Domain 4 - Revenue Cycle Management

Adjudication

Process of paying, denying, and adjusting claims based on a patient’s healthcare insurance coverage benefits

Affordable Care Act (ACA)

Mandated many changes and reimbursement methodologies; Provided national health coverage for Americans

Policy

Contract between the insurer and the person

Premium

Set amount per month or per year to help cover costs of medical expenses

Policy Holder

Person covered by the policy

Revenue Cycle

Process of patient financial health information moving through and out of healthcare organization

Charge Description Master (CDM)

Financial management lists that contains information about the organization’s charges for healthcare services it provides to patients

Technical Component

Facility fee’s; Covers the cost and overhead for providing the service; Examples are lab and radiology tests

Professional Component

Portion of work performed by a physician or other healthcare professional

Eligibility

Verification that the patient is covered by the plan on the date of service and the services provided are covered by the plan

Medical Necessity

Determination that services provided will benefit the patient and are needed

Deductible

Amount of cost the policyholder must incur before the plan will assume liability for the remaining covered expenses

Coinsurance

Pre-established percentage of eligible expenses of eligible expenses after the deductible is met

Copayment

Cost sharing measure in which the policyholder pays a fixed amount per service

Balance Billing

Provider charges the patient for the remainder of the cost not paid by the insurance plan

Explanation of Benefits (EOB)

Detailing how the pair processed the claim for the claim and how much it is paying the healthcare provider

Contractual Adjustment

The difference between what the health care provider charges and what is paid by the payer

Denials Management

Explain the reason for denial, correct any errors on the claim or submit additional documentation requirements

Commercial Insurance

Can be obtained through their employer, purchased individually, or through groups such as a professional association

Private Health Insurance

Individuals, self-employed professionals, and groups such as a professional association

Employer Based Coverage

Obtained when employees and employers share the cost of premium payment

Employer Based Self Insurance Plans

Companies set aside the cost they would have paid for premiums for health coverage and use those funds to pay health care claims

Third Party Administrator (TPA)

Responsible for payment of healthcare claims on behalf of a company

Not for Profit

Do not focus on making money CO-OP’s allow nonprofit companies to provide insurance coverage for nonprofit organizations through low interest loans

For Profit

Exist to make money from the premiums collected

Medical Loss Ratio

Requires companies to spend at least 80% of premium money on medical care

Managed Care

Healthcare delivery system or network organized to manage cost utilization and quality

Managed Care Organization (MCO)

Type of healthcare organized that delivers medical care and handles all aspects of the care and payment for care by limiting providers of care, discounting payment to providers of care, or limiting access to care

Capitation

Providers may agree to see enrollees of an MCO for a set payment per member per month (PMPM)

National Committee for Quality Assurance (NCQA)

Private not for profit organization whose mission is to improve healthcare quality by accreditating, assessing, and reporting the quality of managed care plans

Group Model HMO’s

Contracts with more than one physician

Open Panel Model

Contracts with a network of providers who provide multi-specialty group practices

Staff Model

The HMO employs the physicians

Preferred Provider Organizations (PPO)

Managed care contract, coordinated care plan that contains a network of providers who have agreed to a specified reimbursement, provides for reimbursement for all covered benefits regardless of if they are provided within the network, and offered by an organization that is not licensed under law as an HMO

Fee for Service Plan

Where providers agree to accept lower fees to be part of a network

Point of Service (POS)

Allows enrollees to choose between an HMO or PPO each time they are in need of care

Exclusive Provider Organizations (EPO)

Hybrid MCO’s in that they provide benefits to subscribers only when network providers perform healthcare services

Medicare

Coverage to most Americans aged 65 or older or recieving retirement benefits from social security

Medical Administrator Contractor (MAC)

Private insurance companies that serve as Medicare agents and the administration of the Medicare program

Medicare Part A - Hospital Insurance

Covers inpatient care and hospital including critical access hospitals and skilled nursing facilities

Medicare Part B

Supplemental portion of Medicare for which beneficiaries pay a monthly premium to assist with coverage for physician services and outpatient care

Medicare Part C - Medicare Advantage Plans

Managed care plans offered by private companies for all of Medicare services and extra coverage of services such as dental, vision, acupuncture

Medicare Part B - Prescription Drug Coverage

Plan options for beneficiaries to obtain prescription drug coverage

Medigap Insurance

Supplemental insurance that can help cover out of pocket for deductible copay and non-covered services

Medicaid

Helps with costs of low income and limited resources including the mandatory eligibility groups of children, pregnant women, elderly adults, people with disabilities, and low-income adults

Dual Eligible

People who are enrolled in both Medicare and Medicaid

State Children’s Health Insurance Plan (CHIP)

Provides healthcare coverage to eligible children through both Medicaid and individual chip programs

TRICARE

Healthcare for uniformed service members and their families

Veterans’ Health Administrator (VA)

Offers a variety of health care services from basic primary care to nursing home care for eligible veterans

Civilian Health and Medical Program of the Department of Veteran Affairs (CHAMPVA)

Comprehensive healthcare program in which the VA shares the cost of covered healthcare services and supplies for eligible beneficiaries

Indian Health Services (IHS)

Responsible for providing healthcare to American Indians and Alaskan Natives

Workers Compensation

The insurance to cover employees who were injured on the job

Consumer Directed Health Plans (CDHP)

