Reimbursement Methodologies

Accounts Receivable (AR)

Payments that hospitals receive from third-party payers for providing healthcare services

CMS-1500 Claim Form

Standard insurance claim form used to report outpatient services to insurance companies

Coordination of Benefits (COB)

Also known as crossover; group policy provision that helps determine the primary carrier in situations in which an insured party is covered by more than one policy, thus preventing the insured from receiving claim overpayments

Explanation of Benefits (EOB)

Statement sent to a participant in a health plan as well as the healthcare provider that lists services, amounts paid by the plan, and total amount billed otherwise the patient

Fiscal Intermediaries (FI)

Insurance companies contracted by the government to process claims for government insurance programs, such as Medicare Parts A and B

Remittance Advice

Communication from third-party payer to payee that provides a detailed accounting of payments and healthcare services provided

Revenue Codes

UB-92 payment codes for healthcare services or items

UB-92 Claim Form

Also known as the CMS-1450 form; standardizes the processing of billing for hospital inpatient and outpatient services

Reimbursement

The way that healthcare providers are paid for providing medical services

Healthcare Providers

Doctors, hospitals and healthcare facilities

Medical Coding

The process of assigning codes to certain pieces of information in the health record

Preventable Health Threats

Illnesses that can be prevented before they occur by routine physical examinations and immunizations

Third-Party Payers

Responsible for providing an insurance arrangement that provides benefits in the form of healthcare services

Fee-for-Service Reimbursement

Healthcare provider receives reimbursement based on the amount that they charge for service

Covered Medical Expenses

Medical expenses that are listed in the benefits section of the insurance policy as being reimbursable by the insurance company

Chargemaster

A list of healthcare supplies and services with specific charges assigned for each supply and service

Facility Fee

Fee paid to hospital for services provided

Service Fee

Fee paid to physicians for services provided, such as medical consultation and surgery

Skilled Nursing Facility

A facility designed to treat Medicare-eligible patients

Outcome and Assessment Information Set (OASIS)

A dataset used in home healthcare for patient assessments to help monitor and improve the outcomes of home healthcare

CMS

Centers for Medicare and Medicaid Services’ professional, universal health claim form; used by providers of outpatient health services to bill their fees to health carriers (or third-party payers)

CMS-1450

Institutional claim form used by hospitals to receive payment from third-party payers; also known as the UB-04 or the Uniform Bill

Medicare Carriers

Private companies that have a contract with Medicare to process Medicare Part B bills for physicians and medical suppliers

Audit Trails

Information maintained on coding reviews and the actions needed for improvement

Upcoding

Assigning codes that aren’t supported by the information in the patient’s health record

Unbundling

Breaking down codes that are normally assigned as a set into separate codes for the purpose of obtaining higher reimbursement