Unit 3 - Lesson 1: Reimbusement Methodologies Flashcards Preview

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1

Payments that hospitals receive from third-party payers for providing healthcare services

Accounts receivable (AR)

2

Standard insurance claim form used to report outpatient services to insurance companies

CMS-1500 claim form

3

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)

4

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)

5

Insurance companies contracted by the government to process claims for government insurance programs, such as Medicare part A and B

Fiscal intermediaries (FI)

6

Communication from third-party payer to payee that provides a detailed accounting of payments and healthcare services provided

Remittance advice

7

UB-92 payment codes for healthcare services or items

Revenue codes

8

Also known as the CMS-1450 form, standardizes the processing of billing for hospital inpatient and outpatient services

UB-92 claim form

9

The way that healthcare providers are paid for providing medical services

Reimbursement

10

Doctors, hospitals, and healthcare facilities

Healthcare providers

11

The process of assigning codes to certain pieces of information in the health record

Medical coding

12

Illnesses that can be prevented before they occur by routine physical examinations and immunizations

Preventable health threats

13

Responsible for providing an insurance arrangement that provides benefits in the form of healthcare service

Third-party payers

14

Healthcare provider receives reimbursement based on the amount that they charge for service

Fee-for-service reimbursement

15

Medical expenses that are listed in the benefits section of the insurance policy as being reimbursable by the insurance company

Covered medical expenses

16

A list of healthcare supplies and services with specific charges assigned for each supply and service

Charge master

17

The illness or trauma that brought the patient to the hospital

Admitting diagnosis

18

A method that groups patients based on a specific set of characteristics, including principal diagnosis, procedures and/or resources being used

Case mix

19

Additional illnesses present at the time of the patient’s admission to the hospital, often complicating treatment or prolonging patient’s hospital stay

Comorbidities

20

The diagnosis, after examination and study, determined to be the cause of the patient’s admission to the hospital

Principal diagnosis

21

Fee paid to hospital for services provided

Facility fee

22

Fee paid to physician for services provided, such as medical consultation and surgery

Service fee

23

A facility design for treating Medicare eligible patients

Skilled nursing facility

24

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)

25

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

26

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

27

Private companies that have a contract with Medicare to process Medicare part B bills for physicians and medical suppliers

Medicare carriers

28

Information maintained on coding reviews and the actions needed for improvement

Audit trails

29

Assigned codes that aren’t supported by the information in the patient’s health record

Up coding

30

Codes that are normally assigned as a set or broken into separate codes for the purpose of obtaining higher reimbursement of healthcare services

Unbundling