Chapter 3 and Chapter 4: Revenue Cycle Mngmnt.

Question 1

accept assignment

Answer 1

provider accepts as payment in full whatever is paid on the claim by payer (except for any copayment and/or coinsurance amounts).

Question 2

accounts receivable managment

Answer 2

assists providers in the collection of appropriate reimbursement for services rendered; includes functions such as insurance verifications/eligibility and preauthorization fo services.

Question 3

assignment of benefits

Answer 3

the provider receives reimbursement directly from the payer.

Question 4

balance billing

Answer 4

billing beneficiaries for amounts not reimbursed by payers (not including copayments and coinsurance amounts); this practice is prohibited by state wrkers’ compensation plans and federal govt programs.

Question 5

birthday rule

Answer 5

determines coverage by primary and secondary policies wen ach parent subscribes to a different health insurance plan.

Question 6

case managment

Answer 6

development of pT care plans to coodinate and provide care for complicated cases in cost- effective manner.

Question 7

charge description master (CDM)

AKA: CHARGEMASTER

Answer 7

see chargemaster

Question 8

chargemaster

Answer 8

computer-gen encounter from that contains al list of procedures, svcs, supplies, and revenue codes; chargemaster data are enterd in the outpatient hospital facilities pT accounting system, and charges are automatically posted to the pT’s bill (UB-04)

Question 9

claims denials

Answer 9

unpaid claim returned by 3rd party payers bcuz of beneficiary identification erros, coding errors, diagnosis that dont support necessity, duplicate claims, global days o surgery e/m coverage issue, NCCI program edits, and other pT coverage issues (or anythign not covered).

Question 10

claims rejection

Answer 10

unpaid claim returned by third party payers because it fials to meet certain data requirements such as missing data. These calims can be corrected and resubmitted.

Question 11

data analysis

Answer 11

AKA: data analytics

Question 12

data analytics

Answer 12

tools and systems that are used to analyze (examine and study) clinical and financial date, conduct research, and evaluate the effectiveness of disease treatments.

Question 13

data mining

Answer 13

extracting and analyzing data to identify patterns, whether predictable or unpredicatble

Question 14

data warehouse

Answer 14

database that uses reporting interfaces to consolidate multiple databases, allowing reports to be generated from a single request. Data is accumilated form a wide range of org. sources and is used to guide management decisons.

Question 15

day sheet

Answer 15

AKA: manual daily accounts receivable journal chronological summary used to manually track all transactions posted to individual pT ledgers/accnts on a certain day.

Question 16

discharge not final bill (DNFB)

Answer 16

pT claims that are finalized because of billing delays

Question 17

discharged not final coded (DNFC)

Answer 17

Pt CLAIMS THAT ARE NOT FINALIZED BCUZ OF CODING DELAYS OR INCOMPLETE DOCUMENTATION.

Question 18

encounter form

Answer 18

financial record source document used by providers and other personnel to select treatedmanaged diagnoses and procedures/services provided to the pT during the current encounter.

Question 19

facility billing

Answer 19

AKA: institutional billing

Question 20

guarantor

Answer 20

person responsible for paying health care fees

Question 21

institutional billing

Answer 21

involes generating UB-04 claims for charges generated for inPT and outPT services provided by health care facilties. (braod list: any health care facility you can think of).

Question 22

integrated revenue cycle (IRC)

Answer 22

combinig revenue managment w/ clinical, cosing, and information management decisions because of the impact on financial management

Question 23

metrics

Answer 23

standards of measuremnt, such as those used to evaluate an organization’s revenue to ensure financial viability

Question 24

metrics

Answer 24

standards of measrement, such as those used to evaluate an organizations rev. cycle to ensure financial viability.

Question 25

nonparticipating provider (nonPAR)

Answer 25

does not participate or is contracted with certain inurance organization. pT who sees a nonPAR stands to pay high out-of-pocket expenses.

Question 26

out-of-pocket payment

Answer 26

can be in the form of copayment, exspense not voerage under incs. mainly pertains to health insurance companies for a pT who ahs reavhed theri dectable amount. If someone reaches or maxes their deductable insuracne then coveres reamining charges.

Question 27

participating provider (PAR)

Answer 27

a provider that is listed/contratced with the insurance company. pT who get services in PAR network will get lower final costs and possible chepaer co-pay.

Question 28

pT ledger

Answer 28

AKA: pT account record

Question 29

pT portal

Answer 29

secure online website or cell phone app that allow pTs to view info and make appointments concerning their health and view Rx info etc.

Question 30

primary health insuracne

Answer 30

assocaited w/ how a health insurance plan is billed. The insc. Co listed as primary is the insurance to be billed 1st. pT can list multiple helath insurances.

Question 31

professional services billing

Answer 31

generating CMS-1500 claims for charges generated for pro svcs and supplies provided by physcians and non-physcian practitioners.

Question 32

Quarterly Provider Updates (QPU)

Answer 32

publsihed by CMS to simplify the process of understadning proposed or implemented instructional, policy,and changes to its programs such as medicare.

Question 33

resource allocation

Answer 33

distribution of financial reosuces among competing groups(e.g. hospital departments, state health care organizations).

Question 34

resource allocation monitoring

Answer 34

uses data analytics to meausre whether a health care provider/org achieves operational goals and objectives within the confines of thier financial resources contracted.

Question 35

revenue auditing

Answer 35

assessment process that is conducting as a follow-up to revenue monitioring so that areas of poor perfromance can be identified and corrected.

Question 36

revenue code

Answer 36

a 4 digit code that indicates ;ocation or type of service provided to an institutional pT; reported in FL 42 of UB-04

Question 37

revenue cycle management

Answer 37

process that typically begins upon appt scheduling or physcian order for inpT hospital admission and concludes when reimbursement is obtained or collections have been posted

Question 38

revenue managment

Answer 38

process that facilities and providers use to ensure financially viability

Question 39

revenue monitoring

Answer 39

involves assessing the revenuw process to ensure financial viability and stability using metrics (standards of measure)

Question 40

secondary health insurance

Answer 40

billed after primary health insurance has paid contratced amount, and often contains the same coverage as a primary health plan.

Question 41

single-path coding

Answer 41

combines pro and institutional coding to improve productivity and ensure the submisison of accurate claims, leading to improved reimbursement

Question 42

superbill

Answer 42

an encounter form that contains a list of common diagnoses and ICD 10-CM codes and procedures/services and CPT/HCPCS Level II codes, which is used in physcian office to capture encounter data for billing purposes.

Question 43

utilization management

Answer 43

method controlling health care costs and quality of care by reviewing the appropriateness, efficiency, and necessity of care provided to pT prior and after admission.

Question 44

utilization review

Answer 44

AKA: utilazation management