Glossary

This refers to the intentional misuse or excessive use of healthcare services, resources, or billing practices for personal gain or financial advantage. It often involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices.

An ACO is a healthcare model where a group of providers, such as doctors and hospitals, voluntarily come together to give coordinated high-quality care to their Medicare patients. The goal is to ensure that patients receive the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors.

This term represents the outstanding payments owed to a healthcare organization by patients or insurance companies for services rendered. It's a critical component of a healthcare provider's revenue cycle management, indicating the total amount of uncollected revenue for services provided.

This accounting method involves recording financial transactions when they occur, regardless of when the payment is received or made. It provides a more accurate financial picture of a company's financial position by recognizing economic events regardless of when cash transactions occur.

In healthcare, adjudication refers to the process of evaluating and determining the validity and reimbursement amount of a healthcare claim by a payer. It involves reviewing the claim to ensure that it complies with the payer's policies and procedures.

This occurs when a healthcare claim is rejected due to non-medical reasons, such as missing information, incorrect coding, or failure to adhere to proper filing procedures. These denials result in non-payment and require administrative correction and resubmission for potential reimbursement.

An ABN is a Medicare form that providers use to inform beneficiaries about services Medicare is likely not to cover due to lack of medical necessity. It helps patients make informed decisions about their care and potential financial responsibilities.

This phenomenon occurs when individuals with higher risk or poorer health are more likely to seek and utilize healthcare services, potentially leading to imbalances in the insurance system. It can result in higher premiums and costs for insurers.

This is the maximum amount that a healthcare provider is permitted to bill for a specific service or procedure, as determined by the payer. It's also known as the "allowed amount" or "approved charge." Charges above the allowable amount are typically the patient's responsibility.

An APM is a reimbursement approach that deviates from traditional fee-for-service models. It promotes value-based care by linking payments to quality and cost outcomes, encouraging providers to focus on delivering high-quality, cost-effective care.

This is a Medicare payment system used for outpatient services. It classifies outpatient services into groups that are similar clinically and in terms of the resources they require. Payment rates are set for each APC group.

This is a formal request made by a healthcare provider or a patient to challenge a denied claim or reimbursement decision by an insurance company or payer. Appeals are made when it is believed that the service should be covered and paid for.

This legal agreement allows a patient to authorize their healthcare provider to receive direct payment from the insurance company for services rendered. It simplifies the payment process for providers and ensures timely compensation.

In healthcare, attribution is the process of assigning financial responsibility for healthcare services to the appropriate payer. This ensures accurate reimbursement and is crucial in coordinated care models where multiple providers may be involved.

An audit in healthcare is a systematic examination of financial records, coding accuracy, and compliance with regulations. It aims to ensure accuracy in billing and coding, identify errors or discrepancies, and mitigate risks of fraud and abuse.

This is the predetermined amount established by payers for specific healthcare services. It serves as the starting point for reimbursement calculations and is often adjusted based on various factors like geographic location or facility type.

Benchmarking in healthcare involves comparing an organization's performance metrics against industry standards or best practices. This process helps identify areas for improvement and develop strategies to enhance performance and efficiency.

A beneficiary in the context of healthcare is an individual or entity who receives healthcare services and is eligible to receive benefits from a health insurance plan or government program like Medicare or Medicaid.

In healthcare revenue cycle management, a benefit refers to the positive outcome or advantage gained from a specific action, process, or system. This can include improved patient satisfaction, increased efficiency, or enhanced financial performance.

This is the specific timeframe during which an insurance policyholder is eligible to receive benefits for covered healthcare services. In Medicare, for example, a benefit period begins the day a patient is admitted to a hospital and ends when they haven't received hospital or skilled nursing facility care for 60 consecutive days.

A bundled payment is a reimbursement model where healthcare providers receive a single payment for all services related to a specific episode of care, rather than being paid separately for each service. This model encourages more coordinated and efficient care.

Bundling in healthcare refers to the process of grouping multiple healthcare services or procedures together and billing them as a single unit for reimbursement purposes. It's often used in bundled payment models to simplify billing and encourage comprehensive care.

Case management in healthcare involves coordinating care and services for patients, especially those with complex medical needs. It includes assessing, planning, facilitating, and advocating for options and services to meet an individual's health needs.

This refers to modifications made to a healthcare claim to ensure accurate reimbursement. Adjustments may be necessary due to errors in the original claim, changes in service delivery, or after an appeal.

A claim denial occurs when an insurer rejects a claim due to various reasons, such as lack of medical necessity, improper coding, or eligibility issues. Denied claims can be appealed by the provider or the patient.

