NURSING Flashcards
The act of unnecessary transfer of patients to another healthcare unit in order to keep medical expenses low in change for incentives.
Turfing
The amount of charges a provider or hospital agrees to write off and not change the patient per the contract terms with the insurance company
Example :
Actual amount = $600. 00
Allowed amount = $450.00
Adjustment = $150.00 to be written off
Contractual Adjustment
A service that scrubs and transmits claims electronically to insurance carriers?
Clearinghouse
The process of establishing the validity of the patient’s insurance coverage?
Eligibility
A managed care clause that prohibits service providers, particularly PCPs or primary care providers from discussing treatment options with patients?
Gag Clause
The percentage in reference to the providers accounts receivable. It is the ratio of the payments received to the total amount of money owed on the providers accounts ?
Example:
Amount owed = $100,000.00
Amount collected = $80,000.00
Collection ratio = 80%
Collection ratio
What does DRG stand for?
DIAGNOSIS RELATED GROUP
What does DRG stand for?
DIAGNOSIS RELATED GROUP
A complete insurance claim that has all the necessary correct information without any omissions or mistakes and is submitted in a timely manner is referred to as ___.
Clean claim
The act of billing for services that were not provided ?
Phantom or ghost billing
The act of submitting a code for a procedure or service that is more expensive than what was actually performed or provided ?
Upcoding
The act of reporting individual codes for services or procedures that are bundled into one code, also known as a la carte coding ?
Unbundling
When claim information is automatically sent from Medicare to the secondary insurance such as Medicaid ?
Crossover
_____ are laws that prohibit physicians from giving self-referrals or refer patients to laboratories, specialists, and other healthcare providers with whom they have financial interests.
Stark I & II regulations
When the insurance company reduces the code and reimbursement amount for a claim when there is no documentation to support the level of service submitted by the provider, what is the insurance company doing?
Downcoding