Accountable care organization
Group of doctors, hospitals and other health care providers who come together voluntarily to give coordinated high quality care to specific patients, most often Medicare patients.
Affordable Care Act
Federal Patient Protection and Affordable Care Act, sometimes known as Obamacare.
A process whereby a program of study or an institution is recognized by an external body as meeting certain predetermined standards. For facilities, accreditation standards are usually defined in terms of physical plant, governing body, administration, and medical and other staff. Accreditation is often carried out by organizations created for the purpose of assuring the public of the quality of the accredited institution or program.
Accreditation Association for Ambulatory Health Care (AAAHC)
Accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers, and college student health centers, as well as health plans, such as health maintenance organizations and preferred provider organizations.
Medical care for an injury or an illness that can be provided on a outpatient basis.
American Medical Association (AMA)
This is the group entrusted with establishing and modifying any changes of the medical coding system.
When an insurer denies payment for any treatment provided, providers can appeal by objecting to the decision made and requesting to re-consider the claim.
Billing specialists at reliable medical coding companies can ensure that your practice has only fewer accounts receivable and unresolved dental claims.
AR (Accounts Receivable)
In medical billing, accounts receivable refers to the outstanding reimbursement owed to providers for issued treatments and services, whether the financial responsibility falls to the patient or their insurance company.
AR management is a collection of processes such as identifying denied/unpaid claims, re-filing the corrected claims, minimizing AR days, and eliminating aged AR.
A fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services. The actual amount of money paid is determined by the ranges of services that are provided, the number of patients involved, and the period of time during which the services are provided. Capitation rates are developed using local costs and average utilization of services and therefore can vary from one region of the country to another. In many plans, a risk pool is established as a percentage of the capitation payment. Money in this risk pool is withheld from the physician until the end of the fiscal year. If the health plan does well financially, the money is paid to the physician; if the health plan does poorly, the money is kept to pay the deficit expenses.
Certified Practice Management (CPM)
Certified Practice Management (CPM) is a professional certification program for healthcare practice managers. The CPM certification is awarded by the Professional Association of HealthCare Office Management (PAHCOM) and is designed to recognize individuals who demonstrate a high level of expertise in managing the administrative and financial operations of healthcare practices.
Centers for Medicare and Medicaid Services (CMS)
This federal agency updates and maintains the HCPCS code set and is one of the most important organizations in healthcare today.
A request by you or your provider for the payment of funds or the provision of services under the terms of an insurance contract or policy.
The process of ensuring that the coding of diagnosis, procedures and data complies with all coding rules, laws and guidelines. All provider offices and health care facilities should have a compliance plan.
A consumer operated and oriented plan established under a program created by the ACA to foster the creation of qualified non-profit health insurance issuers to offer competitive health plans in the individual and small group markets.
Corporate Integrity Agreement (CIA)
OIG negotiates corporate integrity agreements (CIA) with health care providers and other entities as part of the settlement of Federal health care program investigations arising under a variety of civil false claims statutes. Providers or entities agree to the obligations, and in exchange, OIG agrees not to seek their exclusion from participation in Medicare, Medicaid, or other Federal health care programs.
Council of Quality Healthcare (CAQH)
Online repository used by insurance companies during the credentialing and recredentialing process.
Current Procedural Terminology (CPT) is a medical code set to report medical, surgical, and diagnostic procedures and services. These codes are also used for administrative management purposes such as claims processing and developing guidelines for medical care review.
The CPT code set is divided into three Categories. Category I codes that describe medical procedures, technologies and services have descriptors that correspond to a procedure or service. Category II includes supplemental codes for performance management, and Category III is temporary alphanumeric codes for new and developing technology, procedures and services.
Provider credentialing in healthcare is the process by which medical organizations verify the credentials of healthcare providers to ensure they have the required licenses, certifications, and skills to properly care for patients.
Credentials Verification Organization (CVO)
A CVO verifies a provider’s credentials by obtaining primary source verification of a provider’s qualifications on the organization’s behalf. Upon verification, a provider may then enroll in payers’ health plans so that the healthcare organization can bill for services.
When groups are large enough (such as hospitals or universities) the payors can grant an addendum to a contract allowing the group to maintain their own credentialing. With delegated credentialing, the group or it’s contracted company are responsible for completing the primary source verification process typically performed by the insurance company. It’s the responsibility of the delegated entity to ensure that all providers meet the standards as set forth by the insurance company.
