Administrative RCM Terms
Charge Description Master (CDM):
A comprehensive list of all billable services and items provided by a healthcare facility to the RCM company, along with their corresponding charges. This is also referred to as the fee schedule.
Claim Scrubbing:
Healthcare organizations use automated software or tools to identify and correct errors or inconsistencies in healthcare claims before submitting them to payers.
CLIA (Clinical Laboratory Improvement Amendments):
Federal regulations establish quality standards for clinical laboratory testing. These standards ensure the accuracy, reliability, and timeliness of patient test results.
Coordination of Benefits (COB):
When a patient has multiple insurance plans, determining the payment order for primary and secondary insurance is necessary. This prevents overpayments or duplicate coverage.
Credentialing:
The RCM Solution involves the process of verifying and assessing the qualifications, training, and experience of healthcare providers to ensure they meet payer and regulatory requirements.
LIMS (Laboratory Information Management System):
A software system used to manage, track, and analyze laboratory samples, workflows, and data, including sample accessioning, testing, reporting, and quality control.
Medical Necessity:
This means that a healthcare service or treatment is reasonable, necessary, and appropriate for a patient’s diagnosis or condition. It’s a crucial factor in determining whether health insurance will cover the cost of the service or treatment.
NPI (National Provider Identifier):
A unique 10-digit identification number is assigned to healthcare providers, including physicians, hospitals, and clinics, to facilitate electronic transactions and billing processes.
PTAN (Provider Transaction Access Number):
A unique identifier assigned to healthcare providers enrolled in the Medicare program is used for billing purposes and accessing the Provider Enrollment Chain Ownership System (PECOS).
Value-Based Payment:
The revenue cycle management (RCM) solution encompasses reimbursement models that incentivize healthcare providers to deliver high-quality care and achieve positive patient outcomes, shifting the focus away from volume-based services.
Electronic Transactions
ANSI 835/ANSI 837:
The ANSI 835 standard format is for electronic remittance advice (ERA) files, offering payment details for healthcare claims. Providers use the ANSI 837 standard format to submit claims to payers electronically.
API (Application Programming Interface):
Rules and protocols enable software interaction, facilitating data exchange and functionality integration between applications.
Billing Integration:
The RCM Solution integrates billing processes and systems in healthcare organizations, ensuring seamless coordination and automation of billing activities. It includes claim generation and submission.
Clearinghouse:
An intermediary organization processes healthcare claims electronically. It transmits them between providers and insurance payers. Compliance with industry standards is ensured, and efficient claim processing is facilitated.
EDI (Electronic Data Interchange):
The RCM Solution facilitates the electronic exchange of data between medical billing software and insurance payers. This is done through standardized formats and protocols.
EFT (Electronic Funds Transfer):
A method of transferring funds electronically from the insurance bank account to the bank account of the healthcare provider. EFT is commonly used for processing healthcare payments between payers and providers.
EHR (Electronic Health Record):
Digital records of patients’ medical history, diagnoses, medications, and treatment plans are accessible to authorized healthcare providers.
Electronic Remittance Advice (ERA):
An electronic statement sent by a payer to a healthcare provider explaining the payment or denial of claims, including reasons for any adjustments.
Health Information Exchange (HIE):
A secure system for sharing patients’ health information electronically between healthcare providers, hospitals, and other organizations.
HL7 (Health Level Seven):
A set of international standards for the exchange, integration, sharing, and retrieval of electronic health information between healthcare systems and devices, facilitating interoperability and data exchange in healthcare settings.
RCM Solution Related
Client Bill:
A service provider sends a billing invoice to its clients for the services rendered. This includes healthcare facilities or laboratories. It indicates the breakdown of the fee for the services rendered.
Clinical Documentation Improvement (CDI):
Initiatives and processes aimed at improving the accuracy and specificity of clinical documentation to support appropriate coding and billing.
Days in Accounts Receivable (AR):
The average number of days it takes for a healthcare provider to collect payment for services rendered is used as a measure of revenue cycle efficiency.
In-Network Contract:
An agreement between a healthcare provider and an insurance network or managed care organization to provide healthcare services to members of the network at negotiated rates and terms.
Insurance Discovery:
This RCM solution is capable of verifying patient’s health insurance details, which includes gathering information such as the name of the insurance company, policy number, and coverage details. This step ensures accurate billing and facilitates seamless reimbursement processes.
Multiplan Coverage:
A type of health insurance coverage that allows patients to access healthcare services from a network of providers participating in multiple insurance plans, offering greater flexibility and choice of providers.
Out-of-Network:
Referring to healthcare providers or services that are not part of an insurance network or preferred provider organization (PPO), requiring patients to pay higher out-of-pocket costs for services rendered.
Prior Authorization:
Before certain medical services or procedures can be performed, obtaining approval from an insurance company is necessary. This ensures coverage and reimbursement for the patient’s healthcare expenses.
Remark Codes:
Insurance payers use standardized codes to provide explanations or additional information regarding the processing of healthcare claims. These codes include reasons for denials or adjustments.
Regulatory and Compliance
FFS-ABN (Fee-for-Service Advanced Beneficiary Notice):
A form filled out by the beneficiaries prior to receiving certain services that Medicare may not cover. FFS-ABN explains the potential costs the beneficiary may have to pay if Medicare denies payment.
HIPAA (Health Insurance Portability and Accountability Act):
Federal legislation that protects the privacy and security of patients’ health information and sets standards for electronic healthcare transactions. All healthcare providers and RCM businesses are governed by this legislature.
LCD (Local Coverage Determination):
A policy created by Medicare Administrative Contractors (MACs) that defines the specific medical services or procedures covered by Medicare in a particular geographic area.
MAC (Medicare Administrative Contractor):
A private organization contracted by CMS to process Medicare claims, enroll providers, and perform other administrative tasks related to the Medicare program.
MCO (Managed Care Organization):
A type of healthcare organization or insurance plan that manages and coordinates healthcare services for its members, often through contracts with healthcare providers and utilization management programs.
Medicare-Medicaid Crossover Rule:
When a patient is eligible for both Medicare and Medicaid, Medicare becomes the primary payer, covering healthcare costs first. Medicaid then serves as the secondary payer, covering expenses only if the Medicaid allowable exceeds the Medicare allowable for the service.
MUE (Medically Unlikely Edit):
CMS establishes a threshold limit based on the number of units or frequency of certain medical procedures or services. These are considered excessive if performed beyond the fixed threshold.
NCCI (National Correct Coding Initiative):
CMS developed coding policies to promote correct coding practices and prevent improper Medicare claim payments. These policies identify and prevent coding errors.
NCD (National Coverage Determination):
A policy created by the Centers for Medicare & Medicaid Services (CMS) that specifies the conditions under which Medicare will cover certain medical treatments, procedures, or services across all states.
