card issuers to provide certain disclosures in direct mail, telephone, and other applications and solicitations for open-end credit and charge accounts and under other circumstances; this law applies to providers that accept credit cards.
Fair Credit Billing Act
federal law passed in 1975 that helps consumers resolve billing issues with card issuers; protects important credit rights, including rights to dispute billing errors, unauthorized use of an account, and charges for unsatisfactory goods and services; cardholders cannot be held liable for more than $50 of fraudulent charges made to a credit card.
Fair Credit Reporting Act
protects information collected by consumer reporting agencies such as credit bureaus, medical information companies, and tenant screening services; organizations that provide information to consumer reporting agencies also have specific legal obligations, including the duty to investigate disputed information.
Fair Debt Collection Practices Act (FDCPA)
specifies what a collection source may and may not do when pursuing payment of past due accounts.
guarantor
person responsible for paying health care fees.
integrated revenue cycle (IRC)
combining revenue cycle management with clinical, coding, and information management decisions because of the impact on financial management.
litigation
legal action to recover a debt; usually a last resort for a medical practice.
manual daily accounts receivable journal
also called the day sheet; a chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day.
metrics
standards of measurement, such as those used to evaluate an organization’s revenue cycle to ensure financial viability.
noncovered benefit
any procedure or service reported on a claim that is not included on the payer’s master benefit list, resulting in denial of the claim; also called noncovered procedure of uncovered benefit.
nonparticipating provider (nonPAR)
does not contract with the insurance plan; patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses.
open claim
submitted to the payer, but processing is not complete.
out-of-pocket payment
established by health insurance companies for a health insurance plan; usually has limits of $1,000 or $2,000; when the patient has reached the limit of an out-of-pocket payment (e.g., annual deductible) for the year, appropriate patient reimbursement to the provider is determined; not all health insurance plans include an out-of-pocket payment provision.
outsource
contract out.
participating provider (PAR)
contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed.
past-due account
one that has not been paid within a certain time frame (e.g., 120 days); also called delinquent account.
patient account record
also called patient ledger; a computerized permanent record of all financial transactions between the patient and the practice.
patient ledger
see patient account record.
preadmission certification (PAC)
review for medical necessity of inpatient care prior to the patient’s admission.
readmission review
see preadmission certification.
preauthorization
health plan review that grants prior approval health care services.
precertification
see preauthorization.
pre-existing condition
any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee’s effective date of coverage.
primary health insurance
associated with how a health insurance plan is billed - the insurance plan responsible for paying health care insurance claims first is considered primary.
prior approval
see preauthorization.
prior authorization
see preauthorization.
prospective review
reviewing appropriateness and necessity of care provided to patients prior to administration of care.
Provider Remittance Notice (PRN)
remittance advice submitted by Medicare to providers that includes payment information about a claim.
Quarterly Provider Update (QPU)
published by CMS to simplify the process of understanding proposed or implemented instructional, policy, and changes to its programs, such as Medicare.
remittance advice remark code (RARC)
additional explanation of reasons for denied claims.
resource allocation
distribution of financial resources among competing groups (e.g., hospital departments, state health care organizations).
resource allocation monitoring
uses data analytics to measure whether a health care provider or organization achieves operational goals and objectives within the confines of the distribution of financial resources, such as appropriately expending budgeted amounts as well as conserving resources and protecting assets while providing quality patient care.
retrospective review
reviewing appropriateness and necessity of care provided to patients after the administration of care.
revenue code
a four-digit code that indicates location or type of service provided to an institutional patient; reported in FL 42 of UB-04.
revenue cycle auditing
assessment process that is conducted as a follow-up to revenue cycle monitoring so that areas of poor performance can be identified and corrected.
revenue cycle management
process facilities and providers use to ensure financial viability.
revenue cycle monitoring
involves assessing the revenue cycle to ensure financial viability and stability using metrics (standards of measurement).
secondary health insurance
billed after primary health insurance has paid contracted amount, and often contains the same coverage as a primary health plan.
source document
the routing slip, charge slip, encounter form, or superbill from which the insurance claim was generated.
superbill
term used for an encounter form in the physician’s office.
suspense
pending.
Truth in Lending Act
see Consumer Credit Protection Act of 1968.
two-party check
check made out to both patient and provider.
unassigned claim
generated for providers who do not accept assignment; organized by year.
unauthorized service
services that are provided to a patient without proper authorization or that are not covered by a current authorization.
unbundling
submitting multiple CPT codes when one code should be submitted.
utilization management
method of controlling health care costs and quality of care by reviewing the appropriateness, efficiency, and medical necessity of care provided to patients prior to the administration of care.
utilization review
see utilization management.
value-added network (VAN)
clearinghouse that involves value-added vendors, such as banks, in the processing of claims; using a VAN is more efficient and less expensive for providers than managing their own system to send and receive transactions directly from numerous entities.
