Chapter 17 Terminology
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| Accounts Receivable | monies owed to a practice
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| Aging Report | report that shows how long a patient’s account has been outstanding
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| Activities of Daily Living (ADLs) | behaviors related to personal care
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| Ambulatory Payment Classifications (APCs) | classification system designed to explain the amount and type resources used in an outpatient encounter
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| Average Length of Stay (ALOS) | predetermined number of days of approved hospital stay assigned to an individual DRG
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| Balance Billing | practice of billing patients for any balance left after deductibles, coinsurance, and insurance payments have been made
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| Business Associate | an entity that contracts with a practice
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| Capitation | provider is paid a fixed, per capita amount for each individual to whom services are provided regardless of the actual number or nature of the services provided to each individual patient
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| Co-morbidity | presence of more than one disease or disorder that occurs in an individual at the same time
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| Contract write-off | when the provider agrees to accept the payer’s allowed fee as payment in full for a particular service or procedure
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| Cost outliers | patients whose stays are shorter or considerably longer that average
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| Covered entity | healthcare plans, providers, and healthcare clearinghouses
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| Diagnosis Related Groups (DRGs) | inpatient classification system used to set a level intended to cover operating costs for treating a typical inpatient
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| Discounted fee-for-service | when a healthcare provider offers services at rates that are lower than UCR
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| Disproportionate share | payment adjustment to compensate hospital for the higher operating costs incurred in treating a large share of low-income patients
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| DRG grouper | computer software program that takes the coded information and identifies the patient’s DRG category
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| Fee-for-service | system of payment for healthcare services where the provider charges a specific fee for each service rendered and is paid that fee by the patient or the patient’s insurance carrier
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| Geographic practice cost index (GPCI) | used by Medicare to adjust for variance in operating costs of healthcare practices located in different parts of the United States
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| Home Health Prospective Payment System (PPS) | determination of payment for these services depends on the Outcome and Assessment Information Set (OASIS)
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| Inpatient rehabilitation | reimbursement for these services is based on the hospital stay, beginning with the admission and ending with the discharge
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| Long-term care hospital | payment system for these services are based on DRGs with a predetermined ALOS
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| Peer Review Organization (PRO) | agency paid by the federal government to evaluate and monitor the quality of care given to patients
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| Principle diagnosis | the reason for admission to the acute care facility
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| Reimbursement | payment to the insured for a covered expense or loss experienced by or on behalf of the insured
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| Relative Value Scale (RVS) | method of determining reimbursement for healthcare services based on establishing a standard unit of value for medical and surgical procedures
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| Residential healthcare facility | nursing home
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| Resource utilization groups (RUGs) | system used to calculate payments to a skilled nursing facility according to severity and level of care
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| Short-stay outlier | case-level adjustment to federal payment rate for LTCH stays that are considerably shorter that the ALOS included in the LTC-DRG
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| Skilled Nursing Facility | nursing home that provides skilled nursing or rehabilitation services or both to patients who need skilled medical care that cannot be provided in a custodial level nursing home or in the patient’s home
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| Standardized amount | figure representing the average cost per case for all Medicare cases during the year
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| Tax Equity and Fiscal Responsibility Act (TEFRA) | provided for limits on Medicare Reimbursement that applied to stays in long-term acute care hospitals; replaced fee-for-service with PPS
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