Healthcare Revenue Management Final Questions With Answers

HEALTHCARE REVENUE MANAGEMENT FINAL
QUESTIONS WITH ANSWERS



Abuse - ansUnknowing or unintentional submission of an inaccurate claim for payment
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Accountable Care Organization (ACO) - anspopulation- nm nm nm nm nm




based model for healthcare delivery and payment
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Accounts Receivable (AR) - nm nm nm




ansThe amounts owed to a facility by patients or insurance companies who receive servi
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ces but whose payments will be made at a later date.
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Actual Charge - nm nm




ansThe amount a physician or supplier actually bills for a particular service or supply.
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Adjudication - nm




ans(1) The determination of the reimbursement amount based on the beneficiary's insur
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ance plan benefits. (2) The process by the payer of paying claims submitted or denying th
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em after comparing the claim to the benefit and coverage requirements.
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Adjustment - ans nm nm




Allowable charge - ansamount the third- nm nm nm nm nm




party payer or insurance company will pay for a service
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Ambulatory Payment Classification (APC) - ansA resource- nm nm nm nm nm nm




based system used in the Medicare Hospital Outpatient Prospective Payment System (O
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PPS). The APC system combines procedures and services that are clinically comparable
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, with respect to resource use, into groups which are used to determine reimbursement le
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vels.

Ambulatory surgery center (ASC) - nm nm nm nm




ansUnder Medicare, an outpatient surgical facility that has its own national identifier; is a
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separate entity with respect to its licensure, accreditation, governance, professional supe
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rvision, administrative functions, clinical services, record keeping, and financial and acco
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unting systems; has as its sole purpose the provision of services in connection with surgi
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cal procedures that do not require inpatient hospitalization; and meets the conditions and
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requirements set forth in the Medicare Conditions of Participation nm nm nm nm nm nm nm nm

,Appeal - nm




ansA request for a review of an insurance claim that has been underpaid or denied by an
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insurance company in an effort to receive additional payment.
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Assignment of benefits - nm nm nm




ansContract between a physician and Medicare in which the physician agrees to bill Med
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icare directly for covered services, to bill the beneficiary only for any coinsurance or dedu
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ctible that may be applicable and to accept the Medicare payment as a payment in full. M
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edicare usually pays 80% of the approved amount directly to the provider of services afte
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r the beneficiary meets the annual Part B deductible. The beneficiary pays the other 20%
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(coinsurance).

Barcoding - ansTagging the packaging of each item with a machine- nm nm nm nm nm nm nm nm nm nm




readable Universal Product Code (UPC) to identify a medication
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Benchmarking - nm




ansThe process of comparing performance with a preestablished standard or performan
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ce of another facility or group.
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Beneficiary - ansAn individual who is eligible for benefits from a health plan
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Benefit Period - nm nm




ansLength of time that a health insurance policy will pay benefits for the member, family,
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and dependents. nm




Birthday rule - nm nm




ansThe method of determining primary coverage for a dependent child, under which the
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plan of the parent whose birthday occurs first in the calendar year is designated as primar
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y.

Bundling - nm




ansOccurs when payment for multiple significant procedures or multiple units of the sam
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e procedure related to an outpatient encounter or to an episode-of-
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care is combined into a single unit of payment.
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Capitation - nm




ansMethod of payment for health services in which an individual or institutional provider i
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s paid a fixed, per capita amount for a period.
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Case management - nm nm




ans1. A process used by a doctor, nurse, or other health professional to manage a patien
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t's healthcare (CMS 2013) 2. The ongoing, concurrent review performed by clinical profes
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sionals to ensure the necessity and effectiveness of the clinical services being provided t
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o a patient
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, Case mix - nm nm




ansSet of categories of patients (type and volume) treated by a healthcare organization
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and representing the complexity of the organization's caseload.
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Case Mix Index (CMI) - nm nm nm nm




ansSingle number that compares the overall complexity of the healthcare organization's
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patients with the complexity of the average of all hospitals. Typically, the CMI is for a spec
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ific period and is derived from the sum of all diagnosis-
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related group (DRG) weights divided by the number of Medicare cases.
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Case-rate methodology - ansType of prospective payment method in which the third-
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party payer reimburses the provider a fixed, preestablished payment for each case.
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Centers for Medicare and Medicaid Services (CMS) -
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ansThe department of Health and Human services agency responsible for Medicare and
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parts of medicaid. Historically, CMS has maintained the UB-
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92 institutional EMC format specifications, the professional EMC NSF specifications, and
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specifications for various certifications and authorizations used by the Medicare and Medi
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caid programs. CMS is responsible for the oversight of HIPPA administrative simplificatio
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n transaction and code sets, health identifiers, and security standards. CMS also maintai
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ns the HCPCS medical code set and the Medicare Remittance Advice Remark Codes ad
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ministrative code set. nm nm




Certificate of Insurance - nm nm nm




ansFormal contract, between healthcare insurance company and individuals or groups p
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urchasing the healthcare insurance, that details the provisions of the healthcare insuranc
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e policy (certificate of coverage, evidence of coverage, or summary
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plan description). nm




Charge (billed charge) - nm nm nm




ansThe amount billed by the provider or facility for a item or service.
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Charge capture - nm nm




ansThe accounting for all reportable services and supplies rendered to a patient.
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Charge Description Master (CDM) - nm nm nm nm




ansData table used by healthcare facilities to manage required billing elements for all ser
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vices provided to patients.nm nm nm




Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) -
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ansA benefits program administered by the Department of Veterans Affairs for the spous
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e or widow.
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Claim - nm




ansA request for payment, or itemized statement of a healthcare services and their costs
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, provided by a hospital, physician's office, or other healthcare provider. Claims are submi
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