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Study sets matching "healthcare reimbursement"

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Study sets matching "healthcare reimbursement"

56 terms
Healthcare Reimbursement
Risk Pool
Premium
Reimbursement
Insurance
Group of people, covered by an insurance plan, with similar r…
Amount of money that policy holders or certificate holder mus…
Compensation or repayment of services already rendered.
A system or reducing a person's exposure to risk of loss by h…
Risk Pool
Group of people, covered by an insurance plan, with similar r…
Premium
Amount of money that policy holders or certificate holder mus…
56 terms
Healthcare Reimbursement
Risk Pool
Premium
Reimbursement
Insurance
Group of people, covered by an insurance plan, with similar r…
Amount of money that policy holders or certificate holder mus…
Compensation or repayment of services already rendered.
A system or reducing a person's exposure to risk of loss by h…
Risk Pool
Group of people, covered by an insurance plan, with similar r…
Premium
Amount of money that policy holders or certificate holder mus…
37 terms
Reimbursement Methodologies - Healthcare Reimbursement
Episode-of-Care
Managed Care- Capitation
PMPM
Global Payment/ Prospective Payment Sy…
determine payment based on one lump sum payment for all the c…
Reimbursement method - third-party payer contracts with the h…
Per Member Per Month
fixed amount of money or lum-sum payment designated to cover…
Episode-of-Care
determine payment based on one lump sum payment for all the c…
Managed Care- Capitation
Reimbursement method - third-party payer contracts with the h…
161 terms
healthcare reimbursement methodologies
Case Mix
Case Mix Index
Chargemaster
Complex Diagnosis
Categorizes patients in such a way as to reflect the complexi…
C M I... Used to represent the facilities case mix... Calculated by…
A financial management system that lists the individual charg…
A further subdivision of a C/C's ... To be classified to some MS…
Case Mix
Categorizes patients in such a way as to reflect the complexi…
Case Mix Index
C M I... Used to represent the facilities case mix... Calculated by…
Healthcare reimbursement
Episode of care
Fee for service
Home health prospective payment system
Indian health services
Reimbursement based on individual services rendered
Reimbursement based in what services are provided
Prospective payment system that uses the HRG adjustment as th…
Uses a per diem system for outpatient physician billing where…
Episode of care
Reimbursement based on individual services rendered
Fee for service
Reimbursement based in what services are provided
Healthcare reimbursement
Accountable care organization
Affordable care act
Allowable fee
Bad debt
primary care led physician and hospital organization that has…
brief name for the patient protection and affordable care act…
average or maximum amount the third party payer will reimburs…
Services for which healthcare organizations expected but did…
Accountable care organization
primary care led physician and hospital organization that has…
Affordable care act
brief name for the patient protection and affordable care act…
24 terms
healthcare reimbursement
hold harmless clause
CMS (centers for medicare & medicaid s…
health insurance specialists
claims examiner
health insurance states that patient is not responsible for p…
agency within federal department of health and human services…
review health-related claims to determine medical necessity f…
employed by 3rd party payers to review health-related claims:…
hold harmless clause
health insurance states that patient is not responsible for p…
CMS (centers for medicare & medicaid s…
agency within federal department of health and human services…
66 terms
Healthcare Reimbursement
Diagnostic coding
Morbidity
Mortality
Procedural coding
assigns a number to a description of the patient's medical co…
the cause of illness
the cause of death
assigns a code to each procedure or service performed on a pa…
Diagnostic coding
assigns a number to a description of the patient's medical co…
Morbidity
the cause of illness
15 terms
Healthcare Reimbursement
Premium
Deductible
Co-pay
Diagnostic Related Groups (DRGs)
$$ charged by insurer (typically paid monthly)
$$ insurer must pay first before benefits are payable
$$ (proportion) insured is responsible for out-of-pocket
Reimbursement system for Medicare inpatients (Part A)... Referr…
Premium
$$ charged by insurer (typically paid monthly)
Deductible
$$ insurer must pay first before benefits are payable
56 terms
Healthcare Reimbursement
Risk Pool
Premium
Reimbursement
Insurance
Group of people, covered by an insurance plan, with similar r…
Amount of money that policy holders or certificate holder mus…
Compensation or repayment of services already rendered.
