REVENUE CYCLE MANAGEMENT AND
HEALTH CARE REIMBURSEMENT
GUIDE WITH SOLUTIONS
RBRVS Structure of Payment ✔ans Physician payment system based on resource costs for providing
services
Quality Payment Program ✔ans Reforms Medicare payments to promote better value and care
Alternative Payment Model ✔ans Payment approach that gives added incentives for high-quality and
cost-efficient care
Claims Production ✔ans Process of generating and preparing insurance claims for submission
Claims Submission ✔ans Process of sending claims to insurance company for processing and payment
Adjudication ✔ans Legal process of resolving a dispute or deciding a case
Benefit Statements ✔ans Written descriptions that communicate the primary benefit of a product or
service
Claims Reconciliation ✔ans Process of ensuring provider's charge data matches payer's processed claim
data
Performance Assessment ✔ans Evaluation of system, process, or individual based on set criteria or
standards
Coding Dashboard ✔ans Tool providing visual representation of coding metrics and data for monitoring
and analysis
, Coding Compliance Plan ✔ans Guidelines and procedures to ensure medical coding practices comply
with laws and regulations
Clinical Documentation Integrity ✔ans Accuracy, completeness, and consistency of clinical
documentation in a patient's health record
Revenue Compliance ✔ans Ensuring revenue-generating activities comply with applicable laws and
regulations
Oversight of Medicare Claims Payments ✔ans Monitoring and management of Medicare claims
payments for accuracy and compliance
Coding and Billing Compliance Tools ✔ans Tools or software used to ensure coding and billing practices
comply with laws and standards
Denials Management ✔ans Process of handling denied claims and implementing strategies to prevent
future denials
Case Mix Index Calculation ✔ans Relative value assigned to each DRG reflecting diversity, clinical
complexity, and resource needs of patients in the hospital
RCM Reimbursement ✔ans Process of managing financial operations related to billing and collecting
revenue for medical services
National Health care Model (Bismarck) ✔ans Insurance system financed jointly by employers and
employees through payroll deduction
Third-party Payer ✔ans Entity that reimburses and manages health care expenses
Health Insurance Risk Pool ✔ans Group of individuals whose medical costs are combined to calculate
premiums
HEALTH CARE REIMBURSEMENT
GUIDE WITH SOLUTIONS
RBRVS Structure of Payment ✔ans Physician payment system based on resource costs for providing
services
Quality Payment Program ✔ans Reforms Medicare payments to promote better value and care
Alternative Payment Model ✔ans Payment approach that gives added incentives for high-quality and
cost-efficient care
Claims Production ✔ans Process of generating and preparing insurance claims for submission
Claims Submission ✔ans Process of sending claims to insurance company for processing and payment
Adjudication ✔ans Legal process of resolving a dispute or deciding a case
Benefit Statements ✔ans Written descriptions that communicate the primary benefit of a product or
service
Claims Reconciliation ✔ans Process of ensuring provider's charge data matches payer's processed claim
data
Performance Assessment ✔ans Evaluation of system, process, or individual based on set criteria or
standards
Coding Dashboard ✔ans Tool providing visual representation of coding metrics and data for monitoring
and analysis
, Coding Compliance Plan ✔ans Guidelines and procedures to ensure medical coding practices comply
with laws and regulations
Clinical Documentation Integrity ✔ans Accuracy, completeness, and consistency of clinical
documentation in a patient's health record
Revenue Compliance ✔ans Ensuring revenue-generating activities comply with applicable laws and
regulations
Oversight of Medicare Claims Payments ✔ans Monitoring and management of Medicare claims
payments for accuracy and compliance
Coding and Billing Compliance Tools ✔ans Tools or software used to ensure coding and billing practices
comply with laws and standards
Denials Management ✔ans Process of handling denied claims and implementing strategies to prevent
future denials
Case Mix Index Calculation ✔ans Relative value assigned to each DRG reflecting diversity, clinical
complexity, and resource needs of patients in the hospital
RCM Reimbursement ✔ans Process of managing financial operations related to billing and collecting
revenue for medical services
National Health care Model (Bismarck) ✔ans Insurance system financed jointly by employers and
employees through payroll deduction
Third-party Payer ✔ans Entity that reimburses and manages health care expenses
Health Insurance Risk Pool ✔ans Group of individuals whose medical costs are combined to calculate
premiums
