Revenue Cycle and Regulatory Compliance

A set of flashcards covering key terms and concepts related to the revenue cycle and regulatory compliance in healthcare.

Revenue Cycle

The process involving administrative and clinical oversight to capture and collect payment for services rendered.

Patient Registration

The initial step in the revenue cycle, including gathering patient demographic details and insurance information.

Charge Capture

The process of selecting and entering codes based on documentation in the patient's record.

Claim Submission

The process of creating and sending a claim to insurers for reimbursement of services rendered.

Insurance Payment Posting

The act of recording payments made by insurers based on submitted claims.

Patient Copayment (Copay)

Flat, fixed amount that a patient pays for specific services.

Eligibility

The process of verifying a patient has insurance coverage and benefits for services.

Preauthorization

Requesting approval for a service or procedure by providing medical history to support medical necessity.

Utilization Management

Method used to review the appropriateness and medical necessity of services before treatment.

Appeals Process

A process to request reconsideration of a denied claim, potentially progressing through multiple levels of appeal.

Accounts Receivable

The amount owed to a provider for health care services rendered.

Fair Debt Collection Practices Act (FDCPA)

A federal law that regulates third-party debt collectors and protects consumer rights.

Deductible

Annual amount a patient must pay before insurance starts covering benefits.

Coinsurance

Predetermined percentage the patient must pay for covered services after meeting the deductible.

Beneficiary

Person eligible to receive benefits for covered health care services.

Medical Necessity

Condition for which supporting diagnosis codes must justify the services rendered.

Encounter Form

Document capturing diagnosis or procedure codes for services during a patient encounter.

Claim Editing Software

Tools used to review and ensure accuracy of codes before claim submission.

Patient Check-Out

Process that determines out-of-pocket expenses and discusses follow-up appointments at the end of a patient visit.