Charge!
assure that billable services are charged
Charge Capture
The time period within which a valid claim may be submitted to the insurer to be considered for payment.
Timely Filing Limit
Refers to accounts that have an outstanding balance (money owed) by the patient and the in accordance with the policies of the healthcare facility has been defined as uncollectible.
Bad Debts
the process of receiving and disbursing cash payments.
cash flow
Can be Corrected and Resubmitted
Rejected claim
charge tickets processed daily
manual
Balances on an account that are to be refunded to an insurer or the patient/responsible party
Credit Balances
A write off occurs when partial payment has been received and all avenues of collecting full payment have been exhausted.
Write-Off
the cost for a service divided by the total charge for the service
cost to charge ratio
Must be Appealed
Denied claim
capture charge at point of service - order entry
Electronic
1. Transaction Rule
2. Standard Code Sets
3. UB-04 (837I) - Facility bill form
4. CMS-1500 (837P) - Physician bill form
Claims Submission
The process of writing off an unpaid balance on a patient's account to make the account zero balance.
Adjustment
when revenue may not cover costs
financial risk
usually awaiting additional information
Suspended claim
Charges not posted to a patient's account within the facility's established bill hold period.
Late charge
The aging of A/R dollars after the claim has been dropped for billing. Aging buckets are usually in 30 day increments and may broaden as the accounts get older.
Best practice is no more than 15-20% of final billed A/R greater than 90 days.
Aging of Accounts
are synonymous and refer to the amount of money the facility receives for the services rendered
Cash & Reimbursement
It notifies the patient that their services may not be covered and gives the option of not having the testing.
Advance Beneficiary Notice
Pays first time - No edits
Clean claim
synonymous they reflect the amount the facility is seeking for services rendered and become the A/R for the account
Revenue & Charges
A document sent to the patient from the third party payer identifying services rendered, provider, charges, allowable, payment, benefits covered or denied, benefit limits, and patient responsibility (deductible and co-pay)
Explanation Of Benefits (EOB)
The difference between the actual charge and the contracted amount is the contractual allowance or contractual write-off.
Patients are not responsible for any of the contractual allowance.
Contractual Allowances
payment categories that are used to classsify patients for the purpose of reimbursing hospitals
diagnosis related group (DRG)
Edits Data/Claims Disposition
Outpatient Code Editor (OCE)