High-deductible plans because the deductible is at least $200 per year and are managed care organizations that influence patients and clients to select cost effective healthcare

Hospital Acquired Condition (HAC)

Reasonably preventable condition that the patient did not have upon admission to a hospital

Medicare Access and CHIP Reauthorization Act (MACRA)

Requires providers to concentrate their health care efforts on the value of the care they provide instead of the volume

Utilization Management (UM)

Evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities

Pre Certification

Process for elective admissions, certain diagnostic procedures and outpatient surgeries

Case Management

Collaboration between health care and service providers to aid in the process of assessment, planning, facilitation, care, coordination, evaluation and advocacy to meet the comprehensive health needs of an individual or family

Fee for Service Reimbursement

Reimbursement method through which providers retrospectively receive payment based on either bill charges for services provided or annually updated fee schedules

Value Based Purchasing (VBP)

Type of incentive to improve clinical performance using the EHR and resulting in additional reimbursement for eligibility for grants and other subsidies to support further health information technology efforts

Traditional Fee for Service Reimbursement

Third party payers or patient issue payments to health care providers after healthcare services have been received

Managed Fee for Service Reimbursement

Third party payers or patients issue payments to health care providers after healthcare services have been received

Managed Fee for Service Reimbursement

Involves utilization controls for reimbursement under traditional fee for service insurance plans; Control cost by handling their members use of health care services

Episode of Care Reimbursement Methodologies (EOC)

Given for a relatively continuous medical treatment provided by the healthcare professional and relation to a particular clinical problem or situation

Capitation

Specified amount of money paid to a healthcare plan or physician to cover the cost of a healthcare plan member services per member per month (PMPM)

Global Payment

Methodology involves payment that combines the professional and technical components of a procedure and disperses payments as a lump sum to be split between the physician and the health care organization

Perspective Payment System (PPS)

Method of reimbursement in which Medicare payment is based on a predetermined dized amount

Medicare Inpatient Prospective Payment System (IPPS)

Under Medicare Part A is a payment methodology in which payment is based on the diagnosis of the patient

Disproportionate Share Hospital (DSH)

Hospital that treats high percentage of low income patients; Can recieve an adjustment or additional reimbursement

Inpatient Rehabilitation Hospital

Unit within a hospital that is a free-standing facility that provides an intensive rehab for patients; Patients must be able to tolerate 3 hours of intense rehab per day

Patient Assessment Instrument (PAI)

Completed on Medicare patients shortly after admission and upon discharge in rehab facilitates

Major Complication/Co-Morbidity (MCC)

Patient has a medical condition that arises during a patient stay (Complication); Medical condition that coexists with the primary reason for admission (comorbidity)

Complication/Co-Morbidity (CC)

Patient has a medical condition that is not considered major

Non - CC

All severity levels are based on the secondary diagnosis

Case Mix Index (CMI)

Represent the average MS-DRG relative weight for a particular hospital

Resource Based Relative Value Scale System (RBRVS)

Payment methodology in which physician payments are determined by the resource costs needed to provide care

Skilled Nursing Facility Prospective Payment System

The case mix model is called the patient driven payment model (PDPM) which focuses on the condition and care requirements of the patient rather than the amount of care provided

Outpatient Prospective Payment System (OPPS)

Medicare prospective payment used for hospital-based outpatient services and procedures that is predicated on the assignment of Ambulatory Patient Classifications (APC)

Ambulatory Patient Classification (APC)

• Distinct entity that operates exclusively for the purpose of diagnosis and procedures that are similar in terms of resources used, complexity of illness, and conditions presented

• APC groups consist of five types of services: significant procedures, surgical services, medical visits, ancilliary services and partial hospitalization

Ambulatory Surgery Prospective Payment System (ASC)

Distinct entity that operates exclusively for the purpose of furnishing surgical services to patients who did not require hospitalization and when the expected duration of services does not exceed 24 hours following admission

Home Health Prospective Payment System (HH PPS)

• Use the patient driver grouping models for payment which is based on a 30-day period of time for service

• Categorized into 432 case mixed groups and five subgroups

Ambulance Fee Schedule

• Medicare will determine the medical necessity for the transportation of a patient by ambulance if the facility to which the patient is taken is appropriate

• Payment includes base rate payment plus a mileage payment to the nearest healthcare organization

NCCI Edits

Prevents improper payments for incorrect code combinations are on the claim

Excising a Malignant Lesion

Diameter of lesion as well as the margins excised in the operative report

Simple

Repair of superficial wounds involving primarily epidermis and dermis or substitute without significant involvement of deeper structures and simple one-layer closure

Intermediate

Includes the repair of a wound that requires a layered closure of one or more of the deeper layers of subcutaneous tissue and superficial facia in addition to the skin closure

Complex

Requires more than layer closure, extensive undermining, stents, or retention sutures

X

Placeholder character at certain codes to allow for future expansion of the classification system

Utilization Management

Process of determining whether the medical care provided to a patient is necessary

Bill Hold

Period of time between discharge and claim submission with a facility defines by policy

Program for Evaluation Payment Patterns Electronic Report (PEPPER)

The quality improvement organizations under contract with CMS conduct audits on high risk and hospital specific data from claims data