Healthcare Admin cram

Alphabetic Files

Files by name (usually by last name, and if last name is the same, first name is used)

Numeric Files

Files by number like patient id numbers, invoice numbers, or medical record numbers

Subject Files

Filed by topic or category

Tickler Files

Reminder files organized by date so staff know when something needs action later. Used for follow-ups, unpaid claims, license renewals, appointments, and deadlines.

Accounts receivable

money owed to a company by its debtors

Accounts payable

short-term liability representing money a company owes vendors for goods or services purchased on credit, usually listed on the balance sheet. It acts as a key indicator of short-term liquidity and cash flow management, typically settled within 30-60 days to maintain vendor relationships

Superbill

A superbill is a summary of the visit for payment purposes. It tells exactly what was done and why it was done in a format that can be used to make an insurance claim.

ICD-10

Diagnosis codes

CPT

Procedure Codes

Electronic Remittance Advice (ERA)

a document sent by the insurance company to the healthcare provider explaining payment, denials, and claim adjustments.

Explanation of Benefits

A statement from an insurance company to the patient explaining what medical services were billed, what the insurer paid, and what amount the patient may be responsible for.

Patient Ledger

A record of all financial transactions for a patient’s account, including charges, payments, credits, and balances due.

Fee schedule

A fee schedule is a list of the standard charges a healthcare provider has for services and procedures.

fee schedule = the office’s list of prices

CMS-1500 Form

The standard form used for billing insurance payers. It is used to submit a claim to an insurance company so the provider can get paid.

UB-04

The UB-04 is the standard claim form used by hospitals and other healthcare facilities to bill insurance companies.

UB-04 is for facility billing, while CMS-1500 is for individual provider/professional billing.

Co-payment

A copayment or copay is a fixed amount the patient pays for a healthcare service.

Co-Insurance

20% coinsurance means you pay 20% of the allowed cost for covered medical services, while your insurance company pays the remaining 80%, typically after you have met your annual deductible.

Retention period for adult medical records

7-10 years following the patient’s last visit

Retention period for pediatric medical records

Pediatric medical records must be retained for at least 10 years or until the patient reaches the age of majority (18–21) plus the applicable state statute of limitations, whichever is longer. This often means keeping records until the patient is at least 21 to 23 years old to account for the ability of minors to file malpractice suits upon turning 18.

Hand sanitizer time

20 secs or until it drys

Antiseptic

Destroy microorganisms (bacteria/germs) on living tissue. For example, skin or wounds. Common antiseptics include iodine, hydrogen peroxide, and isopropyl alcohol.

Disinfectant

Destroys microorganisms on non-living objects like countertops.

Review of Systems (ROS)

The review of systems (ROS) section is the part of a medical note where the provider asks about symptoms across different body systems. It is basically a checklist of what the patient is or is not experiencing.

Tricare

Military healthcare

Medicare and its parts (A,B,C,D)

Medicare Part A is hospital insurance covering inpatient hospital care, skilled nursing facility care, and hospice care

Medicare Part B is Medical insurance covering outpatient care and medical services like doctor visits, preventive services, ambulance services, etc

Medicare Part C is called Medicare Advantage. A private-plan alternative to the original Medicare. It includes parts A and B, and most also include part D. The biggest disadvantage of Medicare Advantage is the restricted provider network, which limits your access to specific doctors and hospitals compared to Original Medicare. Other major drawbacks include mandatory prior authorizations for services, high potential out-of-pocket costs, and the inability to see specialists without referrals.

Medicare Part D helps pay for prescription drugs. It is optional and offered through private companies approved by Medicare.

Terminal Digit Filing

Terminal digit filing is a numeric filing system where records are filed according to the last digits of the number first, then the middle digits, then the first digits.

Record number 123456 would be read as:

• 56 = primary section

• 34 = secondary section

• 12 = tertiary section

Balance sheet

For healthcare administration, a balance sheet is one of the main financial statements. It shows the organization’s financial position at one specific point in time. Assets = liabilities + equity

Income statement

An income statement reports a company’s financial performance over a specific period by detailing revenues, expenses, gains, and losses.

Cash Flow Statement

A cash flow statement is a financial report detailing a company's cash inflows and outflows over a specific period, categorized by operating, investing, and financing activities. It measures liquidity and financial health, showing how changes in balance sheet and income accounts affect cash on hand.

