39 terms

Ins III 153M Ch 17

day outlier review
to certify necessity of admission and medical necessity of services for additional reimbursement
quality improvement organization
responsible for admission review, readmission review, procedure review, day outlier review, cost outlier review, DRG validation, transfer review
readmission review
performed for patients readmitted within 7 days with problems related to the first admission
principal diagnosis
condition that is assigned a code representing the diagnosis established after study that is chiefly responsible for the admission of the pt to the hospital
UB04 (CMS1450)
summary statement; compiles all charges and is accompanied by a detailed statement, which shows itemized charges
insurance billing editor
reviews the claim prior to mailing
Patient's Bill of Rights
a nationally recognized code of conduct published by the American Hospital Association - states the pt has the right to request, examine and question a detailed statement
Phantom charges
physician orders admission procedures for each pt who enters the hosptial; if a pt refuses some of these tests, the charges should be deleted from the financial record before the bill is sent
DRG system
used by Medicare to hold down rising costs; classifications were formed from more than 10,000 ICD9 codes that were divided into 25 major diagnostic categories
tentative DRG
assigned on the basis of admission diagnosis, scheduled procedure, age, and known secondary diagnosis
computer program calculates and assigns the DRG payment (the grouper is not able to consider ay difference between chronic and acute conditions
DRG creep
an unethical practice to code a patient's DRG category for a more severe diagnosis than indicated by the patient's condition
pre-existing condition that because of its effect on the specific principal diagnosis will require more intensive therapy or cause an increase in length of stay by at least 1 day in approx 75% of cases
Appropriateness Evaluation Protocols (AEP)
criteria used by the Utilization Review Department for admission screening
Services provided by the hospital/billed by the hospital
ER dept, facility fee supplies, lab technical component, radiology technical component, physical and occupational therapy facility fees.
Ambulatory payment
outpt classification scheme developed by Health Systems International based on procedures rather than diagnosis
Capitation or percentage of revenue
reimbursement to the hospital on a per-member, per-month basis to cover costs for the member of the plan
Case Rate
an averaging after a flat rate has been given to certain categories of procedures
Diagnosis-related groups (DRGs)
a classification system that categorizes inpatients who are medically related with respect to diagnosis and treatment and are statistically similar in length of hospital stay
Differential by day in hospital
term for the first day of a hospital stay being paid at a higher rate
Differential by service type
type of arrangement in which the hospital receives a flat per-admission reimbursement for the service to which the patient is admitted
Fee schedule
a comprehensive listing of charges based on procedure codes that states fee maximums paid by the health plan
Flat rate
a single charge per hospital admission paid by the managed care plan
method by which part of the plan's payment to the hospital may be withheld or set aside in a bonus pool
Reinsurance stop loss
a form of reinsurance in which the hospital buys insurance to protect against lost revenue and receives less of a capitation fee, and the amount the hospital does not receive helps pay for the insurance
dollar amount owed to a participating provider for health care services rendered to a plan member according to a fee schedule set by the managed care plan
coding inpatient services
use ICD9 volume 3; both the alphabetical and tabular list of surgical and nonsurgical procedures and misc therapeutic and diagnostic procedures
admitting clerk
registers pt by interviewing and obtain demographic info, insurance info, and admitting diagnosis (copies of the admitting facesheet are sent to the PCP or surgeons office)
attending dr. and nurse
enter daily notations on the pt's medical record as the pt receives services
hospital outpt services are coded
from the CPT book
workers compensation pt
will not have insurance card (if it is their first service) an employers first report of injury must be completed and sent to the insurance company and the state industrial accident board before a hospital or physicians insurance claim may be submitted. Non-emergency services must be pre-authorized
Managed care pt non-emergency - hospital without a contract
services must have been pre-approved otherwise the pt could be responsible for the entire bill
managed care pt emergency services
insurance must be notified within 48 hours for authorization number
admitted to hospital for an overnight stay
insurance billing specialist must have basic knowledge of insurance programs
due to diversity in reimbursement methods
larger facilities
greater opportunity for advancement
DOS or Monetary values
are entered with no spaces or decimal points
8 digit numbers
discharge summary
document completed and signed by physician after pt leaves hospital; before hospital bills for sevices