Flashcards in Unit 3 - Lesson 1: Reimbusement Methodologies Deck (30)
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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
