Chapter 3: Introduction to Revenue Management

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50 Terms

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Accept Assignment

provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts).

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Accounts Payable

amount a business owes creditors and suppliers.

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Accounts Receivable

amount owed to a business for services or goods provided.

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Accounts Receivable Management

assists providers in the collection of appropriate reimbursement for services rendered; includes functions such as insurance verification/eligibility and preauthorization of services.

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Accrual Accounting

method that focuses on anticipated revenue and associated expenses; revenue earned and expenses billed are recorded even though third-party payer reimbursement has not been received and expenses have not been paid.

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Assignment of Benefits

the provider receives reimbursement directly from the payer.

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Birthday Rule

determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.

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Case Management

development of patient care plans to coordinate and provide care for complicated cases in a cost-effective manner.

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Chargemaster

computer-generated encounter form that contains a list of procedures, services, supplies, and revenue codes; chargemaster data are entered in the outpatient hospital facility’s patient accounting system, and charges are automatically posted to the patient’s bill (UB-04).

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Chargemaster Maintenance

process of updating and revising key elements of the chargemaster (or charge description master [CDM]) to ensure accurate reimbursement.

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Chargemaster Team

team of representatives from a variety of departments who jointly share responsibility for updating and revising the chargemaster to ensure accuracy.

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Claims Denials

unpaid claim returned by third-party payers because of beneficiary identification errors, coding errors, diagnosis that does not support medical necessity of procedure/service, duplicate claims, global days of surgery E/M coverage issue, NCCI program edits, and other patient coverage issues (e.g., procedure or service required preauthorization, procedure is not included in patient’s health plan contract, such as cosmetic surgery).

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Claims Rejections

unpaid claim returned by third-party payers because it fails to meet certain data requirements, such as missing data (e.g., patient name, policy number); rejected claims can be corrected and resubmitted for processing.

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Concurrent Review

continued-stay review for continued appropriateness of care and medical necessity of tests and procedures ordered during an inpatient hospitalization.

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Data Analytics

tools and systems that are used to analyze (examine and study) clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.

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Data Mining

extracting and analyzing data to identify patterns, whether predictable or unpredictable.

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Data Warehouse

database that uses reporting interfaces to consolidate multiple databases, allowing reports to be generated from a single request; data is accumulated from a wide range of sources within an organization and is used to guide management decisions.

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Day Sheet

also called manual daily accounts receivable journal; chronological summary used to manually track all transactions posted to individual patient ledgers/accounts on a specific day.

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Discharge Planning

involves arranging appropriate health care services for the discharged patient (e.g., home health care).

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Discharged Not Final Billed(DNFB)

patient claims that are not finalized because of billing delays.

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Discharged Not Final Coded(DNFC)

patient claims that are not finalized because of coding delays or incomplete documentation.

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Encounter Form

financial record source document used by providers and other personnel to select treated/managed diagnoses and procedures/services provided to the patient during the current encounter.

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Guarantor

person responsible for paying health care fees.

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Institutional Billing

involves generating UB-04 claims for charges generated for inpatient and outpatient services provided by health care facilities, which according to CMS include hospitals, long-term care facilities, skilled nursing facilities, home health agencies, hospice organizations, end-stage renal disease providers, outpatient physical therapy/occupational therapy/speech pathology services, comprehensive outpatient rehabilitation facilities, community mental health centers, critical access hospitals, federally qualified health centers, histocompatibility laboratories, Indian Health Service facilities, organ procurement organizations, religious non-medical health care institutions, and rural health clinics.

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Integrated Revenue Cycle(IRC)

combining revenue management with clinical, coding, and information management decisions because of the impact on financial management.

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Manual Daily Accounts Receivable Journal

also called the day sheet; a chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day.

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Metrics

standards of measurement, such as those used to evaluate an organization’s revenue cycle to ensure financial viability.

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Nonparticipating Provider(nonPAR)

does not contract with the insurance plan; patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses.

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Out-of-pocket Payment

established by health insurance companies for a health insurance plan; usually has limits of $1,000 or $2,000; when the patient has reached the limit of an out-of-pocket payment (e.g., annual deductible) for the year, appropriate patient reimbursement to the provider is determined; not all health insurance plans include an out-of-pocket payment provision.

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Participating Provider(PAR)

contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed.

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Patient Account Record

also called patient ledger; a computerized or manual permanent record of all financial transactions between the patient and the practice.

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Pre-admission Certification(PAC)

review for medical necessity of inpatient care prior to the patient’s admission.

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Preauthorization

health plan review that grants prior approval of patient health care services.

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Primary Health Insurance

associated with how a health insurance plan is billed—the insurance plan responsible for paying health care insurance claims first is considered primary.

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Professional Billing

involves generating CMS-1500 claims for charges generated for professional services and supplies provided by physicians and non-physician practitioners (NPPs), which according to CMS include nurse practitioners, physician assistants, clinical nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists.

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Prospective Review

reviewing appropriateness and necessity of care provided to patients prior to administration of care.

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Quarterly Provider Updates(QPUs)

published by CMS to simplify the process of understanding proposed or implemented instructional, policy, and changes to its programs, such as Medicare.

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Requisition Form

document electronically or manually submitted to a health care organization that serves as provider orders for outpatient services.

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Resource Allocation

distribution of financial resources among competing groups (e.g., hospital departments, state health care organizations).

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Resource Allocation Monitoring

uses data analytics to measure whether a health care provider or organization achieves operational goals and objectives within the confines of the distribution of financial resources, such as appropriately expending budgeted amounts as well as conserving resources and protecting assets while providing quality patient care.

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Retrospective Review

reviewing appropriateness and necessity of care provided to patients after the administration of care.

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Revenue Auditing

assessment process that is conducted as a follow-up to revenue monitoring so that areas of poor performance can be identified and corrected.

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Revenue Code

a four-digit code that indicates location or type of service provided to an institutional patient; reported in FL 42 of UB-04.

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Revenue Cycle Management

process that typically begins upon appointment scheduling or physician order for inpatient hospital admission and concludes when reimbursement is obtained or collections have been posted.

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Revenue Management

process that facilities and providers use to ensure financial viability.

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Revenue Monitoring

involves assessing the revenue process to ensure financial viability and stability using metrics (standards of measurement).

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Secondary Health Insurance

billed after primary health insurance has paid contracted amount, and often contains the same coverage as a primary health plan.

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Single-path Coding

combines professional and institutional coding to improve productivity and ensure the submission of clean claims, leading to improved reimbursement.

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Superbill

an encounter form that contains a list of common diagnoses and ICD-10-CM codes and procedures/services and CPT/HCPCS Level II codes, which is used in the physician’s office to capture encounter data for billing purposes.

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Utilization Management

method of controlling health care costs and quality of care by reviewing the appropriateness, efficiency, and medical necessity of care provided to patients prior to and after the administration of care.