A system or reducing a person's exposure to risk of loss by h…
Risk Pool
Group of people, covered by an insurance plan, with similar r…
Premium
Amount of money that policy holders or certificate holder mus…
56 terms
Healthcare Reimbursement
Risk Pool
Premium
Reimbursement
Insurance
Group of people, covered by an insurance plan, with similar r…
Amount of money that policy holders or certificate holder mus…
Compensation or repayment of services already rendered.
A system or reducing a person's exposure to risk of loss by h…
Risk Pool
Group of people, covered by an insurance plan, with similar r…
Premium
Amount of money that policy holders or certificate holder mus…
56 terms
Healthcare Reimbursement
Risk Pool
Premium
Reimbursement
Insurance
Group of people, covered by an insurance plan, with similar r…
Amount of money that policy holders or certificate holder mus…
Compensation or repayment of services already rendered.
A system or reducing a person's exposure to risk of loss by h…
Risk Pool
Group of people, covered by an insurance plan, with similar r…
Premium
Amount of money that policy holders or certificate holder mus…
15 terms
Healthcare Reimbursement
Prospected payment system
Ambulatory patient groups (APG)
Ambulatory payment classification (APC)
Prospective Payment System (PPS)
promotes more efficient use of healthcare resources & encoura…
a reimbursement method for outpatient procedures uses diagnos…
attempt to predict the amount & type of resources used for va…
for home carevisits
Prospected payment system
promotes more efficient use of healthcare resources & encoura…
Ambulatory patient groups (APG)
a reimbursement method for outpatient procedures uses diagnos…
69 terms
Healthcare Reimbursement
Ambulatory Patient Groups (APGs)
Ambulatory Payment Classification (APCs)
Prospective Payment System (PPS)
Home Health Resources Groups (HHRGs)
A reimbursement method for outpatient procedures created by t…
A more refined reimbursement strategy created by CMS meant to…
The payment system created by CMS for various healthcare prov…
The payment system created by CMS for home care visits Must h…
Ambulatory Patient Groups (APGs)
A reimbursement method for outpatient procedures created by t…
Ambulatory Payment Classification (APCs)
A more refined reimbursement strategy created by CMS meant to…
16 terms
Healthcare Reimbursement
When was the first group of health ins…
When was medicare and medicaid created?
When did managed care emerge?
When did BC/BS cover 1 in 3 Americans?
1929
1965
1990's
2006
When was the first group of health ins…
1929
When was medicare and medicaid created?
1965
85 terms
Principles of Healthcare Reimbursement
Which of the following points is a gui…
What is the average of the sum of the…
Select the highest level of the IPPS h…
What is the general term for software…
Incentive for cost control because hospitals retain profits o…
Case mix index
Major diagnostic category
Grouper
Which of the following points is a gui…
Incentive for cost control because hospitals retain profits o…
What is the average of the sum of the…
Case mix index
85 terms
Principles of Healthcare Reimbursement
Which of the following points is a gui…
What is the average of the sum of the…
Select the highest level of the IPPS h…
What is the general term for software…
Incentive for cost control because hospitals retain profits o…
Case mix index
Major diagnostic category
Grouper
Which of the following points is a gui…
Incentive for cost control because hospitals retain profits o…
What is the average of the sum of the…
Case mix index
35 terms
Healthcare reimbursement part 2
APCs
CMS
Ambulatory Payment Classification
ACS
Ambulatory Payment Classifications
Centers for medicaid and medicare services
CMS looks at what resources are required to provide services.…
Ambulatory Surgical Center system
APCs
Ambulatory Payment Classifications
CMS
Centers for medicaid and medicare services
Healthcare Reimbursement Ch. 1
Accountable care organization (ACO)
Affordable Care Act (ACA)
Allowable charge
Bad debt
Primary-care led physician and hospital organization that has…
Brief name for Patient Protection and Affordable Care Act of…
Average or maximum amount the third-party payer will reimburs…
Services for which healthcare organizations expected, but did…
Accountable care organization (ACO)
Primary-care led physician and hospital organization that has…
Affordable Care Act (ACA)
Brief name for Patient Protection and Affordable Care Act of…
Healthcare Reimbursement Ch. 4
Beneficiary
Civilian Health and Medical Program: V…
Federal Employees' Compensation Act of…
Indian Health Service
An individual who is eligible for benefits from a health plan.
