Chapter 8 - Revenue Cycle Management Flashcards
Accounts Receivable (A/R) days
Records of the payments owned to the organization by outside entities such as third-party payers and patients. 2. Department in a healthcare facility that manages the accounts owed to the facility by customers who have received services by whose payment is made at a later date.
Adverse Determination
Occurs when a health care insurer denies payment for proposed or already rendered healthcare service
Bill Hold Period
The span of time during which a bill is suspended in the billing system awaiting late charges, diagnosis or procedure codes, insurance verification, or other required information
Case Management
A process used by a doctor, nurse, or other health professional to manage a patient’s healthcare. 2. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient.
Case Manager
A nurse, doctor, or social worker who arranges all services that are needed to give proper healthcare to a patient or group of patients
Case-mix Index (CMI)
The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system; calculated by dividing the sum of the weights of diagnosis-related groups for patients discharged during a given period by the total number of patient discharges.
Charge Capture
The process of collecting all services, procedures, and supplies provided during patient care
Charge Description Master (CDM)
A financial management form that contains information about the organization’s charges for the healthcare services it provides to patients
Charity Care
Services for which healthcare organizations did not expect payment because they had previously determined the patients’ or clients inability to pay
Claims Scrubber Software
A type of computer program at a healthcare facility that checks the claim elements for accuracy and agreement before the claims are submitted
Clean Claim
A completed insurance claim form that contains all the required information (without any missing information) so that it can be processed and paid promptly
Denial
When a bill has been returned unpaid for any of several reasons (for example, sending the bill to the wrong insurance company, patient not having current coverage, inaccurate coding, lack of medical necessity, and so on)
Discharge, no final bill (DNFB)
A report that includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete
Facility charge
Allows the capture of an E/M charge that represents those resources not included with the CPT code for the clinic environment
Financial counselor
Staff dedicated to helping patients and physicians determine sources of reimbursement for healthcare services; counselors are responsible for identifying and verifying the method of payment and debt resolution for services rendered to patients
Hospital-issued notice of noncoverage (HINN)
If the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered because it: is not medically necessary, is not delivered in the most appropriate setting, or is not custodial in nature, hospitals have the responsibility to issue notification to Medicare beneficiaries prior to admission, at admission, or at any point during an inpatient stay
Insurance verification
A vital component of the prearrival process for scheduled patients, substantiation of the patient’s insurance for unscheduled patients occurs at the time of their registration for clinical services or shortly thereafter; the verification process entails validating that the patient is a member of the insurance plan given and is covered for the scheduled service date, as well as whether the patient’s insurance plan is innetwork versus out-of-network, whether the scheduled service expenses will be covered, whether a referral or an authorization is required prior to the service being rendered, and whether the patient will incur an out-of-pocket expense
Key performance indicator (KPI)
A quantifiable measure used over time to determine whether some structure, process, or outcome in the provision of care to a patient supports high-quality performance measured against best practice criteria
Local coverage determination (LCD)
Established by Section 522 of the Benefits Improvement and Protection Act, a decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862 (a)(1)(A) of the Social Security Act, which is a determination regarding whether the service is reasonable and necessary. LCDs consist only of reasonable and necessary information. Effective December 27, 2003, CMS’s contractors will begin issuing LCDs instead of LMRPs.
MAP Key
Measures a specific revenue cycle function and provides the purpose for the measurement, the value of the measure, and the specific equation (numerator and denominator) to consistently calculate the measure.
Medical necessity
The likelihood that a proposed healthcare service will have a reasonable beneficial effect on the patient’s physical condition and quality of life at a specific point in his or her illness or lifetime. 2. As amended by HITECH, a covered entity or business associate may not use or disclose protected health information, except as permitted or required. 3. The concept that procedures are only eligible for reimbursement ad a covered benefit when they are performed for a specific diagnosis or specified frequency.
National coverage determination (NCD)
An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs.
Point-of-service (POS) collection
The collection of the portion of the bill that is likely the responsibility of the patient prior to the provision of service
Preauthorization
The requirement that a healthcare provider obtain permission from the health insurer prior to predefined services being provided to the patients. 2. Control number issued when a healthcare service is approved.
Revenue cycle
The process of how patient financial and health information move into, through, and out of the healthcare facility, culminating with the facility receiving reimbursement for services provided. 2. The regularly repeating set of events that produces revenue
Utilization management
A collection of systems and processes to ensure that facilities and resources, both human and nonhuman, are used maximally and are consistent with patient care needs. 2. A program that evaluates the healthcare facility’s efficiency in providing necessary care to patients in the most effective manner.
