HLTHST 333 -Chapters 9
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Accounts Receivable (AR)
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Department in a healthcare facility that manages the amounts owed to the facility by customers who have received services but whose payment is made at a later date.
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Charge Capture
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The process of collecting all services, procedures, and supplies provided during patient care.
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Charge Description Master (CDM)
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Database used by healthcare facilities to house the price list for all services provided to patients.
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Copayment
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Cost-sharing measure in which the policy or certificate 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 poli-cyholder pays may vary by type of service, such as $20.00 per prescription or $15.00 per physician office visit.
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Deductible
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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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Explanation of Benefits (EOB)
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Report sent from a healthcare insurer to the policyholder and to the provider that describes the healthcare service, its cost, applicable cost sharing, and the amount the healthcare insurer will cover. The remainder is the policyholder's responsibility.
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Fiscal Intermediary (FI)
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Local payment branch of the Medicare program. Intermediaries are public or private insurance companies that contract with the Centers for Medicare and Medicaid Services (CMS) to act as agents of the federal government in dealing directly with participating providers of Medicare services. An intermediary is usually, but not necessarily, an insurance company, such as Blue Cross. FIs reimburse for inpatient or hospital services (Part A Medicare) and some Part B services.
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Hard Coding
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Use of the charge description master to code repetitive services.
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Key Performance Indicator (KPI)
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Area identified for needed improvement through benchmarking and continuous quality improvement.
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Medicare Administrative Contractor (MAC)
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Newly established contracting authority to administer Medicare Part A and Part B as required by section 911 of the Medicare Modernization Act of 2003. Fifteen Medicare Administrative Contractors will replace Medicare Carriers and Fiscal Intermediaries by 2011. Each MAC will process and manage both Part A and Part B claims.
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Medicare Carrier
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Contractor with Medicare to process Medicare Part B claims; determines charges allowed by Medicare and makes payment to physicians and suppliers on behalf of Medicare.
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Medicare Summary Notice (MSN)
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Statement that describes services rendered, payment covered, and benefits limits and denials for Medicare beneficiaries.
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Remittance Advice (RA)
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Report sent by third-party payer that outlines claim rejections, denials, and payments to the facility; sent via electronic data interchange.
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Revenue Cycle (RC)
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The regularly repeating set of events that produces revenue.
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Revenue Cycle Management (RCM)
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The supervision of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.
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The first step in the revenue cycle is ______________.
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Preclaims submission activities such as collecting responsible parties' information, educating patients about their ultimate financial responsibility for services rendered, collecting appropriate waivers, and verifying data about procedures before they are performed and their charges submitted.
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How are charges for healthcare at all of the points of services collected and reported to the appropriate patient account for entry onto the provider's claim?
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Electronic order entry systems help to capture charges at their point-of-service delivery. If facilities lack electronic systems, staff collect paper-based charges on charge tickets, superbills, or encounter forms to be entered by billing staff into the patient accounting system.
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What do scrubbers do?
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Scrubbers edit claims to locate and flag for correction any data that may contain errors, such as dates of service that are incompatible, inaccurate diagnosis and procedure codes, no substantiation of medical necessity, and inaccurate assignment of revenue codes.
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Healthcare facilities should design key performance indicators so they ______________.
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Can be measured to gauge performance improvement
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What system is typically used to audit Medicare claims?
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The Medicare Outpatient Code Editor (OCE)
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Describe at least two problems uncovered during the claims audit at facility A.
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The charge description master (CDM) stored several incorrect codes and retained a previous code after it was updated; training in updated codes was not conducted for everyone who used them; and the chart flow process bypassed the staff who would have coded and reported use of supplies on claims.
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Use of the charge description master has made manual coding by HIM coders obsolete. True or false?
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False
