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MBG 150
Chapter 17 Terminology
| Question | Answer |
|---|---|
| Accounts Receivable | monies owed to a practice |
| Aging Report | report that shows how long a patient’s account has been outstanding |
| Activities of Daily Living (ADLs) | behaviors related to personal care |
| Ambulatory Payment Classifications (APCs) | classification system designed to explain the amount and type resources used in an outpatient encounter |
| Average Length of Stay (ALOS) | predetermined number of days of approved hospital stay assigned to an individual DRG |
| Balance Billing | practice of billing patients for any balance left after deductibles, coinsurance, and insurance payments have been made |
| Business Associate | an entity that contracts with a practice |
| 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 |
| Co-morbidity | presence of more than one disease or disorder that occurs in an individual at the same time |
| Contract write-off | when the provider agrees to accept the payer’s allowed fee as payment in full for a particular service or procedure |
| Cost outliers | patients whose stays are shorter or considerably longer that average |
| Covered entity | healthcare plans, providers, and healthcare clearinghouses |
| Diagnosis Related Groups (DRGs) | inpatient classification system used to set a level intended to cover operating costs for treating a typical inpatient |
| Discounted fee-for-service | when a healthcare provider offers services at rates that are lower than UCR |
| Disproportionate share | payment adjustment to compensate hospital for the higher operating costs incurred in treating a large share of low-income patients |
| DRG grouper | computer software program that takes the coded information and identifies the patient’s DRG category |
| 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 |
| 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 |
| Home Health Prospective Payment System (PPS) | determination of payment for these services depends on the Outcome and Assessment Information Set (OASIS) |
| Inpatient rehabilitation | reimbursement for these services is based on the hospital stay, beginning with the admission and ending with the discharge |
| Long-term care hospital | payment system for these services are based on DRGs with a predetermined ALOS |
| Peer Review Organization (PRO) | agency paid by the federal government to evaluate and monitor the quality of care given to patients |
| Principle diagnosis | the reason for admission to the acute care facility |
| Reimbursement | payment to the insured for a covered expense or loss experienced by or on behalf of the insured |
| Relative Value Scale (RVS) | method of determining reimbursement for healthcare services based on establishing a standard unit of value for medical and surgical procedures |
| Residential healthcare facility | nursing home |
| Resource utilization groups (RUGs) | system used to calculate payments to a skilled nursing facility according to severity and level of care |
| 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 |
| 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 |
| Standardized amount | figure representing the average cost per case for all Medicare cases during the year |
| 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 |
Created by:
Alyshia
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