Reimbursement Terminology Flashcards
A measure of how sick patients are
Acuity
Auxilary or supplemental services rendered in patient care such as physical therapy
Ancillary Services
The best known value for a specific measure, from any source
Benchmark
Desirable levels of key financial indicators established at the start of the budget process by the governing board.
Budget Guidelines
Forecasts of cash income and outgo by period.
Cash Flow Budget
Payment for each hospital stay regardless of actual care costs and length of stay.
Case Rate
Is the government bureaucracy that oversees health care provision for Medicare and Medicaid beneficiaries.
CMS - Center for Medicare and Medicaid Services
Anticipated volumes of demand or output with emphasis on direct costs controllable by the responsibility center or unit.
Cost Budget
Groups of inpatient discharges with final diagnoses that are similar clinically and in resource consumption; used as a basis of payment by the Medicare program, and as a result, widely accepted by others.
DRG - Diagnostic Related Group
The costs of resources used directly in an activity that can be controlled through the unit accountable for the activity.
Direct Cost
Payment for each service provided
Fee for service
Expectations of future financial performance composed of income and expenses.
Financial Budgets
Hospital - These owned by private corporations that declare dividends or distributions to individuals.
For-Profit-Hospital
A scoring system driven by the OASIS which determines reimbursement allotment for home health care.
HHRG - Home Health Resource Group
health insurance plans emphasizing comprehensive care under a single insurance premium and using a variety of devices to control cost and quality.
HMO - Health Maintenance Organization
The official system of assigning codes to diagnoses and procedures associated with hospital utilization in the US.
ICD-9 Codes
Cost incurred for large aggregates of the organization that cannot be directly attributed to components or responsibility centers.
Indirect Costs
These are licensed facilities that provide rehabilitation care services on a post acute, inpatient basis.
IRF - Inpatient Rehabilitation Facilities
An intermediary bearing insurance risk
Insurance Carrier
Network of healthcare providers and organizations which provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the clinical outcomes.
IDN - Integrated Delivery Network
A system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A
IPPS - Inpatient Prospective Payment System
The total # of days a patient is in hospital.
LOS - Length of stay
Are certified facilities that furnish extended medical and rehab care to people who are clinically complex - average stay of 25 days.
LTHC - Long Term Care Hospitals
an assessment form which provides patient clinical info to help determine reimbursement for a SNF.
MDS - Minimum Data Set
Governmental assistance for care of the poor, and occasionally, the near-poor.
Medicaid
Government insurance for the elderly
Medicare Part A
Government insurance for outpatient and ancillary services.
Medicare Part B
The comprehensive assessment that drives the HHRG and reimbursement for patients in home health.
OASIS - Outcome and Assessment Information Set
A forecast of responsibility center costs, aggregate expenditures, and revenue.
Operating Budget
Services rendered by medical care providers in setting that does not require overnight stays.
Outpatient
The group of payers that reimburses within a particular institution.
Payer Group
Payment for each hospital day regardless of actual patient care costs.
Per Diem
A healthcare financing plan that encourages subscribers to seek care from selected hospitals, doctors, and other providers with whom the PPO has established a contract; often and intermediary arrangement w/insurance risk remaining with the employer.
PPO - Preferred Provider Organization
Organizations led by doctors which do not insure or provide care but which audit the quality of care and the use of insurance benefits for Medicare and other insurers.
PRO - Professional Review Organizations
Payment to medical providers for services rendered.
Reimbursement
A number code derived from the info on the MDS that is sent to Medicare to determine reimbursement.
RUG - Resource Utilization Group
The most commonly used post acute setting, a health care institution that meet criteria for Medicaid and Medicare reimbursement for nursing care.
SNF - Skilled Nursing Facility
The Social Security Act permits certain small, rural hospitals to enter into this type of agreement under which the hospital can use its beds as needed to provide either acute of SNF care.
Swing Beds
Comprehensive outpatient clinics designed to treat patients with chronic, non healing wounds. Services provided typically include debridement, advanced wound care, HBO, growth factors, bioengineered skin grafting, etc etc.
WCC - Wound Care Center
