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CHapter 17 Green Mod
Terms in this set (26)
the total amount of money owed from all patient ledgers
ambulatory payment classifications (APCs)
A service classification system that the CMS developed for facility reimbursement of hospital outpatient services. It is intended to simplify the outpatient hospital payment system, to ensure the payment is adequate to compensate hospital costs, and implement deficit-reduction goals of the
Average length of stay (ALOS)
The predetermined number of days of approved hospital stay assigned to an individual diagnosis-related group.
The practice of billing patients for any balance left after deductibles, coinsurance, and insurance payments have been made.
defined by HIPAA as an individual or corporate person who performs on behalf of the covered entity any function or activity involving the use or disclosure of protected health information and is not a member of the covered entity's workforce.
A common method of reimbursement used primarily by health maintenance organizations in which the provider or medical facility is paid a fixed, per capita amount for each individual enrolled in the plan, regardless of how many or few services the patient uses.
the presence of more than one disease or disorder that occurs in an individual at the same time
When the provider agrees, through a contractual agreement, not to be paid the remaining amount of a fee after the patient has paid his or her deductible and coinsurance and all third-party payers have paid their share.
diagnosis-related groups (DRGs)
Groups of procedures or tests related directly to a diagnosis. The fixed fees paid by Medicare Part A are based on DRGs. In other words, Medicare uses DRGs to determine appropriate reimbursement for medical diagnoses and procedures, as do many private insurers. DRGs are assigned in the hospital when a patient is discharged.
when a healthcare provider offers services at rates that are lower than the usual, customary, and reasonable fees
payment adjustment to compensate hospitals for the higher operating costs they incur in treating a large share of low-income patients
geographic practice cost index (GPCI)
Used by Medicare to adjust for variances in operating costs of medical practices located in different parts of the United States.
inpatient rehabilitation facility prospective payment system (IRF PPS)
a reimbursement system activated by the CMS in 2001. Reimbursement is based on the hospital stay, beginning with an admission to the rehabilitation hospital or unit and ending with discharge from that facility
long-term care facilities
facilities that provide care for adults who are chronically ill or disabled and are no longer able to manage in independent living situations
the reason for admission to the acute care facility
relative value scale (RVS)
Method of determining reimbursement for medical services on the basis of establishing a standard unit value for medical and other surgical procedures. RVS compares and rates each individual service according to the relative value of each unit and converts this unit value to a dollar value
residential health care facility
A facility for the care of individuals who do not require hospitalization and who cannot be cared for at home; nursing home.
resource utilization groups (RUGs)
to calculate freimbursement in a skilled nursing facility (SNF) according to severity and level of care. Under Medicare's prospective payment system, patients are classified inot an RUG that determines how much Medicare would pay the SNF per day for that patient.
An adjustment to the federal payment rate for long-term care hospital stays that are considerably shorter than the average length of stay for an LTC diagnosis-related group.
A figure representing the average cost per case for all Medicare cases during the year.
represents a geographic calculation base on whetehr the hospital is located in a large urban or other area
advanced beneficiary notice of noncoverage
Common Working File (Medicare)
Joint Commission (formerly Joint Commission on Accreditation of Helathcare Organizations)
Health Insurance Claim Number
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