Chapters 15 Revenue Cycle

Adjudication

Term used by the ins industry for the process of paying, denying, and adjusting claims based on the patient’s healthcare insurance coverage benefits.

Health Insurance

Is a contract that requires a health Insurer to pay some or all of the healthcare costs associated with a covered individual in exchange for a monthly fee

Out of pocket

The individual pays for services provided with their own money

Policy

Is a contract between an insurance company and an individual

Benefits

Healthcare services or items covered in an ins plan

Health Insurer

Is the company or organization that provides coverage

Eligibility

Process of determining if a patient is covered by their health insurance plan on the date they receive services

Medical Necessity

Is the determination that the services or treatment provided are appropriate and effective based on excepted standards of medical practice

(EOB) Explanation of Benefits

Notification that the claim has been processed

Includes:

Total charges for services, how much is owed, how much the provider can charge and how much the health plan has paid

(ADR) Additional Document Request

Additional information for the provider to complete the claims process

(RA) Remittance Advice

A notification from the health plan insurer that explains how the claim charges have been adjusted due to contract agreements, benefit coverage, copays, and coinsurance

Beneficiaries

Individuals who are eligible for benefits from a health plan

(TPA) Third Party Administrator

Provides administrative oversight to process the medical claims payments for the emplyer

Deductible

The amount of cost the policyholder is required to pay each benefit period

(ABN) advanced beneficiary notice of non coverage

Written notice from Medicare given to the beneficiary that certain services may not be covered, and Medicare may deny payment for service

Medicaid

Is a federal and state government program designed to to cover medical costs of outpatient and inpatient services for individuals who meet federal eligibility Americans with low income and limited resources

(MAGI) Modified Adjusted Gross Income

Eligibility of a person or family and its calculated relation to income and assets being a certain percentage of federal poverty level

(COB) Coordination of Benefits

Process used by insurance companies to prevent duplicate payments when a person is covered by more than 1 health plan

(CHAMPVA) Civilian Health & Medical Program of the Department of Veterans Affairs

Is is a comprehensive healthcare program in which the VA shares cost of covered healthcare services and supplies with the eligible beneficiaries

Indian Health Service

Is a HHS agency responsible for providing healthcare to indigenous populations in the US

(NCQA) National Committee for Quality Assurance

Is a private nonprofit organization whose mission is to improve healthcare quality by accrediting assessing and reporting the quality of managed care plans

(HEDIS) Healthcare Effectiveness Data and Information Set

A set of performance measuress

Revenue Cycle

Is the process of patient financial & health information moving through and out of the HO, culminating with the healthcare organization receiving reimbursement for services provided.

(HAC) hospital acquired condition

A reduction program to incentivize hospitals in minimizing HAC

(POA) Present on admission

Designates whether a condition was present at time admission

Chargemaster

Electronic file representing the master financial management list and contains information about the organizations charges for healthcare services

Hard coding

Contains HCPCS LEVELS 1&2

(HCFA) Healthcare Financing administration

The agency that originally developed the health insurance claim form also known as the CMS-1500

(FFS) Fee for service

Reimbursement model through which providers retrospectively receive payment by billing for specific services or by adhering to an annually updated fee schedule

Capitation

Or prepayment is a fixed payment per patient to a healthcare plan or physician to cover costs of a healthcare plan member for a certain length of time, regardless of the level of care or services provided

(EOC) Episode of care model

A single payment that covers the entire care of the patient for a condition or a procedure

Value based purchasing

Is a Payment model where providers are awarded based on quality and efficiency of the care they deliver

(DSH) Disproportionate share hospital

A hospital that treats a high percentage of of low-income patients

(CMI) Case-Mix index

Represents the average MS-DRG relative weight for that hospital

(ADL)s Activities of Daily living

Ability to complete activities of daily living

(IRF-PAI) Inpatient rehabilitation facility

Is a assessment tool used to gather comprehensive data on patients health & functional status including motor and cognitive functions

(RUG) resources utilization group

Uses data from assessments such as the Minimum data set (MDS), reflects an intensity of care required

Utilization Management (UM)

Involves assessing the medical necessity, appropriateness and efficiency of use of healthcare services, procedures, and facilities within the parameters of the applicable health benefits plan

Prospective Review

Review that takes place prior to elective procedures & admissions to ensure that services meet predetermined criteria set forth by the insurance company or payor

Concurrent review

Occurs during the patients hospitalization focusing on medical necessity appropriateness, and timeliness of care delivery from admissions to discharge

Retrospective Review

Involves analyzing actual utilization data after the patient is discharged to ensure services provided were appropriate and met quality standards.

(QIO) Quality Improvement Organization

Hired by CMS conducts an external review of the UM processes in the H.C.O.

Case Management

A collaboration between healthcare and service providers aimed at facilitating the comprehensive care of individuals or families

Telehealth

Allow a doctor to provide treatment outside of traditional office visit.

The Consolidated Appropriations Act of 2023

Continued several Telehealth flexibility waivers which provide continued support for HC providers.

(MACRA) The Medicare & Chip Reauthorization Act

Changed how Medicare pays professionals and created the Quality Payment Program

Quality Payment Program

Requires providers to concentrate their efforts on the quality of care they provide instead of volume.

(MIPS) Merit Based Incentive Program

Streamlines multiple quality payment programs into one system.