A benefits program administered by the Department of Veterans…
A benefit program that ensures that civilian employees of the…
And agency within the Department of Health and Human Services…
Beneficiary
An individual who is eligible for benefits from a health plan.
Civilian Health and Medical Program: V…
A benefits program administered by the Department of Veterans…
Healthcare Reimbursement Ch. 3
Actual charge
Adjudication
Adjustment
Adverse selection
Amount provider actually bills a patient, which may differ fr…
The determination of the reimbursement payment based on the m…
Amount that healthcare insurers deduct providers' payments pe…
Enrollment of excessive proportion of persons with poor healt…
Actual charge
Amount provider actually bills a patient, which may differ fr…
Adjudication
The determination of the reimbursement payment based on the m…
Healthcare Reimbursement Ch. 5
Capitation
Carve-out
Case management
Cherry-picking
Method of payment for health services in which an individual…
Contracts that separate out services or populations of patien…
Coordination of individuals' care over time and across multip…
Targeting the enrollment of healthy patients to minimize heal…
Capitation
Method of payment for health services in which an individual…
Carve-out
Contracts that separate out services or populations of patien…
Healthcare Reimbursement Ch. 2
Abuse
AHA Coding Clinic for ICD-9-CM
AHA Coding Clinic for ICD-10-CM and IC…
AHA Coding Clinic for HCPCS
Unknowing or unintentional submission of an inaccurate claim…
A publication issued quarterly by the American Hospital Assoc…
A publication issued quarterly by the American Hospital Assoc…
Official coding guidance for Healthcare Common Procedure Codi…
Abuse
Unknowing or unintentional submission of an inaccurate claim…
AHA Coding Clinic for ICD-9-CM
A publication issued quarterly by the American Hospital Assoc…
Healthcare Reimbursement Ch. 7
All-inclusive rate (AIR)
Ambulatory payment classification (APC)
Ambulatory surgical center (ASC)
Ambulatory surgery center list of cove…
Reimbursement rate for federally qualified health centers and…
Hospital outpatient prospective payment system. The classific…
Freestanding outpatient facility in which outpatient surgerie…
Procedures that Medicare will cover when they are performed i…
All-inclusive rate (AIR)
Reimbursement rate for federally qualified health centers and…
Ambulatory payment classification (APC)
Hospital outpatient prospective payment system. The classific…
Healthcare Reimbursement Ch. 9
Accounts receivable
Charge capture
Charge description master (CDM)
Claim processing activities
One of the four components of the revenue cycle. It includes…
The process of collecting all services, procedures, and suppl…
Database used by healthcare facilities to house the price lis…
One of the four components of the revenue cycle. It includes…
Accounts receivable
One of the four components of the revenue cycle. It includes…
Charge capture
The process of collecting all services, procedures, and suppl…
23 terms
Healthcare Reimbursement Ch 6
Which Congressional act called for the…
Select the highest level of the IPPS h…
Which is the correct formula for wage…
How are per-diem rates for SNF PPS pat…
Balanced Budget Refinement Act of 1999
Major diagnostic category
(payment rate labor portion WI) + (payment rate * labor p…
Per-diem rates are case mix adjusted using the fifty-three gr…
Which Congressional act called for the…
Balanced Budget Refinement Act of 1999
Select the highest level of the IPPS h…
Major diagnostic category
46 terms
Healthcare Reimbursement Mid-Term
ICD-10-CM
CPT
WHO
lessons learned from RAC demonstration
The coding system that is used primarily for reporting diagno…
