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Methods used by the government programs to provide reimbursement to hospitals for outpatient and impatient services:

a. APC, b. DRG, c. RBRVS

Reimbursement methods commonly used by commercial payers for impatient services:

a. Fee Schedule, b. UCR Case Rate, c. Per Diem, d. Contract Rate.

Contract Rate and Capitation -

reimbursement methods commonly utilized by managed care plans for outpatient and inpatient hospital services.

Chargemaster -

a computerized system designed to capture charges for all services and items provided for the purpose of posting charges to the patient's account and billing those charges on the claim.

CMS- 1500 -

the universal claim form used to submit charges for outpatient professional services provided by a hospital-employed provider.

Balance billing-

the INAPPROPRIATE billing sent to the patient for balances in excess of the payer's approvesd contractual amount.

Reason codes-

codes containesd on a remittance advice of explanation of benefits sent to the hospital that desscsribes how the claim was processed.

Common reasons for claim denials:

a. Service is only payable for a specific diagnosis, b. Services does not meet standards of medical necessity with diagnosis submitted, c. The procedure is bundled in a more comprehensive procedure

Accounts Resceivable Aging Report-

a report ussed to identify and analyze outstanding accounts

Fair Debt Collection Practice Act-

a law designesd to protect consumers from unfair collection activities.

Advantages of electronic claim submission include:

a. Tracking, b. Proof of receipt, c. Processing time is reduced.

Optical scanning

improvesd claim processing by replacing the process of having to input data manually from the claim form into a computer system.

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