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MBG 150

Chapter 17 Terminology

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