Chapter 3 and Chapter 4: Revenue Cycle Mngmnt. Flashcards
accept assignment
provider accepts as payment in full whatever is paid on the claim by payer (except for any copayment and/or coinsurance amounts).
accounts receivable managment
assists providers in the collection of appropriate reimbursement for services rendered; includes functions such as insurance verifications/eligibility and preauthorization fo services.
assignment of benefits
the provider receives reimbursement directly from the payer.
balance billing
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.
birthday rule
determines coverage by primary and secondary policies wen ach parent subscribes to a different health insurance plan.
case managment
development of pT care plans to coodinate and provide care for complicated cases in cost- effective manner.
charge description master (CDM)
AKA: CHARGEMASTER
see chargemaster
chargemaster
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)
claims denials
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).
claims rejection
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.
data analysis
AKA: data analytics
data analytics
tools and systems that are used to analyze (examine and study) clinical and financial date, conduct research, and evaluate the effectiveness of disease treatments.
data mining
extracting and analyzing data to identify patterns, whether predictable or unpredicatble
data warehouse
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.
day sheet
AKA: manual daily accounts receivable journal chronological summary used to manually track all transactions posted to individual pT ledgers/accnts on a certain day.
discharge not final bill (DNFB)
pT claims that are finalized because of billing delays
discharged not final coded (DNFC)
Pt CLAIMS THAT ARE NOT FINALIZED BCUZ OF CODING DELAYS OR INCOMPLETE DOCUMENTATION.
encounter form
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.
facility billing
AKA: institutional billing
guarantor
person responsible for paying health care fees
institutional billing
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).
integrated revenue cycle (IRC)
combinig revenue managment w/ clinical, cosing, and information management decisions because of the impact on financial management
metrics
standards of measuremnt, such as those used to evaluate an organization’s revenue to ensure financial viability
metrics
standards of measrement, such as those used to evaluate an organizations rev. cycle to ensure financial viability.
nonparticipating provider (nonPAR)
does not participate or is contracted with certain inurance organization. pT who sees a nonPAR stands to pay high out-of-pocket expenses.
out-of-pocket payment
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.
participating provider (PAR)
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.
pT ledger
AKA: pT account record
pT portal
secure online website or cell phone app that allow pTs to view info and make appointments concerning their health and view Rx info etc.
primary health insuracne
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.
professional services billing
generating CMS-1500 claims for charges generated for pro svcs and supplies provided by physcians and non-physcian practitioners.
Quarterly Provider Updates (QPU)
publsihed by CMS to simplify the process of understadning proposed or implemented instructional, policy,and changes to its programs such as medicare.
resource allocation
distribution of financial reosuces among competing groups(e.g. hospital departments, state health care organizations).
resource allocation monitoring
uses data analytics to meausre whether a health care provider/org achieves operational goals and objectives within the confines of thier financial resources contracted.
revenue auditing
assessment process that is conducting as a follow-up to revenue monitioring so that areas of poor perfromance can be identified and corrected.
revenue code
a 4 digit code that indicates ;ocation or type of service provided to an institutional pT; reported in FL 42 of UB-04
revenue cycle management
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
revenue managment
process that facilities and providers use to ensure financially viability
revenue monitoring
involves assessing the revenuw process to ensure financial viability and stability using metrics (standards of measure)
secondary health insurance
billed after primary health insurance has paid contratced amount, and often contains the same coverage as a primary health plan.
single-path coding
combines pro and institutional coding to improve productivity and ensure the submisison of accurate claims, leading to improved reimbursement
superbill
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.
utilization management
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.
utilization review
AKA: utilazation management
