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116 Cards in this Set

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  • Back
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Accept assignment
A term used to refer to a provider’s or a supplier’s acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided
Accounts receivable (A/R)
Records of the payments owed to the organization by outside entities such as third-party payers and patients
Acute care prospective payment system (PPS)
The reimbursement system for inpatient hospital services provided to Medicare and Medicaid beneficiaries that is based on the use of diagnosis-related groups as a classification tool
Administrative services only (ASO) contract
An agreement between an employer and an insurance organization to administer the employer’s self-insured health plan
Advance Beneficiary Notice (ABN)
A statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that he will be responsible for any charges
All-patient refined diagnosis-related groups (APR-DRGs)
An expansion of the inpatient classification system that includes four distinct subclasses (minor, moderate, major, and extreme) based on the severity of the patient’s illness
All-patient diagnosis-related groups (AP-DRGs)
A case-mix system developed by 3M and used in a number of state reimbursement systems to classify non-Medicare discharges for reimbursement purposes
Ambulatory payment classification (APC) system
The prospective payment system used since 2000 for reimbursement of hospitals for outpatient services provided to Medicare and Medicaid beneficiaries
Ambulatory surgery center or ambulatory surgical center (ASC)
Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, record keeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation
Ambulatory Surgery Center Prospective Payment System (ASC PPS)
The system that resulted from the Medicare Modernization Act (MMA) of 2003 extensively revising the ASC payment system with changes going into effect on January 1, 2008
Audit
A review process conducted by healthcare facilities (internally and/or externally) to identify variations from established baselines; See external review
Automated code assignment
Uses data that have been entered into a computer to automatically assign codes; uses natural language processing (NLP) technology––algorithmic (rules based) or statistical––to read the data contained in a CPR
Balance billing
A reimbursement method that allows providers to bill patients for charges in excess of the amount paid by the patients’ health plan or other third-party payer (not allowed under Medicare or Medicaid)
Balanced Budget Refinement Act (BBRA) of 1999
The amended version of the Balanced Budget Act of 1997 that authorizes implementation of a per-discharge prospective payment system for care provided to Medicare beneficiaries by inpatient rehabilitation facilities
Blue Cross and Blue Shield (BC/BS)
The first prepaid healthcare plans in the United States; Blue Shield plans traditionally cover hospital care and Blue Cross plans cover physicians’ services
Blue Cross and Blue Shield Federal Employee Program (FEP)
A federal program that offers a fee-for-service plan with preferred provider organizations and a point-of-service product
Bundled payments
A period of relatively continuous medical care performed by healthcare professionals in relation to a particular clinical problem or situation
Capitation
A method of healthcare reimbursement in which an insurance carrier prepays a physician, hospital, or other healthcare provider a fixed amount for a given population without regard to the actual number or nature of healthcare services provided to the population
Case mix
A description of a patient population based on any number of specific characteristics, including age, gender, type of insurance, diagnosis, risk factors, treatment received, and resources used
Case-mix group (CMG) relative weights
Factors that account for the variance in cost per discharge and resource utilization among case-mix groups
Case-mix index (CMI)
The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system; calculated by dividing the sum of the weights of diagnosis-related groups for patients discharged during a given period divided by the total number of patients discharged
Categorically needy eligibility
Categories of individuals to whom states must provide coverage under the federal Medicaid program
Chargemaster
A financial management form that contains information about the organization’s charges for the healthcare services it provides to patients
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
A federal program providing supplementary civilian-sector hospital and medical services beyond that which is available in military treatment facilities to military dependents, retirees and their dependents, and certain others
Civilian Health and Medical Program-Veterans Administration (CHAMPVA)
The federal healthcare benefits program for dependents of veterans rated by the VA as having a total and permanent disability, for survivors of veterans who died from VA-rated service-connected conditions or who were rated permanently and totally disabled at the time of death from a VA-rated service-connected condition, and for survivors of persons who died in the line of duty
Claim
An itemized statement of healthcare services and their costs provided by a hospital, physician office, or other healthcare provider; submitted for reimbursement to the healthcare insurance plan by either the insured party or the provider
CMS-1500
A Medicare claim form used to bill third-party payers for provider services (for example, physician office visits)
Coding
The process of assigning numeric representations to clinical documentation
Coinsurance
Cost sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met
Comorbidity
A medical condition that coexists with the primary cause for hospitalization and affects the patient’s treatment and length of stay
Compliance
1. The process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organization’s ethical and business policies 2. The act of adhering to official requirements
Computer-assisted coding
The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-9-CM and CPT evaluation and management codes for billing and coding purposes
Coordination of benefits (COB) transaction:
The electronic transmission of claims and/or payment information from a healthcare provider to a health plan for the purpose of determining relative payment responsibilities
Cost outlier
Exceptionally high costs associated with inpatient care when compared with other cases in the same diagnosis-related group
Cost outlier adjustment
Additional reimbursement for certain high-cost home care cases based on the loss-sharing ratio of costs in excess of a threshold amount for each home health resource group
Current Procedural Terminology (CPT)
Published by the AMA, this codebook has become widely used as a standard for outpatient and ambulatory care procedural coding in contexts related to reimbursement; it is updated every year on January 1
Department of Health and Human Services (HHS)
The cabinet-level federal agency that oversees all the health- and human-services–related activities of the federal government and administers federal regulations
Diagnosis-related group (DRG)
A unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of more than 500 diagnostic classifications in which cases demonstrate similar resource consumption and length-of-stay patterns
