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Exploring healthcare reimbursement

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tigrebright's version from 2017-01-12 16:54

Section 1

Question Answer
HMO health maintenance organizationFollow a set of care guidelines patients must follow in order to receive maximum benefits. HMOs (third-party payers) contract with physicians, physician groups, hospitals, and clinics to provide care under the terms of the HMO. HMO patients are seen at steeply discounted rates and providers have a “pipeline” of patients through the HMO.
International Classification of Diseases (ICD) codesstandard diagnostic codes for diseases, signs, and symptoms
morbiditythe cause of illness
mortalitythe cause of death
adjudicationThe process of checking the details of the claim against the information the third party has on the patient and his/her insurance benefits. This process will also check for completeness of the claim, bundling issues for CPT® codes, medical necessity, and recent claims (to avoid unnecessary service or duplicate claims).
common data filean overview of claims recently filed on the patient
allowed chargethe amount an insurance policy states is payable for a particular procedure
explanation of benefits (EOB)lists the patient and claim information and gives an explanation of the benefits covered and payments to be made.
open/pending claimsClaims that have not yet completed the claims processing cycle. Open claims may have been recently submitted, re-submitted, or appealed; whatever the case, they have not been completed.
closed/paid claimsClaims for which the entire process has been completed. Open and closed claims may be organized and filed by date and/or the third-party payer to whom they were submitted.
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Section 2

Question Answer
aging reporta report to manage paid and unpaid claims reconciled by date (current, 30 days unpaid, 60 days unpaid, etc.)
peer reviewa group of physicians who can review the claim as well as the supporting documentation and arbitrate the differences between the payer and the provider
superbill/encounter formthis preprinted form is filled out on each visit and contains the codes that are used in the particular healthcare setting. This form will have the diagnosis codes and procedure codes designated by the physician at the completion of the encounter.
retrospective payment systemwhen a patient receives healthcare services and reimbursement is determined based on past events
usual, customary, and reasonable (UCR)the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service
resource-based relative value scale (RBRVS)the fee-for-service reimbursement methodology used by Medicare to determine reimbursement amounts for physician-based services
episode-of-caredetermines payment based on the “unit of time” a patient is treated.
fee-for-servicethe provider receives payment for each service provided to the patient.
capitationA reimbursement method where the third-party payer contracts with the healthcare provider(s) to pay a flat fee per individual enrolled in the healthcare plan. The actual services provided to the patient—few or numerous—don’t affect the reimbursement to the provider.
global prospective payment system (GPPS)the Medicare system used to reimburse home health services: HHPPS, or home health prospective payment system
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Section 3

Question Answer
prospective payment systemThe third-party payer is interested in looking at averages over time and paying the average cost for each patient instead of the actual cost for each patient. Prospective payment systems establish payment amounts in advance for future healthcare services.
National Provider Identifier (NPI)HIPAA required all physicians and anyone else who will be reimbursed by insurance companies to apply for one of these numbers. The main purpose was to ease medical information transference.
referralsa request by a physician for a patient to be seen by another physician, usually a specialist
CMS-1500the claim form used to bill professional services: a surgeon’s fees for a surgery performed at an outpatient surgery center or an emergency physician’s fee for professional services provided in the emergency room
UB-04the claim form used to bill outpatient facility charges: surgery centers, freestanding radiology clinics, laboratories, and emergency rooms
Current Procedural Teminology (CPT) codesstandard codes used to designate procedures and tests in outpatient claims
guarantorthe person who is financially responsible for a medical bill
preauthorization (precertification)the process of calling the patient’s insurance carrier to obtain permission for them to receive prescribed procedures
premiumThe cost of coverage for the insurance policy. This is typically paid on a monthly basis. Employees usually share in the cost of the healthcare insurance premium with their employers.
exclusionsprocedures, tests, or services that are not covered under an insurance policy
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