Intro to the revenue cycle

Question 1

cash flow

Answer 1

• movement of monies into or out of a business

Question 2

accounts receivable

Answer 2

• monies owed to a medical practice

Question 3

accounts payable

Answer 3

• a practice’s operating expenses

Question 4

revenue cycle

Answer 4

• all administrative and clinical functions that help capture and collect patient’s payment for medical expenses

Question 5

health information technology (HIT)

Answer 5

computer information systems that record, store, and manage patient information

Question 6

practice management program (PMP)

Answer 6

accounting software used for scheduling appointments, billing, and financial record keeping

Question 7

electronic health record (EHR)

Answer 7

computerized lifelong healthcare record for an individual that incorporates data from all sources

Question 8

PM/EHR

Answer 8

software program that combines both a PMP and an EHR into a single product

Question 9

medical insurance

Answer 9

a written policy stating the terms of an agreement between a policy holder and a health plan

Question 10

policyholder

Answer 10

person who buys an insurance plan

Question 11

health plan

Answer 11

individual or group plan that provides or pays for medical care

Question 12

benefits

Answer 12

health plan payments for covered medical services

Question 13

payer

Answer 13

health plan or program

Question 14

third-party payer

Answer 14

private of government organization that insures or pays for healthcare on behalf of beneficiaries

Question 15

schedule of benefits

Answer 15

list of medical expenses covered by a health plan

Question 16

medical necessity

Answer 16

payment criterion that requires medical treatments to be appropriate and provided in accordance with generally accepted standards

Question 17

provider

Answer 17

person or entity that supplies medical or health services and bills for, or is paid for, the services in the normal course of business

Question 18

covered services

Answer 18

medical procedures and treatments that are included as benefits in a health plan

Question 19

preventive medical services

Answer 19

care provided to keep patients healthy or prevent illness

Question 20

noncovered services

Answer 20

medical procedures that are not included in a plan’s benefits

Question 21

excluded services

Answer 21

services not covered in a medical insurance contract

Question 22

indemnity plan

Answer 22

health plan that reimburses a policyholder for medical services under the terms of its schedule of benefits

Question 23

healthcare claim

Answer 23

electronic transaction or a paper document filed to receive benefits

Question 24

premium

Answer 24

money the insured pays to a health plan for a policy

Question 25

deductible

Answer 25

amount the insured must pay for healthcare services before a health plan’s payment begins

Question 26

coinsurance

Answer 26

portion of charges an insured person must pay for covered healthcare services after the deductible

Question 27

out-of-pocket

Answer 27

expenses the insured must pay prior to benefits

Question 28

fee-for-service

Answer 28

payment method based on provider charges

Question 29

managed care

Answer 29

system combining the financing and delivery of healthcare services

Question 30

managed care organization (MCO

Answer 30

organization offering a managed healthcare plan

Question 31

participation

Answer 31

contractual agreement to provide medical services to a payer’s policyholders

Question 32

health maintenance organization

Answer 32

managed healthcare system in which providers offer healthcare to members for fixed periodic payments

Question 33

capitation

Answer 33

a fixed prepayment covering provider’s services for a plan member for a specified period

Question 34

per member per month (PMPM)

Answer 34

periodic capitated prospective payment to a provider that covers only services listed on the schedule of benefits

Question 35

network

Answer 35

a group of healthcare providers including physicians and hospitals, who sign a contract with a health plan to provide services to plan members

Question 36

out-of-network

Answer 36

provider who does not have a participation agreement with a plan

Question 37

preauthorization

Answer 37

prior authorization from a payer for services to be provided

Question 38

copayment

Answer 38

specified amount a beneficiary must pay at the time of a healthcare encounter

Question 39

primary care physician (PCP)

Answer 39

physician in a health maintenance organization who directs all aspects of a patient’s care

Question 40

referral

Answer 40

transfer of patient care from one physician to another

Question 41

preferred provider organization (PPO)

Answer 41

managed care organization in which a network of providers supplies discounted treatment for plan members

Question 42

consumer driven health plan (CMHP)

Answer 42

medical insurance that combines a high deductible health plan with a medical savings plan

Question 43

self funded (self insured) health plan

Answer 43

organization pays for health insurance directly and sets up a fund from which to pay

Question 44

medical insurance specialist

Answer 44

staff member who handles billing, checks insurance, and processes payments

Question 45

medical coder

Answer 45

staff member with specialized training who handles diagnostic and procedural coding

Question 46

diagnosis code

Answer 46

number assigned to a diagnosis

Question 47

procedure code

Answer 47

code that identifies medical treatment or diagnostic services

Question 48

patient ledger

Answer 48

record of a patient’s financial transactions

Question 49

compliance

Answer 49

actions that satisfy official requirements

Question 50

adjudication

Answer 50

health plan process of examining claims and determining benefits

Question 51

professionalism

Answer 51

acting for the good of the public and the medical practice

Question 52

ethics

Answer 52

standards of conduct based on moral principles

Question 53

etiquette

Answer 53

standards of professional behavior

Question 54

certification

Answer 54

recognition of a superior level of skill by an official organization