Healthcare Billing and Contracts

These flashcards cover essential terms and definitions related to healthcare billing and contracts, providing a comprehensive review tool for the exam.

Managed Care Contract

A legal agreement between an insurer and provider.

Right of offset

A contractual clause that allows a health plan or insurer to recover previous overpayments to a healthcare provider by deducting that amount from future payments.

Evergreen clause

A contractual provision that allows for automatic renewal of the agreement for a specified period.

Universal Billing (UB) form

A standardized claim form used by institutional healthcare providers like hospitals and outpatient facilities to bill for services provided to patients with Medicare, Medicaid, and other government programs.

Who can execute (sign) a contract

An officer of the corporation, as shown on the corporation’s filings with the Secretary of State.

Coordination of Benefits (COB)

A set of rules governing which insurance company is responsible for payment when a patient is covered by two different health insurance policies.

Provider Manual

A comprehensive document published by healthcare payors that provides essential information, policies, and procedures for participating healthcare providers.

Advance Beneficiary Notice (ABN)

A written notice that provider must give to the patient if provider has reason to believe payor will not pay for the service.

No balance billing clause

Means a patient isn’t responsible for paying the difference between a provider’s charges and the amount their insurance plan pays.

Dispute resolution: mediation vs. arbitration

Mediation is a less formal, non-binding process where a neutral third party helps disputing parties reach a mutually agreeable solution while arbitration is more formal and binding.

Purpose of the Medicare cost-to-charge ratio (CCR)

To convert a hospital’s billed charges into estimated costs for services to help determine if a case’s costs exceed the fixed-loss outlier threshold.

DRG price calculation

Case weight multiplied by the hospital base rate.

Average case-mix index (CMI)

The sum of a group of patients’ relative case weights divided by the number of patients in that group.

UB04

Standardized, uniform institutional claim form used by hospitals and other healthcare facilities to bill insurance companies for services.

Benchmarking accounts receivable

Involves comparing key AR performance indicators against industry standards to identify inefficiencies.

ICD-10-CM

A global system used to classify and code diseases, injuries, and health conditions.

Average length of stay (ALOS)

The sum of a group of patients’ number of days in the hospital divided by the number of patients in that group.

Charge description master (CDM)

A comprehensive list of all services, procedures, supplies, and medications provided by a hospital with their prices.

CPT codes

A standardized set of five-character codes used to describe medical, surgical, and diagnostic services.

Days in accounts receivable

The total value of accounts receivable divided by average daily revenue.