Discharge planning
The process of coordinating the activities related to the release of a patient when inpatient hospital care is no longer needed
Discounting
The application of lower rates of payment to multiple surgical procedures performed during the same operative session under the outpatient prospective payment system; the application of adjusted rates of payment by preferred provider organizations
DRG grouper
A computer program that assigns inpatient cases to diagnosis-related groups and determines the Medicare reimbursement rate
Emergency Maternal and Infant Care Program (EMIC)
The federal medical program that provides obstetrical and infant care to dependents of active-duty military personnel in the four lowest pay grades
Employer-based self-insurance
An umbrella term used to describe health plans that are funded directly by employers to provide coverage for their employees exclusively in which employers establish accounts to cover their employees’ medical expenses and retain control over the funds but bear the risk of paying claims greater than their estimates
Encoder
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system
Episode-of-care (EOC) reimbursement
A category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time period; also called bundled payments because they include multiple services and may include multiple providers of care
Exclusive provider organization (EPO)
Hybrid managed care organization that provides benefits to subscribers only when healthcare services are performed by network providers; sponsored by self-insured (self-funded) employers or associations and exhibits characteristics of both health maintenance organizations and preferred provider organi-zations
Explanation of Benefits (EOB)
A statement issued to the insured and the healthcare provider by an insurer to explain the services provided, amounts billed, and payments made by a health plan
External review (audit)
A performance or quality review conducted by a third-party payer or consultant hired for the purpose
Federal Employees’ Compensation Act (FECA)
The legislation enacted in 1916 to mandate workers’ compensation for civilian federal employees, whose coverage includes lost wages, medical expenses, and survivors’ benefits
Fee schedule
A list of healthcare services and procedures (usually CPT/HCPCS codes) and the charges associated with them developed by a third-party payer to represent the approved payment levels for a given insurance plan; also called table of allowances
Traditional fee-for-service (FFS) reimbursement
A reimbursement method involving third-party payers who compensate providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers
Fiscal intermediary (FI)
An organization that contracts with the Centers for Medicare and Medicaid Services to serve as the financial agent between providers and the federal government in the local administration of Medicare Part B claims
Fraud and abuse
The intentional and mistaken misrepresentation of reimbursement claims submitted to government-sponsored health programs
Geographic practice cost index (GPCI)
An index developed by the Centers for Medicare and Medicaid Services to measure the differences in resource costs among fee schedule areas compared to the national average in the three components of the relative value unit: physician work, practice expenses, and malpractice coverage
Global payment
A form of reimbursement used for radiological and other procedures that combines the professional and technical components of the procedures and disperses payments as lump sums to be distributed between the physician and the healthcare facility
Group health insurance
A prepaid medical plan that covers the healthcare expenses of an organization’s full-time employees
Group model health maintenance organization
Type of health plan in which an HMO contracts with an independent multispecialty physician group to provide medical services to members of the plan
Group practice without walls (GPWW)
A type of managed care contract that allows physicians to maintain their own offices and share administrative services
Hard-coding
The process of attaching a CPT/HCPCS code to a procedure located on the facility’s chargemaster so that the code will automatically be included on the patient’s bill
Health maintenance organization (HMO)
Entity that combines the provision of healthcare insurance and the delivery of healthcare services, characterized by: (1) organized healthcare delivery system to a geographic area, (2) set of basic and supplemental health maintenance and treatment services, (3) voluntarily enrolled members, and (4) predetermined fixed, periodic prepayments for members’ coverage
Health Plan Employer Data and Information Set (HEDIS)
A set of performance measures developed by the National Commission for Quality Assurance that are designed to provide purchasers and consumers of healthcare with the information they need to compare the performance of managed care plans
Healthcare Common Procedure Coding System (HCPCS)
A classification system that identifies healthcare procedures, equipment, and supplies for claim submission purposes; the three levels are as follows: I, Current Procedural Terminology codes, developed by the AMA; II, codes for equipment, supplies, and services not covered by Current Procedural Terminology codes as well as modifiers that can be used with all levels of codes, developed by CMS; and III (eliminated December 31, 2003 to comply with HIPAA), local codes developed by regional Medicare Part B carriers and used to report physicians’ services and supplies to Medicare for reimbursement
Healthcare provider
A provider of diagnostic, medical, and surgical care as well as the services or supplies related to the health of an individual and any other person or organization that issues reimbursement claims or is paid for healthcare in the normal course of business
Home Assessment Validation and Entry (HAVEN)
A type of data-entry software used to collect Outcome and Assessment Information Set (OASIS) data and then transmit them to state databases; imports and exports data in standard OASIS record format, maintains agency/patient/employee information, enforces data integrity through rigorous edit checks, and provides comprehensive online help
Home health agency (HHA)
A program or organization that provides a blend of home-based medical and social services to homebound patients and their families for the purpose of promoting, maintaining, or restoring health or of minimizing the effects of illness, injury, or disability
Home health prospective payment system (HHPPS)
The reimbursement system developed by the Centers for Medicare and Medicaid Services to cover home health services provided to Medicare beneficiaries
Home health resource group (HHRG)
A classification system with 80 home health episode rates established to support the prospective reimbursement of covered home care and rehabilitation services provided to Medicare beneficiaries during 60-day episodes of care
Hospice
An interdisciplinary program of palliative care and supportive services that addresses the physical, spiritual, social, and economic needs of terminally ill patients and their families
Hospital-acquired conditions (HAC)
Eight conditions (not present on admission) identified by CMS as “reasonably preventable”
• Foreign object retained after surgery