Electronic Health Record (EHR)

A digital patient record that contains health information and can be used and shared by authorized healthcare providers to support patient care.

Electronic Medical Record (EMR)

A digital record used mainly within one provider’s office or organization

Chain of Infection

1. Infectious agent (The pathogen that causes disease, for example, bacteria, viruses, fungi, and parasites.)

2. Reservoir (where the pathogen lives and grows), for example, humans, animals, water, food, and equipment.)

3. Portal of exit (how the pathogen leaves the reservoir, for example, blood, saliva, mucus, feces, etc.)

4. Mode of transmission (how it spreads)

5. Portal of entry (how it enters a new host)

6. Susceptible host ( a person likely to get infected, for example, elderly people)

History and physical (H&P)

Record of the patient’s medical history and physical examination findings.

Progress notes

Written notes by the provider about the patient’s condition, exam, and treatment.

Patient medical record / chart

The main document for a patient’s health information, history, treatment, and progress.

Wave Scheduling

Several patients are booked at the same time, usually at the start of the hour, and then seen as the provider becomes available. First come first serve at that specific time. If 5 people are scheduled at 9am, they are seen in the order that they come.

Modified wave scheduling

Patients are scheduled in a wave at the beginning of the hour, but the end of the hour is left open for catching up, charting, or walk-ins.

Double booking

Two patients are scheduled for the same time slot.

Cluster scheduling

Appointments with similar needs are grouped, for example, all physicals in the morning.

Stream Scheduling

Assigns each patient a unique, fixed time slot.

Procedure Scheduling

Organizes visits based on the specific task or required duration.

EMTALA (Emergency Medical Treatment and Labor Act)

Requires Medicare-participating hospitals with emergency departments to give a medical screening exam to anyone who comes in requesting emergency care, regardless of ability to pay. If the person has an emergency medical condition, the hospital must provide stabilizing treatment or an appropriate transfer.

Stark Law

Generally prohibits a physician from referring patients for certain designated health services payable by Medicare or Medicaid to an entity where the physician or an immediate family member has a financial relationship, unless an exception applies.

Anti-Kickback Statute (AKS)

Makes it illegal to knowingly and willfully offer, pay, solicit, or receive something of value in exchange for referrals involving federal healthcare programs such as Medicare or Medicaid. This is a major fraud-and-abuse law.

False Claims Act (FCA)

Punishes submitting false or fraudulent claims for payment to the federal government, including Medicare and Medicaid.

ACA (Affordable Care Act)

Expanded access to health insurance and made major changes to healthcare coverage and regulation.

Patient Self-Determination Act (PSDA)

Requires healthcare facilities to inform patients of their rights to make decisions about medical care, including advance directives.

CLIA (Clinical Laboratory Improvement Amendments)

Regulates laboratory testing and quality standards.

NACHRI

The non-profit advocacy group for pediatric hospitals in the US. National Association of Children's Hospitals and Related Institutions. It is how called apart of the CHA (children’s hospital association)

ASC

An ambulatory surgery center is a healthcare facility that provides outpatient surgical services to patients who do not need hospitalization.

The expected duration of care does not exceed 24 hours, so patients are typically admitted, treated, and discharged the same day. An Ambulatory Surgery Center typically costs 50% less than an inpatient hospital procedure because it practices line-by-line billing.

Patients go home the same day and are used for same-day surgery

HHS

HHS is the U.S. Department of Health and Human Services. Its main job is to protect the health and well-being of people in the United States and provide essential human services.

Examples of agencies under HHS:

• CDC — disease control and public health

• FDA — safety of foods, drugs, and medical devices

• NIH — medical research

• CMS — Medicare and Medicaid (Centers for Medicare & Medicaid Services)

• SAMHSA — mental health and substance use services. (substance abuse and mental health services administration)

SAMHSA

SAMHSA — mental health and substance use services. (substance abuse and mental health services administration)

CMS

Medicare and Medicaid (Centers for Medicare & Medicaid Services)

CHIP

CHIP stands for the Children’s Health Insurance Program. It provides low-cost health coverage to eligible children in families whose income is too high to qualify for Medicaid but who still need help getting insurance. In some states, CHIP also covers pregnant people.