coding systems created for reporting procedures and services…
ICD is maintained by
-RACs are able to find large volume of improper payments... -Ove…
ICD-10-CM
The coding system that is used primarily for reporting diagno…
CPT
coding systems created for reporting procedures and services…
Healthcare Reimbursement Ch. 10
Accountability
Accountable care organization (ACO)
Attribution
Measure (indicator)
Obligation of individuals or organizations to provide informa…
Primary care-led physician and hospital organization that has…
Assignment of the costs of a patient's care and the outcomes…
1. The quantifiable data about a function or process. 2. An a…
Accountability
Obligation of individuals or organizations to provide informa…
Accountable care organization (ACO)
Primary care-led physician and hospital organization that has…
20 terms
RM - Healthcare Reimbursement
First-Party Payer
Third-Party Payer
Reimbursement Methodologies
Fee-for-service
Patient pays healthcare provider directly for services
Entity other than patient reimburses healthcare provider for…
The processes used by payers to determine how much is actuall…
When a specific payment is made for a set amount
First-Party Payer
Patient pays healthcare provider directly for services
Third-Party Payer
Entity other than patient reimburses healthcare provider for…
57 terms
Healthcare Reimbursement - Chapter 1 Key Terms
Accountable care organization (ACO)
Affordable Care Act (ACA)
Allowable Charge
Bad Debt
Primary-care led physician and hospital organization that has…
Brief name for Patient Protection and Affordable Care act of…
Average or maximum amount the third-party payer will reimburs…
Services for which healthcare organizations expected, but did…
Accountable care organization (ACO)
Primary-care led physician and hospital organization that has…
Affordable Care Act (ACA)
Brief name for Patient Protection and Affordable Care act of…
Healthcare Reimbursement Ch. 8
Activities of daily living (ADL)
Average length of stay (ALOS)
Base rate
Base year
Everyday tasks that people can perform without assistance and…
Average number of days patients are hospitalized.
1. Rate per discharge for operating and capital-related compo…
1. Most recent 12-month period for which the Centers for Medi…
Activities of daily living (ADL)
Everyday tasks that people can perform without assistance and…
Average length of stay (ALOS)
Average number of days patients are hospitalized.
30 terms
Healthcare Reimbursement Ch. 4
A national health insurance program th…
Medicare benefits are available for:
ACA provides provisions to do the foll…
This act created an outpt prescription…
Medicare... 1/30
1. Persons 65 or older... 2. Those entitled to social sec. or r…
1. Improve the quality of M'care services... 2. Support innovat…
Medicare Modernization Act (MMA) of 2003... 4/30
A national health insurance program th…
Medicare... 1/30
Medicare benefits are available for:
1. Persons 65 or older... 2. Those entitled to social sec. or r…
Healthcare Reimbursement Ch. 6
Add-on
Arithmetic mean length of stay (AMLOS)
Base rate
Case mix
Payment adjustment in a federal system that increases reimbur…
Sum of all lengths of stay in a set of cases divided by the n…
1. Rate per discharge for operating and capital-related compo…
Set of categories of patients treated by a healthcare organiz…
Add-on
Payment adjustment in a federal system that increases reimbur…
Arithmetic mean length of stay (AMLOS)
Sum of all lengths of stay in a set of cases divided by the n…
190 terms
Exploring Healthcare Reimbursement
Chargemaster/fee schedule
Charge-based Fees
Usual, customary, and reasonable
Annualy
Healthcare provider's comprehensive price list of all supplie…
The fees that many providers charge for similar services
What does UCR stand for?
