Shared Flashcard Set

Details

mod.150 unit3
vocab.
50
Insurance
Graduate
02/27/2012

Additional Insurance Flashcards

 


 

Cards

Term
Admission Review
Definition
A review for appropriations and necessity of admissions
Term
APC's
Definition
A system of outpatient hospital reimbursment based on procedures rather than diagnoses.
Term
AEP's
Definition
Nineteen criteria for admission under the prospective payment system, separated into two categories, severity and intensity of illness.
Term
Capitation
Definition
A system of payment used by managed care plans in which physicians and hospitals are paid a fixed per capita amount for each patient enrolled over a stated period of time, regardless of the type and number of services provided.
Term
Case Rate
Definition
An average after a flat rate is given to certain categories and procedures.
Term
CDM
Definition
A computer program that is linked to carious hospital departmetns and includes procedures coes, procedure descriptions, service descriptions, fees, and revenue codes.
Term
Charges
Definition
The dollar amount a hospital buills an outlier case on the itemized bill
Term
Clinical Outliers
Definition
Cases that cannot adequately be assigned to an appropriate DRG owing to unique combination of diagnoses and surgeries, very rare conditions or other unique clincal reasons.
Term
Code Sequence
Definition
The correct order of diagnostic codes when submitting an insurance claim that affects maximum reimbursement.
Term
Comorbidity
Definition
An ongoing condition that exists along with the condition for which the patient is receiving treatment.
Term
Cost Outlier
Definition
A typical case that has an extraordinary high cost when compared with most discharges calssified to the same DRG.
Term
Preadmission Testing (PAT)
Definition
Treatment and tests done 72 hours before admission.
Term
Day Outlier Review
Definition
A review of potential day outliers to determine the necessity of admission and number of days before the day outlier threshold is reached as well as the number of days beyone the threshold.
Term
DRG's
Definition
A patient classification system that categorized patients who are medically related with respect to diagnosis and treatment and statistically similar in length of hospital stay.
Term
DRG Validation
Definition
To find out whether the diagnostic and procedural information affection DRG assignment is substantiated by the clincal information in the patient's chart.
Term
DRG Creep
Definition
Coding that is inappropriately altered to obtain a higher payment rate
Term
Elective Surgery
Definition
A surgical procedure that may be scheduled in advance, is not an emergency, and is discretionary on the part of the physician and the patient.
Term
Grouper
Definition
The computer software program that assigns DRGs of discharge patients using the following information, patient's age, sex, principal diagnisis, complications, co morbid conditions, principal prodecure, and discharge status.
Term
Inpatient
Definition
A term used when a patient is admitted to the hospital for overnight stay
Term
Principal Diagnosis
Definition
A condition that is chiefloy responsible for admission
Term
Looping
Definition
The automated grouper process of searching all listed diagnosis for the presence of any comorbility condition or complication or searching all procedures for operating room procedure or other specific procedures.
Term
Procedure Review
Definition
A review of diagnosis and procedure to determine appropriateness.
Term
Outpatient
Definition
A patient whoi receives services in a health care center,emergency department, or ambulatory surgical center and goes home the same day.
Term
Percentage of Revenue
Definition
The fixed percentage of the collected premium rate that is paid to the hospital to cover services.
Term
Per Diem
Definition
A single charge for a day in the hospital regardless of any actual charges or costs incurred.
Term
Autologous Bone Marrow
Definition
Bone marrow collected from the patient, processed & later transplanted back into the patient.
Term
Approach Procedure
Definition
Method used to obtain exposure of a lesion; an anatomical location
Term
Lumbar Puncture
Definition
AKA spinal tap; obtains cerebrospinal fluid into subarachnoid space in the lumbar region.
Term
Quality Improvement Organization (QIO) Program
Definition
A program that replaces the peer review organization program and it designed to monitor and improve the usage and quality of care for Medicare beneficiaries.
Term
Readmission Review
Definition
A review of patients readmitted to a hospital within 7 days with problems related to the first admission, to determine whether the first discharge was premature or the second admission is medically necessary.
Term
Scrubbing
Definition
The process in which computer software checks for errors before a claim is submitted to an insurance carrier for payments.
Term
Stop Loss
Definition
An agreement between a managed care company and a reinsure in which absorption of prepaid patient expenses is limited.
Term
Transfer Review
Definition
Review of transfers to different areas of the same hospital that are exempted from prospective payments.
Term
Uniform Bill (UB-04)
Definition
A Uniform Bill insurance claim developed by the National Uniform Billing committee for hospital inpatient billing and payment transactions.
Term
AHA
Definition
American Hospital Association
Term
AMIA
Definition
American health information management association
Term
Professional Component
Definition
Discribes the services of a physician, including supervision and interporetation of the report.
Term
DDE
Definition
Direct Data Entry
Term
Technical Component
Definition
Describes the services of the technological as well as the use of the equipment,film and other supplies.
Term
EDI
Definition
Electronic Data Interchange
Term
FL
Definition
Fiscal intermediary, field locator
Term
GAO
Definition
General Accounting Officer
Term
Global Components
Definition
Describes the combination of the professional and technical components.
Term
Bone Marrow Aspiration
Definition
Bone marrow sample taken with a needle inserted into marrow cavity and pulled into a syringe.
Term
LOS
Definition
Length of Stay
Term
NF
Definition
Nursing Facility
Term
OPPS
Definition
Outpatient Prospective Payment System
Term
RHIA
Definition
Registered Health Information Administrator
Term
RHIT
Definition
Registered Health Information Technician
Term
TEFRA
Definition
Tax Equity and Fiscal Responsibility Act
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