PPO Plan

Preferred Provider Organization. A prepaid health insurance plan in which providers agree to deliver services at discounted rates; patients can go to any provider, but using nonparticipating providers results in higher costs for the patient. Part of managed care.

HMO Plan

Health Maintenance Organization. A prepaid health insurance plan in which patients receive health care from designated providers. Part of managed care.

EPO Plan

Exclusive Provider Organization: A plan where you generally must use providers in the network for coverage, except in emergencies. Main idea: less flexibility than PPO, often cheaper.

POS Plan

Point of Service Plan: A mix of HMO and PPO features. You pay less if you use in-network providers, and you usually need a primary care physician (PCP) and referrals for specialists. Out-of-network care may be covered at a higher cost.

HDHP

High Deductible Health Plan: A plan with a higher deductible, meaning you pay more out of pocket before insurance pays for many services. Premiums are usually lower. These plans are often paired with an HSA. Main idea: lower monthly cost, higher upfront medical cost.

Indemnity Insurance

Indemnity insurance is a traditional health insurance plan that lets the patient choose almost any doctor or hospital, and then the insurance company pays part of the cost. You directly get paid back.

Tort

Any wrongdoing for which an action for damages may be brought.

National Labor Relations Act

Also known as the Wagner Act, the act allows private-sector employees to organize, form unions, engage in bargaining, and take part in strikes or other concerted actions.

Fair Labor Standards Act

Federal law establishing minimum wage, overtime pay, recordkeeping, and youth employment standards for most private and public sector employees.

Rehabilitation Act

The Rehabilitation Act of 1973 is a landmark U.S. federal law prohibiting discrimination based on disability in programs conducted by federal agencies, receiving federal financial assistance, or involving federal contractors. It promotes employment, independent living, and equal opportunity, serving as a model for the ADA.

Basically, they protect the rights of handicapped people.

COBRA

U.S. federal law allows employees to temporarily keep employer-sponsored health insurance after losing their job, reducing hours, or experiencing other qualifying life events.

Worker Adjustment and Retraining Notification Act

U.S. labor law requiring employers with 100+ employees to provide 60 days' advance notice of plant closings or mass layoffs.

Americans with Disabilities Act

1990 law that gives people with disabilities access to public services and requires employers to provide reasonable accommodation for applicants and employees.

Family Medical and Leave Act

It permits employees in organizations to take up to 12 weeks of unpaid leave each year for family or medical reasons.

HIPAA

Health Insurance Portability and Accountability Act

Percentage of expenditures in healthcare that go to pay the workforce.

56%

Number of thousands of patients who die each year from medical errors.

Hundreds of thousands 2-400k

Hill Burton Act

The 1946 Hill-Burton Act (Hospital Survey and Construction Act) provided federal grants and loans for modernizing and building hospitals, nursing homes, and public health centers, particularly in underserved areas. In exchange, facilities promised to provide free or reduced-cost care to local residents and serve everyone regardless of race, creed, or color.

Employee Polygraph Protection Act

It prevents private employers from using lie detector tests (polygraphs, voice stress analyzers, etc.) for pre-employment screening or during employment.

FUTA

The Federal Unemployment Tax Act (FUTA) is a federal employer-paid payroll tax that funds unemployment compensation for workers who lose their jobs through no fault of their own.

Latent

Incubation period. Infections are persistent and go into relapse.

JCAHO

(Joint Commission on Accreditation Healthcare Organizations) Reviews and accredits hospitals

NCQA

(National Committee for Quality Assurance) Reviews and accredits health plans

Compliance

The % of goods and services used in hospitals that have been negotiated with the GPO's

HEDIS

(Healthcare Effectiveness Data and Information Set) Compares health plan performance

UHDDS

UHDDS stands for Uniform Hospital Discharge Data Set. It is a standardized set of data elements for inpatient hospital discharges so hospitals collect discharge information in a uniform way.

In Loco Parentis

Court makes decisions in place of the parents

Patient Bill of Rights

Patient Bill of Rights is a statement of the basic rights and protections every patient should have when receiving healthcare.

MSDS/SDS

Safety Data Sheets (SDS), formerly known as Material Safety Data Sheets (MSDS), are standardized documents provided by manufacturers containing crucial information on chemical properties, hazards, handling precautions, and emergency procedures.