How often is the chargemaster/fee schedule updated
Chargemaster/fee schedule
Healthcare provider's comprehensive price list of all supplie…
Charge-based Fees
The fees that many providers charge for similar services
38 terms
Healthcare Reimbursement Systems
prospective payment system
prospective cost-based rates
prospective price-based rates
fee schedule
reimbursement methodology that establishes predetermined rate…
healthcare costs from which a prospective per diem rate is de…
associated with a particular category of patient & rates are…
cost-based, fee-for-service reimbursement methodology - inclu…
prospective payment system
reimbursement methodology that establishes predetermined rate…
prospective cost-based rates
healthcare costs from which a prospective per diem rate is de…
103 terms
Principles in Healthcare Reimbursement
Assignment of benefits
Coinsurance
Deductible
Diagnoses
authorization by policyholder that allows a health plan to pa…
the portion of charges that an insured person must pay for he…
An amount of money that an insured person must pay annually b…
a physician's opinion of the nature of patients' illness or i…
Assignment of benefits
authorization by policyholder that allows a health plan to pa…
Coinsurance
the portion of charges that an insured person must pay for he…
26 terms
Principles of Healthcare Reimbursement Chapter 3
Voluntary Healthcare Insurance
Voluntary Healthcare Insurance (cont.)
Types of Voluntary Healthcare Insurance
Confusing Terminology
Denotes healthcare insurance that is purchased... Related to emp…
Indemnity health insurance (Retrospective fee-for-service)... Gu…
Umbrella term for 2 major categories, 3 classifications, and…
"Private" used two ways... Synonym for commercial insurance... Purc…
Voluntary Healthcare Insurance
Denotes healthcare insurance that is purchased... Related to emp…
Voluntary Healthcare Insurance (cont.)
Indemnity health insurance (Retrospective fee-for-service)... Gu…
58 terms
Chapter 1: Healthcare Reimbursement Methodologies
Accountable Care Organization
Affordable Care Act
Allowable fee
bad debt
primary care led physician and hospital organization that has…
brief name for patient protection and affordable care act of…
allowable charge, average or maximum around the third party p…
services for which healthcare organizations expected, but did…
Accountable Care Organization
primary care led physician and hospital organization that has…
Affordable Care Act
brief name for patient protection and affordable care act of…
67 terms
Healthcare Reimbursement Ch. 1
What factor in the healthcare system m…
What are some of the fragments of the…
System of reducing a person's exposure…
Group of people who will be covered by…
Fragmentation... 1/67
1. sources of healthcare services (phys., lrg/small hosptials…
Insurance... 3/67
Risk pool... 4/67
What factor in the healthcare system m…
Fragmentation... 1/67
What are some of the fragments of the…
1. sources of healthcare services (phys., lrg/small hosptials…
29 terms
Principles of Healthcare Reimbursement 8
What is the average of the sum of the…
What is the general term for software…
The federal government is determined t…
What is the term for an index based on…
Case mix index
Grouper
Conversion Factor
GPCI
What is the average of the sum of the…
Case mix index
What is the general term for software…
Grouper
16 terms
Healthcare Reimbursement Ch. 5
What is the main purpose of managed ca…
Entity that combines the provision of…
What are the characteristics of a HMO?
