Chapter 8 - Revenue Cycle Management

Question 1

Accounts Receivable (A/R) days

Answer 1

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.

Question 2

Adverse Determination

Answer 2

Occurs when a health care insurer denies payment for proposed or already rendered healthcare service

Question 3

Bill Hold Period

Answer 3

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

Question 4

Case Management

Answer 4

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.

Question 5

Case Manager

Answer 5

A nurse, doctor, or social worker who arranges all services that are needed to give proper healthcare to a patient or group of patients

Question 6

Case-mix Index (CMI)

Answer 6

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.

Question 7

Charge Capture

Answer 7

The process of collecting all services, procedures, and supplies provided during patient care

Question 8

Charge Description Master (CDM)

Answer 8

A financial management form that contains information about the organization’s charges for the healthcare services it provides to patients

Question 9

Charity Care

Answer 9

Services for which healthcare organizations did not expect payment because they had previously determined the patients’ or clients inability to pay

Question 10

Claims Scrubber Software

Answer 10

A type of computer program at a healthcare facility that checks the claim elements for accuracy and agreement before the claims are submitted

Question 11

Clean Claim

Answer 11

A completed insurance claim form that contains all the required information (without any missing information) so that it can be processed and paid promptly

Question 12

Denial

Answer 12

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)

Question 13

Discharge, no final bill (DNFB)

Answer 13

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

Question 14

Facility charge

Answer 14

Allows the capture of an E/M charge that represents those resources not included with the CPT code for the clinic environment

Question 15

Financial counselor

Answer 15

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

Question 16

Hospital-issued notice of noncoverage (HINN)

Answer 16

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

Question 17

Insurance verification

Answer 17

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

Question 18

Key performance indicator (KPI)

Answer 18

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

Question 19

Local coverage determination (LCD)

Answer 19

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.

Question 20

MAP Key

Answer 20

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.

Question 21

Medical necessity

Answer 21

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.

Question 22

National coverage determination (NCD)

Answer 22

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.

Question 23

Point-of-service (POS) collection

Answer 23

The collection of the portion of the bill that is likely the responsibility of the patient prior to the provision of service

Question 24

Preauthorization

Answer 24

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.

Question 25

Revenue cycle

Answer 25

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

Question 26

Utilization management

Answer 26

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.