Clinical documentation involves creating detailed records of a patient's medical care and history. Accurate and thorough documentation is essential for effective patient care, accurate billing, and compliance with regulatory requirements.

Co-insurance is the patient's share of the costs for covered healthcare services, typically expressed as a percentage. For example, if the insurance covers 80% of the cost, the patient's co-insurance would be the remaining 20%.

In workers' compensation, the compensation schedule is a list of payments for various medical services provided to injured workers. It outlines the maximum allowable amounts that medical providers can charge for specific services.

Compliance in healthcare refers to the adherence to legal, regulatory, and policy standards. It involves following laws and regulations related to healthcare delivery, billing, and patient privacy, among others.

Cost containment involves efforts to control or reduce healthcare expenses. This can include strategies to improve efficiency, reduce waste, and manage the cost of care while maintaining high-quality patient outcomes.

Coverage determination is the decision made by an insurer on what services are covered under a policy. It involves evaluating whether a particular medical service or treatment is necessary and covered under the terms of the insurance plan.

Current Procedural Terminology (CPT) codes are medical codes used to describe healthcare services and procedures for billing purposes. They are used by providers to communicate with payers about the services provided to patients.

Denial management is the process of addressing and resolving denied claims. It involves identifying the reasons for denials, correcting claims, and resubmitting them for reimbursement, as well as implementing strategies to prevent future denials.

Dependent coverage refers to insurance coverage that is extended to an employee's family members, such as a spouse and children. It is a common feature of employer-sponsored health insurance plans.

A diagnosis code is a code used to describe a patient's medical condition. These codes are part of the International Classification of Diseases (ICD) system and are used for billing, record-keeping, and statistical purposes.

Disability management involves coordinating and managing care for individuals with disabilities. It includes a range of services and supports designed to address the individual's medical, psychological, and vocational needs.

Discharge planning is the process of planning for a patient's care after they leave the hospital. It involves coordinating services and support needed for the patient to safely transition from hospital to home or another care setting.

DME refers to long-term medical equipment used by patients, such as wheelchairs, hospital beds, or oxygen concentrators. These items are prescribed by a healthcare provider and are typically covered by insurance.

The Experience Modification Rate (E-Mod) is a factor used in calculating workers' compensation insurance premiums. It reflects a company's claim history relative to other businesses in the same industry.

Eligibility verification is the process of confirming a patient's insurance coverage before services are provided. It ensures that the patient is covered for the services and helps prevent billing issues and denials.

An EMR is a digital version of a patient's medical history maintained by a healthcare provider. It includes the patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, and test results.

An encounter form, also known as a superbill, is a document used in healthcare settings that lists the services provided during a patient visit. It includes information necessary for billing, such as CPT and diagnosis codes.

An EOB is a document sent by an insurance company to a patient explaining what medical treatments and services were paid for on their behalf. It details the amount billed, the payment made by the insurer, and any patient responsibility.

Fee-for-service is a payment model where healthcare providers are paid individually for each service they provide. Payments are typically based on a fee schedule or a percentage of the billed charges.

The FROI is the initial report made by an employer after a workplace injury or illness occurs. It is a critical step in the workers' compensation claim process, documenting the details of the incident and the injury.

In healthcare, fraud involves intentional deception or misrepresentation in healthcare billing for unauthorized benefit. This can include billing for services not rendered, upcoding, or falsifying patient records.

Healthcare Common Procedure Coding System (HCPCS) codes are a set of medical codes used for billing Medicare and other health insurers. They represent services, procedures, and equipment not covered by CPT codes.

HIE refers to the electronic sharing of health information among different healthcare organizations. It enables healthcare providers to access and securely share a patient's vital medical information electronically.

HIPAA is a federal law that protects sensitive patient health information from being disclosed without the patient's consent or knowledge. It sets standards for the privacy and security of health information.

The International Classification of Diseases, Tenth Revision (ICD-10) is a coding system used to classify and code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care in the United States.

An IME is an evaluation conducted by a third-party physician to confirm the nature and extent of an injury and the appropriate treatment. It is often used in workers' compensation cases to resolve disputes about medical opinions.

An impairment rating is an assessment used in workers' compensation to quantify an injured worker's functional loss. It is expressed as a percentage and is used to determine the level of disability and compensation.

An in-network provider is a healthcare provider who has a contract with an insurance plan to provide services to plan members for specific pre-negotiated rates. Using in-network providers usually results in lower out-of-pocket costs for patients.

IBNR refers to liabilities for events that have occurred but have not yet been reported to the insurer. In workers' compensation, it represents the estimated cost of claims that have occurred but are not yet known.

