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Methods used by the govenment programs to provide reimbursement to hospitals for outpatient and inpatient services
a. APC b. DRG c. RBRVS
Reimbersement methods commonly used by commercial payers for inpatient services
a. Fee Schedule b. UCR Case Rate c. Per Diem d. Contract Rate
Contract Rate and Capitaiton
reimbursment methods commonly utilized by managed care plans for outpatient and inpatient hospital services
a computerized system designed to capture charges to the patient's account and billing those charges on the claim
the universal claim form used to submit charges to the outpatient professional services provided by a hospital-employed provider
the INAPPROPRIATE billing sent to the patient for balances in excess of the payer's approved contractual amount
codes contained on a remittance advice of explanation of benefits sent to the hospital that describes 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
Fair Debt Collection Practice Act
a law designed to protect consumers from unfair collection activities
Advantages of electronic claim submission include
a. tracking b. Proof of receipt c. Processing time is reduced
improved claim processing by replacing the process of having to input data manually from the claim form into a computer system
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