• Air embolism

• Blood incompatibility

• State III and IV pressure ulcers

• Falls and trauma

• Catheter-associated urinary tract infection

• Vascular catheter-associated infection

• Surgical site infection—mediastinitis after coronary artery bypass graft
Hospitalization insurance (HI) (Medicare Part A)
A federal program that covers the costs associated with inpatient hospitalization as well as other healthcare services provided to Medicare beneficiaries
ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification)
A classification system used in the United States to report morbidity and mortality information
Indemnity plans
Health insurance coverage provided in the form of cash payments to patients or providers
Independent practice organization (IPO) or association (IPA)
An open-panel health maintenance organization that provides contract healthcare services to subscribers through independent physicians who treat patients in their own offices; the HMO reimburses the IPA on a capitated basis; the IPA may reimburse the physicians on a fee-for-service or a capitated basis
Indian Health Service (IHS)
The federal agency within the Department of Health and Human Services that is responsible for providing federal healthcare services to American Indians and Alaska natives
Inpatient psychiatric facility (IPF)
A healthcare facility that offers psychiatric medical care on an inpatient basis; CMS established a prospective payment system for reimbursing these types of facilities using the current DRGs for inpatient hospitals
Inpatient rehabilitation facility (IRF)
A healthcare facility that specializes in providing services to patients who have suffered a disabling illness or injury in an effort to help them achieve or maintain their optimal level of functioning, self-care, and independence
Inpatient Rehabilitation Validation and Entry (IRVEN)
A computerized data-entry system used by inpatient rehabilitation facilities
Insured
A holder of a health insurance policy
Insurer
An organization that pays healthcare expenses on behalf of its enrollees
Integrated delivery system (IDS)
A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care
Integrated provider organization (IPO)
An organization that manages the delivery of healthcare services provided by hospitals, physicians (employees of the IPO), and other healthcare organizations (for example, nursing facilities
Long-term care hospital (LTCH)
A healthcare organization that provides medical, nursing, rehabilitation, and subacute care services to residents who need continual care
Low-utilization payment adjustment (LUPA)
An alternative (reduced) payment made to home health agencies instead of the home health resource group reimbursement rate when a patient receives fewer than four home care visits during a 60-day episode
Major diagnostic category (MDC):
Under diagnosis-related groups (DRGs), one of 25 categories based on single or multiple organ systems into which all diseases and disorders relating to that system are classified
Major medical insurance (catastrophic coverage)
Prepaid healthcare benefits that include a high limit for most types of medical expenses and usually require a large deductible and sometimes place limits on coverage and charges (for example, room and board)
Managed care
1. Payment method in which the third-party payer has implemented some provisions to control the costs of healthcare while maintaining quality care 2. Systematic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare
Management service organization (MSO)
An organization, usually owned by a group of physicians or a hospital, that provides administrative and support services to one or more physician group practices or small hospitals
Medicaid
An entitlement program that oversees medical assistance for individuals and families with low incomes and limited resources; jointly funded between state and federal governments
Medical foundation
Multipurpose, nonprofit service organization for physicians and other healthcare providers at the local and county level; as managed care organizations, medical foundations have established preferred provider organization, exclusive provider organizations, and management service organizations, with emphases on freedom of choice and preservation of the physician-patient relationship
Medically needy option (Medicaid)
An option in the Medicaid program that allows states to extend eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups but whose income and resources fall above the eligibility level set by their state
Medicare
A federally funded health program established in 1965 to assist with the medical care costs of Americans sixty-five years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities
Medicare Advantage (Medicare Part C)
Optional managed care plan for Medicare beneficiaries who are entitled to Part A, enrolled in Part B, and live in an area with a plan; types include health maintenance organization, point-of-service plan, preferred provider organization, and provider-sponsored organization
Medicare carrier
A health plan that processes Part B claims for services by physicians and medical suppliers (for example, the Blue Shield plan in a state)
Medicare fee schedule (MFS)
A feature of the resource-based relative value system that includes a complete list of the payments Medicare makes to physicians and other providers
Medicare Summary Notice (MSN)
A summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided
Medigap
A private insurance policy that supplements Medicare coverage
Minimum Data Set 2.0 (MDS)
The instrument specified by the Centers for Medicare and Medicaid Services that requires nursing facilities (both Medicare certified or Medicaid certified) to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity
National Committee for Quality Assurance (NCQA)
A private not-for-profit accreditation organization whose mission is to evaluate and report on the quality of managed care organizations in the United States
National conversion factor (CF)
A mathematical factor used to convert relative value units into monetary payments for services provided to Medicare beneficiaries
National Correct Coding Initiative (NCCI)
A series of code edits on Medicare Part B claims
Network model health maintenance program
Program in which participating HMOs contract for services with one or more multispecialty group practices
Network provider
A physician or another healthcare professional who is a member of a managed care network
Nonparticipating provider
A healthcare provider who did not sign a participation agreement with Medicare and so is not obligated to accept assignment on Medicare claims
Omnibus Budget Reconciliation Act (OBRA) of 1989
Federal legislation that mandated important changes in the payment rules for Medicare physicians; specifically, the legislation that requires nursing facilities to conduct regular patient assessments for Medicare and Medicaid beneficiaries
Outcome and Assessment Information Set (OASIS)
A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs
Out-of-pocket expenses
Healthcare costs paid by the insured (for example, deductibles, copayments, and coinsurance) after which the insurer pays a percentage (often 80 or 100 percent) of covered expenses
Outpatient code editor (OCE)
A software program linked to the Correct Coding Initiative that applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent the services provided
Outpatient prospective payment system (OPPS)
The Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications
Packaging
A payment under the Medicare outpatient prospective payment system that includes items such as anesthesia, supplies, certain drugs, and the use of recovery and observation rooms
Payer of last resort (Medicaid)
A Medicaid term that means that Medicare pays for the services provided to individuals enrolled in both Medicare and Medicaid until Medicare benefits are exhausted and Medicaid benefits begin
Payment status indicator (PSI)
An alphabetic code assigned to CPT/HCPCS codes to indicate whether a service or procedure is to be reimbursed under the Medicare outpatient prospective payment system
Per patient per month (PPPM)
A type of managed care arrangement by which providers are paid a fixed fee in exchange for supplying all of the healthcare services an enrollee needs for a specified period of time (usually one month but sometimes one year)
Physician-hospital organization (PHO)
An integrated delivery system formed by hospitals and physicians (usually through managed care contracts) that allows for cooperative activity but permits participants to retain some level of independence
Point-of-service (POS) plan
A type of managed care plan in which enrollees are encouraged to select healthcare providers from a network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the cost
Policyholder
An individual or entity that purchases healthcare insurance coverage
Preferred provider organization (PPO)
A managed care arrangement based on a contractual agreement between healthcare providers (professional and/or institutional) and employers, insurance carriers, or third-party administrators to provide healthcare services to a defined population of enrollees at established fees that may or may not be a discount from usual and customary or reasonable charges