Revenue Cycle and Healthcare Terminology (Video Notes)

Vocabulary-style flashcards covering Revenue Cycle concepts, Medicare/Medicaid topics, CDI, and related healthcare administration terms.

Revenue Cycle Process

The process that begins when a patient comes in for services and ends with billing the patient at the end of the encounter.

Front-End

Stage of the revenue cycle handling patient access activities such as pre-registration, scheduling, insurance verification, and upfront collections.

PRE-REGISTRATION

Collect information before the patient’s arrival.

REGISTRATION

Collect subsequent patient information during registration.

INSURANCE VERIFICATION

Process of checking the patient’s insurance coverage and benefits before service.

PRE-AUTHORIZATION

Utilization management process used by some insurers to determine if a procedure will be covered.

PRE-CERTIFICATION

Pre-approval of a service by the insurer before it is performed.

INSURANCE FOLLOW-UP

Collect payments from third-party insurers after services are rendered.

COLLECTIONS

Process of collecting payments from patients, insurers, or other payers.

REMITTANCE PROCESSING

Apply or reject payments that have been received.

SUBMISSION

Submitting claims of billable fees to insurance companies.

CLAIM

Statement of services submitted by a healthcare provider to a third-party payer.

CODING

Assigning diagnoses and procedures to render billable charges.

CHARGE CAPTURE

Rendering medical services into billable charges.

UTILIZATION REVIEW

Health plans review requests for medical treatment to determine necessity and appropriateness.

CDM (Charge Description Master)

Electronic file representing a master list of all charged services, supplies, devices, and medications.

CLEAN CLAIMS

Completed insurance claim forms with all required information for prompt processing.

DENIALS

Claims returned unpaid for various reasons.

BILL HOLD PERIOD

Period during which charges are held from billing until patient discharge or other events.

FACILITY CHARGE

E/M charge for resources not included with the CPT code in a clinic environment.

MEDICAL NECESSITY

Likelihood that a proposed service will have a reasonable beneficial effect on health.

ACCOUNTS RECEIVABLE DAYS (A/R Days)

Days payments are owed by outside entities to the organization.

PARTS OF MEDICARE (A, B, C, D)

Part A: Inpatient hospital care; Part B: Medical insurance; Part C: Medicare Advantage; Part D: Prescription drug coverage.

PART A

Medicare coverage for inpatient hospital care and some related services.

PART B

Medicare coverage for outpatient medical services and supplies.

PART C

Medicare Advantage plans that combine Part A, Part B, and usually Part D.

PART D

Medicare prescription drug coverage.

Medigap

Supplemental private insurance that pays for costs not covered by Original Medicare Parts A and B.

Original Medicare

Original Medicare refers to Parts A and B as traditional government-provided coverage.

Medicare Advantage (Part C)

Private plans that provide Part A, B (and usually D) benefits.

CHIP

Children’s Health Insurance Program for uninsured, low‑income children.

TRICARE

Healthcare program for active-duty military members and their families.

CHAMPVA

Health program for dependents and survivors of disabled or deceased veterans.

WORKERS’ COMPENSATION

State-mponsored program providing medical care and wage replacement for workplace injuries.

HMOs, PPOs, PFFS, SNP, HMO-POS, MSA

Types of Medicare/health plans with varying network rules and coverage features.

PFFS

Private Fee-For-Service plan; you can see any provider that agrees to treat you.

HMO

Health Maintenance Organization; typically requires a PCP, referrals, and generally lower premiums.

PPO

Preferred Provider Organization; more flexibility and broader network; usually no referral required.

SNP

Special Needs Plan for people with specific conditions or circumstances.

HMO-POS

HMO Point-of-Service option allowing some out-of-network services.

MSA

Medical Savings Account plan combining a high-deductible plan with a savings account funded by Medicare.

RBRVS

Resource-Based Relative Value Scale; Medicare’s method for paying physicians based on work, practice expense, and insurance costs.

Grouper

Software that assigns MS-DRGs to episodes of care after data is entered.

MS-DRG

Medicare Severity-Diagnosis Related Groups; used to determine payment for hospital stays.

OCE (Outpatient Code Editor)

Software applying coding rules to outpatient claims to ensure correct code use.

Scrubber

Program that checks claims for formatting and coding accuracy before submission.

Rider

Policy provision that adds or limits coverage beyond the base policy.

Superbill

Itemized form used by providers detailing services for billing.

ABN (Advance Beneficiary Notice)

Notice given before a service indicating Medicare may not pay; patient may choose to be billed.

EOB (Explanation of Benefits)

Payer's explanation of services billed, amounts paid, and patient responsibility.

MSN (Medicare Summary Notice)

Statement showing what Medicare paid, what was billed, and what the patient owes.

Remittance Advice (RA)

Provider-facing document explaining payments and adjustments from a payer.

MAC (Medicare Administrative Contractor)

Regionally contracted entities that administer Part A and Part B claims.

Coordination of Benefits

Determining primary vs secondary payer to prevent duplicate payments.

Participating vs Non-Participating Providers

Participating providers accept Medicare assignment and payment; non-participating may bill more and may or may not accept assignment.

Deductible, Coinsurance, Limiting Charge

Patient cost-sharing concepts: deductible is annual payment before coverage; coinsurance is share of cost; limiting charge is extra amount non-participants can bill beyond Medicare approved amount.

MAP Keys

Performance indicators developed for revenue cycle excellence.

KPIs

Key performance indicators used to measure and benchmark healthcare performance.

HEDIS

standardized measures used to compare quality of care across managed care plans.

NCQA

Non-profit organization accrediting and reporting on quality of managed care plans.

Joint Commission

Organization evaluating and accrediting healthcare organizations and programs.

QIO (Quality Improvement Organization)

Reviews inpatient hospital claims to prevent improper payments and upcoding.

CDI (Clinical Documentation Improvement)

Process to ensure accurate documentation and coded data reflecting patient status.

CDI Staff/Physician Champion

Role focusing on educating clinicians about documentation and coding for accurate billing.

Case Mix and Case-Mix Index

Describes patient population characteristics and the MS-DRG weights that reflect resource use.

Query Process

Provider-CDI team communication to clarify documentation with documented data requests.

OASIS

Outcome and Assessment Information Set; core assessment tool for home health patient outcomes.

HAVEN/RAVEN/IRVEN

Data-entry systems used to collect home health and rehab data (OASIS, MDS, etc.).

Home Health Agency

Organization providing home-based medical and social services to homebound patients.

Tracer Methodology

Surveyors verify care access, safety, and consistency by tracing patient care across the organization.

Time-Out

Universal protocol check completed before surgical or invasive procedures.

Deemed Status

CMS accreditation indicating an organization meets or exceeds required standards.

Fraudulent and Abusive Practices (Unbundling, Upcoding, Jamming, Clustering, Exploding charges)

Coding/charging practices aimed at increasing reimbursement; ethical/documentation integrity is the goal.

Query vs CDI

Query is a request for clarification; CDI is a program to improve documentation quality for accurate billing.