Indemnity benefits in workers' compensation are payments made to compensate for lost wages due to a work-related injury or illness. They are designed to partially replace lost income while the worker is unable to work.

A job analysis is an evaluation of the physical and mental demands of a job. It is used in workers' compensation to determine the suitability of a job for an injured worker and to develop return-to-work plans.

In the context of workers' compensation, liability refers to the legal responsibility of an employer for the costs associated with a work-related injury or illness. This includes medical expenses, lost wages, and rehabilitation costs.

A lost time claim in workers' compensation is a claim involving time away from work due to a work-related injury or illness. It typically requires payment of indemnity benefits to compensate for lost wages.

Managed care is a healthcare delivery system designed to manage the cost, utilization, and quality of healthcare services. It often involves the use of networks of providers and pre-authorization for services.

Medical necessity refers to healthcare services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. It is a criterion used by insurers to determine coverage and reimbursement.

An MPN is a group of healthcare providers used by an insurer, particularly in workers' compensation, to treat injured workers. Providers in an MPN have agreed to specific terms regarding care and billing.

In medical billing, a modifier is a code that indicates a service has been altered in some way without changing the basic service. Modifiers provide additional information to payers about the service performed.

An independent advisory organization that collects and analyzes data on workers' compensation insurance. NCCI develops recommendations for rate and loss cost filings, and provides a range of services to insurance companies, state workers' compensation agencies, and employers. It plays a crucial role in ensuring a stable and sustainable workers' compensation system.

A reduction in healthcare service rates negotiated between healthcare providers and insurance networks. These discounts are often part of a managed care organization's strategy to control costs, and they benefit insurers and insured members by providing services at lower rates than standard charges.

Refers to healthcare providers or services that are not part of an insurance plan's network. When patients use out-of-network services, they typically incur higher out-of-pocket costs, as these services are either not covered or covered at a lower rate than in-network services.

The portion of healthcare costs that a patient is responsible for paying out of their own pocket. This can include deductibles, co-payments, and co-insurance, and is determined after the insurance company has made its payment or adjustment.

An entity, usually an insurance company or government program, responsible for paying healthcare claims. Payers reimburse healthcare providers for services rendered to insured individuals based on the terms of the insurance policy or coverage program.

The process of having a healthcare service or provider's work evaluated by a group of their peers. This is often used to maintain standards, improve performance, and ensure the quality of healthcare services.

A condition where an injured worker sustains a permanent injury that partially impairs their ability to perform work-related tasks. Compensation for PPD is typically determined based on the severity and impact of the impairment on the worker's ability to earn.

A situation where an injured worker is permanently and completely unable to perform any kind of work due to their injury. PTD claims often result in higher compensation payments, reflecting the significant impact on the worker's earning capacity.

A requirement by some insurance plans that a healthcare provider must obtain approval from the insurance company before providing certain services or treatments to ensure coverage.

A type of health insurance plan that offers a network of healthcare providers. Members have the flexibility to use providers outside of the network but will typically pay less when using in-network services.

The amount paid, often on a monthly basis, for health insurance coverage. Premiums are paid by individuals, employers, or shared between both, and are used to fund the costs of the health insurance plan.

The process by which health insurance networks and healthcare organizations verify the qualifications, experience, and professional standing of healthcare providers to ensure they can deliver quality care.

The agreed-upon amount that an insurance company or payer will pay a healthcare provider for services rendered. This rate is often negotiated between the provider and the payer and can vary based on the service and the provider's contract with the payer.

A program designed to help injured workers transition back to work. It may include modified duties, part-time hours, or accommodations to the worker's role to facilitate their return to the workforce after an injury.

The process of identifying, assessing, and controlling threats to an organization's capital and earnings. In healthcare, this includes managing the risks to patient safety, data security, and compliance with regulations.

The process by which a healthcare provider obtains approval from a health insurance company to provide specific services or treatments to a patient. This is often required for services that are expensive, unusual, or outside of standard care.

The legal process by which an insurance company seeks reimbursement from a third party that is responsible for causing an injury or loss to the insured party. This is common in cases where another party is at fault for an injury that resulted in a workers' compensation claim.

A condition where an injured worker is temporarily unable to perform some, but not all, of their work duties due to an injury. Compensation for TPD is typically provided until the worker can return to their full duties.

A situation where an injured worker is temporarily completely unable to work due to an injury. TTD benefits provide compensation to the worker during the period they are recuperating and unable to work.

An organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity. TPAs are often used in the administration of workers' compensation claims, employee benefits, and self-insured health plans.

A set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care.

The process of ensuring healthcare services are used effectively and efficiently. It involves reviewing the necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities.