Healthcare Reimbursement Chapter 1 Vocab

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Brief name for patient protection and affordable care act of 2010, as amended by the health care and education reconciliation act of 2010. Collectively these two acts are known as this.

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Affordable Care Act (ACA)

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Combination of supply and pharmaceutical costs or medical visits with associated procedures or services for one lump sum payment

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Bundling

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Method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount for each person enrolled without regard to the actual number or nature of services provided or number of persons served.

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Capitation

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Price assigned to a unit of medical or health service such as a visit to a physician or a day in a hospital. The charge for service may be unrelated to the actual cost of providing the service.

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Charge

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Request for payment, or itemized statement of healthcare services and their costs, provided by a hospital, physicians office, or other healthcare provider. Claims are submitted for reimbursement to the healthcare insurance plan by either the policy or certificates holder or the provider. Also called bills for Medicare Part A and Part B, services billed through fiscal intermediaries, and for Part B, physician or supplier services billed through carriers.

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Claim

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Cost-sharing measure in which the policy or certificates holder pays a fixed dollar amount (flat fee) per service, supply, or procedure that is owed to the healthcare facility by the patient. The fixed amount that the policyholder pays may vary by type of service, such as 20$ per prescription or $15 per physician office visit

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Copayment

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Type of retrospective fee-for-service payment method in which third-party payer pays for fees that are customary, prevailing, and reasonable

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Customary, prevailing, and reasonable (CPR)

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Annual amount of money that the policyholder must incur (and pay) before the health insurance will assume liability for the remaining charges or covered expenses

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Deductible

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Healthcare insurance benefits for spouses, children, or both of the member (enrolle, subscriber, certificate holder) coverage is dependent on relationship with member

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Dependent (family) coverage

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Healthcare payment method in which providers receive one lump sum for all care they provide related to a condition or disease

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Episode of care Reimbursement

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Price assigned to a unit of medical or health service, such as a visit to a physician or a day in a hospital. A fee for a service may be unrelated to the actual cost of providing the service

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Fee

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Third party payer's predetermined list of maximum allowable fees for each healthcare service

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Fee schedule

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Healthcare payment method in which providers retrospectively receive payment for each service rendered

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Fee for service (FFS) reimbursement

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Method of payment in which the third party payer makes one consolidated payment to cover the services of multiple providers who are treating a single episode of care

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Global payment method

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Person who is responsible for paying the bill or guarantees payment For healthcare services. Patients guarantee payments for the healthcare costs of their children.

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Guarantor

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Providers use of electronic health records to achieve significant improvement in health services. Included ate activities such as entering basic patient data, using software applications to improve safety and quality, exchanging health information, and submitting clinical quality and other measures.

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Meaningful use

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Medicare refinement to diagnosis-related group (DRG) classification system, which allows for payment to be more closely aligned with resource intensity.

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Medicare-severity diagnosis-related group (MS-DRG)

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A payer is an entity that pays for health services, such as an insurance company, workers compensation, Medicare, or an individual.

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Payer

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Type if prospective payment method in which the third party payer reimburses the provider a fixed rate for each day a covered member is hospitalized.

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Per diem (per day) payment

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Amount of money that policyholder or certificate holder must periodically pay a healthcare insurance plan in return for healthcare coverage

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Premium

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Type if episode of care reimbursement in which the third party payer established the payment rates for healthcare services in advance for a specific time period

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Prospective payment method

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Physician, clinic, hospital, nursing home, or other healthcare entity (second party) rendering the care.

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Provider

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Type of retrospective fee-for-service payment method that classifies health services based in the cost of providing physician services in terms of effort, practice expenses (overhead), and malpractice insurance

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Resource-based relative value scale (RBRVS)

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Type of fee for service reimbursement in which providers receive recompense after health services have been rendered

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Retrospective payment method

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Type of fee for service reimbursement in which the patients or their guarantors pay a specific amount for each service received

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Self pay

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Insurance company or health agency that pays the physician, clinic, or other healthcare provider (second party) for the care or services to the patient (first party). An insurance company or healthcare benefits program that reimburses healthcare providers and or patients for covered medical services

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Third-party payer

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Type of retrospective fee for service payment method in which the third party payer pays for fees that are usual, customary, and reasonable, wherein usual means usual for the individual providers practice, customary means customary for the community, and reasonable is reasonable for the situation.

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Usual, customary, and reasonable (UCR)