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hospital billing 17

DRG diagnosis related group
APC ambulatory payment classification
QIO quality improvement orginazation
nineteen criteria for admission under the prospective payment system, separated into two categories severity and intensity of illness in which one criterion from each category must be meet for admission to an acute care facility is known as appropriatness evaluation protocals (AEP)
AEP appropriatmess evaluation protocals
UR utilization review
a process baced on established criteria of reviewing and controlling the medical necessity for services and providers use of medical care resources is known as utilization review (UR)
PAT preadmission testing
treatment, tests, and procedures done 48 to 72 hours before admission of a patient into the hospital that is done to eliminate extra hospital days is known as preadmission testing (PAT)
A time frame in which medical diagnostic test and hospital outpatient services are done before admission is called 72 hour rule
A program that replaces the peer review organization program and is designed to monitor and improve the usage and quality of care for mecicare beneficiaries is called quality improvement organization
the name of a disease, anatomic structure, operation, or procedure, usually derived from the name of a place where it first occured or a person who discovered or first described it is called eponym
what is the term sometimes used for discharge clinical resume
DDE direct data entry
what term is the time between the discharge of the patient form the hospital and the input of the late charge to the time when the final bill is printed dropped
CDM charge description master
a computer program that is linked to verious hospital departments and includes procedure codes, procedure descriptions, service descriptions, fees, and revenue codes is called charge description master (CDM)
this occurs continually when blind charts are pulled and audited to maintaine quality control random internal audit
when a patient request an audit to verify charges it is known as autit by request
When an insurance company request an audit in which both the insurance auditor and the hospital auditor should be present is known as defense audit
the person who registers the patient by interviewing and obtaining personal demograghic and insurance info and admitting diagnosis or symptoms is called admitting clerk
the person who checks the completeness of each patients medical record for dictated reprots and signatures is known as the discharge analyst
a system of outpatient hospital rembursment based on procedures rather than diagnosis ambulatory payment classification (APC)
rembursment to the hospital on a per-member, per-month basis regardless of wether the patient is hospitalized capsation
a fixed percentage paid to hospital to cover charges is known as percentage of revenue
an averaging after a flat rate has been given to certain categories of procedures is called cace rate
a set amount for payment to the hospital is established in the contract between the hospital and the managed care plan is called contract rate
a classification system that categorizes patients who are medically related with respect to diagnosis and treatment and are statistically similar in length of hospital stay is known as diagnosis related group (DRG)
this kind of reimbursement is when the first day of the hospital stay is paid higher than the subsequent days differental by day in hospital
when the hospital receives a flat per-admission reimbursement for the service to which the patient is admitted is known as differental by service type
when the hospital is paid for each medical service provided on the basis of an established schedule of fees it is known as fee-for-service (FFS)
FFS fee-for-service
a comprehendive listing of charges based on procedure codes, under a FFS arangement, or discounted FFS, state states fee maximums paid by the heath plan within the period of the managed care contract is known as fee schedule
a set amount or single charge per hospital admission is paid by the managed care plan, regardless of the cost of the actual service the patient recives is known as flat rate
a single charge for a day in the hospital egardless of actual charges or cost incurred is known as per diem
when payment calculates reimbursement on the basis of a percentage of total approved charges accrued during a hospital stay and submitted the the insurance plan it is known as percentage of accured charges
the methodin which the plan advances cash to cover expected claims to the hospital in which funds are replenished periodically it is known as periodic interim payments and cash advance (PIP)
PIP periodic interim payment and cash advance
a list of procedure codes for professional services and procedures are assigned unit values that indicate the relative value of one procedure over another is called relative value studies (RVS)
RVS relative value studies or scale
this payment system is implemented under the prospective payment system for medicare and other government programs and provides rembursement for outpatient services based on a formula resource-based relative value scale (RBRVS)
the relative value unit of each service must equal the sum of the relative value units representing physicians work practice expenses, and cost of professional liability insurance is the formula for RBRVS
RBRVS resource-based relative value scale
this method is used by third-party payers to establish fee schedules, the usual fee which is submitted by the provider, the customary fee charge by the provider in a geographic area, and reasonable fee is consedered justifiable because of circumstances usual, customary, and reasonable (UCR)
RBRVS resource-based relative value scale
this method is used by third-party payers to establish fee schedules, the usual fee which is submitted by the provider, the customary fee charge by the provider in a geographic area, and reasonable fee is consedered justifiable because of circumstances usual, customary, and reasonable (UCR)
when a part of the plans payment to the hospital is withheld or set aside in a bonus pool until the hospital meets or exceeds the criteria set down, the hospital receives it s withhold or bouns it is known as withhold
the most common stop loss and can apply to the physician, on a smaller case basis, as well as to the individual hospital claim is called case-based stop loss
when the hospital buys insurance to protect against lost revenue and receives less of a capitation fee, the amount they do not receive helps pay for the insurance this is known as renisurance stop loss
some manage care contracts bay a percentage of charges when the total charge exceeds a listed contracted amount this would be known as percentage stop loss
the dollar amount owed to a participating provider for health care services rendered to a plan member, according to the fee schedual set by the managed care plan is known as charges
a form of discount with a limit in which the percentage amount increases, based on the hospital numbers is known as discount in the form of sliding scale
baced on the total volume of business generated, this is a method in which an interim per diem is paid for each day in the hospital this is known as sliding scale for discount and per diem
the process in which computer software checks for errors before a claim is submitted to an insurance carrier for payment is called scrubbing
a surgical procedure that may be scheduled in advance and is not an emergency and is descretionary on the part of the physician and the patient is called elective surgery
MDC major diagnostic categories
a typical case that has an extraordinarily high cost when compared with most discharges classified to the same DRG is known as cost outlier
cases that cannot adequately be assigned to an appropriate DRG, owing to unique combination of diagnoses and surgeries, rare conditions, or other unique clinical reasons. such cases are grouped together in DRGs and considered outliers clinical outliers
coding that is inappropriately altered to obtain a higher payment rate is known as DRG creep
a preexisting condition that because of its prescnce with a certain principal diagnosis, causes an increase in length of stay by at least 1 day in 75% of cases comorbidity
the automated grouper process of searching all listed diagnoses for the presence of any comorbid condition or complication, or searching all procedures for operating room procedures or other specific procedures is known as looping
Created by: maryce
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