Payment method in which the third part…
Provide affordable, high quality care
Health Maintenance Organization
1. Organized healthcare delivery system to a geographic area…
Managed Care Organization (MCO)
What is the main purpose of managed ca…
Provide affordable, high quality care
Entity that combines the provision of…
Health Maintenance Organization
85 terms
Principles of Healthcare Reimbursement
Which of the following points is a gui…
What is the average of the sum of the…
Select the highest level of the IPPS h…
What is the general term for software…
Incentive for cost control because hospitals retain profits o…
Case mix index
Major diagnostic category
Grouper
Which of the following points is a gui…
Incentive for cost control because hospitals retain profits o…
What is the average of the sum of the…
Case mix index
16 terms
Principles of Healthcare Reimbursement Chapter 7
RBRVS Formula
Resource-Based Relative Value Scale
Resource-Based Relative Value Scale pe…
Geographic Practice Cost Indices
[(WORK RVU) (WORK GPCI) + (PE RVU) (PE GPCI) + (MP RVU) (MP G…
Payment system that reimburses physicians' practice expenses…
Controlled Fee-for-Service System Based on CMS's Estimation o…
Geographic Practice Cost Index (GPCI) An adjustment that acco…
RBRVS Formula
[(WORK RVU) (WORK GPCI) + (PE RVU) (PE GPCI) + (MP RVU) (MP G…
Resource-Based Relative Value Scale
Payment system that reimburses physicians' practice expenses…
29 terms
Principles of Healthcare Reimbursement 8
What is the average of the sum of the…
What is the general term for software…
The federal government is determined t…
What is the term for an index based on…
Case mix index
Grouper
Conversion Factor
GPCI
What is the average of the sum of the…
Case mix index
What is the general term for software…
Grouper
68 terms
Principles of Healthcare Reimbursement ch 10keeper
P4P
VBP
P4P (or PFP) systems
VBP and P4P Systems
started by large private employers and coalitions seeking to…
implemented by federal reimbursement systems
Any type of providers' payment system that is based on perfor…
Spur interest in redesigning healthcare to focus on quality... -…
P4P
started by large private employers and coalitions seeking to…
VBP
implemented by federal reimbursement systems
143 terms
HIM 2430 -- Principles of Healthcare Reimbursement FINAL
True or False: A group of insureds wit…
Reimbursement for healthcare depends o…
True or false: The premiums received b…
True or false: Health insurance became…
True
health insurance
False. Insurance premiums do offset the loss the insurance co…
True
True or False: A group of insureds wit…
True
Reimbursement for healthcare depends o…
health insurance
43 terms
healthcare reimbursement part 1
Who administers Medicare & Medicaid?
PPS
Blue Cross/Blue Shield
Group Health Insurance
CMS
Prospective Payment System
Paid for services up to specific spending limit
Started as a way to attract wartime labor. Provided health be…
Who administers Medicare & Medicaid?
CMS
PPS
Prospective Payment System
8 terms
Chapter 14 - Healthcare Reimbursement
A patient classification system, initi…
The payment system used for reimbursin…
A prospective payment system for hospi…
A payment method whereby a provider is…
Diagnostic Related Groups (DRGs)
Resource Based Relative Value Scale (RBRVS)
Ambulatory Payment Categories (APCS)
Fee-For Service:
A patient classification system, initi…
Diagnostic Related Groups (DRGs)
The payment system used for reimbursin…
Resource Based Relative Value Scale (RBRVS)
20 terms
Concepts Healthcare Reimbursement
Define Medicare
Medicaid
HMO
PPO "Preferred Provider"
federally funded for over 65, if you have ESKD and on dialysi…
Limited to certain groups, children, preg women, chronic dise…
the primary care provider is going to manage all the care, ha…
you can go wherever you want but you pay a little bit more
Define Medicare
federally funded for over 65, if you have ESKD and on dialysi…
Medicaid
Limited to certain groups, children, preg women, chronic dise…
23 terms
Principles of Healthcare Reimbursement chapter 9
Accounts receivable
Charge capture
Copayment
Deductible
Accounts Receivable (A/R) Department -A department in a healt…
Revenue cycle management use a _____ to collect information a…
A provision under which the insured pays a flat dollar amount…
Specified amount of money that the insured must pay for cover…
Accounts receivable
Accounts Receivable (A/R) Department -A department in a healt…
Charge capture
Revenue cycle management use a _____ to collect information a…
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