Procedures for payment on accounts

Procedures for payment on accounts in healthcare administration involve a structured revenue cycle: patient registration/insurance verification, medical coding, claim submission, payment posting (ERA/EFT), and managing patient responsibilities (copays/deductibles).

ERA

The ERA is sent from the insurance company to the provider.

ERA stands for Electronic Remittance Advice. It tells the provider:

• how the claim was processed

• how much was paid

• what was denied or adjusted

• what amount, if any, the patient still owes

EFT

EFT stands for Electronic Funds Transfer.

In healthcare billing, it means the insurance company sends payment electronically to the provider’s bank account instead of mailing a paper check.

Insurance approves a claim.

• The EFT deposits the money into the provider’s bank account.

• The ERA tells the provider why that exact amount was paid.

The Medical Billing process

1. Patient registration
The office collects:

• patient demographics

• insurance information

• guarantor information

• consent forms

2. Insurance verification
The office checks:

• whether insurance is active

• copay

• deductible

• coverage

• referral or preauthorization requirements

3. Patient encounter / visit
The provider sees the patient and documents:

• symptoms

• diagnosis

• procedures or services performed

4. Medical coding
The visit is translated into billing codes:

• ICD-10-CM = diagnosis codes

• CPT = procedure/service codes

• HCPCS = supplies, services, some equipment

5. Charge entry
The codes and charges are entered into the billing system.

6. Claim creation
A claim is prepared using the patient, provider, insurance, and coding information.

7. Claim submission
The claim is sent to the insurance company, often electronically through a clearinghouse.

8. Claim adjudication
The insurance company reviews the claim and decides:

• how much to pay

• what to deny

• what to adjust

• what the patient owes

9. Payment posting
The provider receives:

• ERA = explanation/details of payment

• EFT = actual electronic payment
  The payment is posted to the patient account.

10. Patient billing
If there is a remaining balance, the patient is billed for:

• copay

• coinsurance

• deductible

• noncovered charges

11. Follow-up on unpaid or denied claims
The office may:

• correct errors

• resubmit claims

• appeal denials

• contact insurance

• contact patient

12. Account resolution
The account is closed when the balance is fully paid or otherwise resolved.

Register patient → verify insurance → see patient → code visit → enter charges → submit claim → insurance processes claim → payment posted → bill patient → collect remaining balance

Processing past-due accounts

A common sequence is:

• First reminder: about 5–10 days after the due date

• Second reminder: about 30 days past due

• More serious follow-up: around 60 days past due

• Final notice / collections warning: around 90 days past due, depending on office policy

Reconciling a bank statement

Reconciling a bank statement is the process of comparing the bank statement with the office’s financial records, identifying differences, making needed adjustments, and verifying that both balances agree.

NSF check

bounced check / not sufficient funds

Deposit in transit

recorded by office but not yet shown by bank

Outstanding check

written but not yet cleared

Petty Cash Fund & its maintenance

A petty cash fund is a small, accessible amount of physical cash kept on hand by a business to pay for minor, incidental expenses—such as office supplies, postage, or taxi fares—where using a check or credit card is impractical. It provides convenience for quick, low-value purchases (typically under $25–$100) and enables efficient reimbursement for staff.

Maintaining a petty cash fund means keeping a small fixed amount of cash secure, using it only for minor expenses, recording each use, and replenishing it as needed.

Invoice

bill from a vendor or supplier to the medical office

Day sheet

summary of daily charges, payments, and adjustments

Fee schedule

list of charges for services and procedures

Coordination of Benefits (COB) form

used when a patient has more than one insurance plan

Processing referrals

Processing referrals is the procedure of verifying insurance requirements, preparing and sending referral information to another provider, documenting the referral, and following up on the patient’s specialty care.

Components of the medical record

who the patient is, why they came, what was found, what was done, and what follow-up is needed.

Record life cycle

The phases of the record life cycle are:

1. Creation
   The record is made or received.

2. Distribution
   The record is shared or routed to the right people.

3. Use
   The record is actively used for patient care, billing, legal purposes, or administration.

4. Maintenance / Storage
   The record is filed, protected, and kept accessible for future use.

5. Retention
   The record is kept for the required legal or policy-based period of time.

6. Disposition
   At the end of the retention period, the record is either:

   • destroyed properly, or

   • archived if it has long-term value

A simpler way to remember it:

Create → Use → Store → Retain → Destroy/Archive