Unit 3 - Lesson 1: Reimbusement Methodologies Flashcards
Payments that hospitals receive from third-party payers for providing healthcare services
Accounts receivable (AR)
Standard insurance claim form used to report outpatient services to insurance companies
CMS-1500 claim form
Also known as crossover; group policy provision that helps determine the primary carrier in situations in which an insured party is covered by more than one policy, thus preventing the insured from receiving claims over payments
Coordination of benefits (COB)
Statement sent to a participant in a health plan as well as the healthcare provider that lists services, amounts paid by the plan, and total amount billed to the patient
Explanation of benefits (EOB)
Insurance companies contracted by the government to process claims for government insurance programs, such as Medicare part A and B
Fiscal intermediaries (FI)
Communication from third-party payer to payee that provides a detailed accounting of payments and healthcare services provided
Remittance advice
UB-92 payment codes for healthcare services or items
Revenue codes
Also known as the CMS-1450 form, standardizes the processing of billing for hospital inpatient and outpatient services
UB-92 claim form
The way that healthcare providers are paid for providing medical services
Reimbursement
Doctors, hospitals, and healthcare facilities
Healthcare providers
The process of assigning codes to certain pieces of information in the health record
Medical coding
Illnesses that can be prevented before they occur by routine physical examinations and immunizations
Preventable health threats
Responsible for providing an insurance arrangement that provides benefits in the form of healthcare service
Third-party payers
Healthcare provider receives reimbursement based on the amount that they charge for service
Fee-for-service reimbursement
Medical expenses that are listed in the benefits section of the insurance policy as being reimbursable by the insurance company
Covered medical expenses
A list of healthcare supplies and services with specific charges assigned for each supply and service
Charge master
The illness or trauma that brought the patient to the hospital
Admitting diagnosis
A method that groups patients based on a specific set of characteristics, including principal diagnosis, procedures and/or resources being used
Case mix
Additional illnesses present at the time of the patient’s admission to the hospital, often complicating treatment or prolonging patient’s hospital stay
Comorbidities
The diagnosis, after examination and study, determined to be the cause of the patient’s admission to the hospital
Principal diagnosis
Fee paid to hospital for services provided
Facility fee
Fee paid to physician for services provided, such as medical consultation and surgery
Service fee
A facility design for treating Medicare eligible patients
Skilled nursing facility
A data set used in home health care for patient assessments to help monitor and improve the outcomes of home health care
Outcome and assessment information set (OASIS)
Centers for Medicare and Medicaid services professional, universal health claim form; used by providers of outpatient health services for billing fees to health carriers
CMS– 1500
Institutional claim form used by hospitals to receive payment from third-party payers; also known as the UB – 04 or the uniform bill
CM/S-1450
Private companies that have a contract with Medicare to process Medicare part B bills for physicians and medical suppliers
Medicare carriers
Information maintained on coding reviews and the actions needed for improvement
Audit trails
Assigned codes that aren’t supported by the information in the patient’s health record
Up coding
Codes that are normally assigned as a set or broken into separate codes for the purpose of obtaining higher reimbursement of healthcare services
Unbundling