Electronic Medical Record (EMR)
An Electronic Medical Record (EMR) is a digital version of a patient’s medical history that is stored and managed by healthcare providers electronically. It includes information such as the patient’s medical history, diagnoses, treatments, medications, allergies, immunizations, lab results, and other relevant clinical information.
The process that Medicare and Medicaid uses to establish eligibility to submit. claims for Medicare covered services and supplies
Essential community providers (ECP)
Health care provider that provides services to high risk, special needs people, including those with special medical needs or chronic conditions, as well as those living in medical shortage areas.
Evaluation and Management Codes
Evaluation and Management, or E&M codes are used to describe the assessment of a patient’s health and the management of their care. Reviewed on a periodic basis by the AMA, Evaluation and management codes are a part of the CPT-4 system. E&M codes range from 99201 – 99499.
Explanation of Benefits (EOB)
An Explanation of Benefit (EOB) refers to a statement generated by a health insurance provider describing what costs they will cover for the medical care received by the patient. The EOB is generated when the provider submits a claim for the services rendered.
A physician who provides primary health care for individuals and families.
Payment made to a physician or other practitioner each time a patient is seen or a service is rendered.
Fee for Service Contract
A method in which doctors and other healthcare providers are paid for each service performed.
Group NPI (Type II)
Referred to as an organizational NPI or technically as a Type II NPI. Your type I NPI is for the individual while your Type II is for your TAX ID or for locations under your tax id
Maintained by CMS, Healthcare Common Procedure Coding System (HCPCS) is a collection of standardized codes that represent medical procedures, supplies, products and services. The codes are used to facilitate the processing of health insurance claims by Medicare and other insurers.
HCPCS is divided into two subsystems, Level I and Level II. Level I HCPCS includes Current Procedural Terminology codes (CPT) for hospital providers, which consists of five numeric digits. Level II HCPCS codes include a letter followed by four numeric digits. These codes are used to report non-physician services like ambulance rides, wheelchairs, walkers, durable medical equipment, and other medical services. HCPCS codes include A-codes, C-codes, G-codes, J-codes, and Q-codes.
Financial protection against all or part of the medical care costs to treat illness or injury. Health insurance may also include benefits for preventive health care to help you stay healthy.
Hierarchical Condition Category (HCC)
Sets of medical codes that are linked to specific clinical diagnoses. HCCs have been used by the Centers for Medicare and Medicaid Services (CMS) as part of a risk-adjustment model that identifies individuals with serious acute or chronic conditions.
ICD or International Classification of Disease codes help classify diseases, injuries, and causes of death. These codes ensure proper treatment and correct charges for any medical services provided.
The ICD code set is maintained by the World Health Organization (WHO) and distributed in countries across the globe. In the U.S., ICD codes are overseen by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS).The latest version of the ICD, ICD-11 came into effect on 1st January 2022.
When the healthcare provider submits claims to an insurance company for reimbursement, each service is described by a CPT code, which is matched to an ICD code. If the two codes don’t align each other, the company may deny payment.
ICD-11 stands for International Classification of Diseases, Eleventh Revision. It is a standardized coding system used to classify and code medical diagnoses, symptoms, and procedures. The World Health Organization developed and maintains the ICD-11 coding system, which is used by healthcare providers, researchers, and public health officials worldwide.
An insurance contract where individuals are reimbursed for medical expenses covered by the contract which they purchase from a licensed insurance company.
Individual NPI (Type I)
This is your Type I NPI and each provider is required to have one in order to submit claims. This individual NPI is linked to the group that claims are submitted under.
A document that represents the business relationship between a provider and a payor.
The Joint Commission (formerly JCAHO)
A United States-based organization that accredits more than 22,000 US health care organizations and programs, including hospitals and facilities.
Strategies used by health plan companies to control the cost of providing health care while providing high quality services.
A federal and state funded health insurance program for low income individuals who meet certain guidelines
Medically necessary care
Health services that are deemed appropriate for an individual based on his or her condition or diagnosis, according to recognized standards of practice.
A federal health insurance program for people over 65 and for certain people with disabilities.
A type of health plan offered by a private company that contracts with Medicare.
Medicare Risk Adjustment Factors (RAF)
Risk adjustment is a methodology that equates the health status of a person to a number, called a risk score, to predict healthcare costs. The “risk” to a health plan insuring members with expected high healthcare needs is “adjusted” by also insuring members with anticipated lower healthcare costs.
Modifiers are two-character codes that are added to a CPT® or HCPCS Level II code to report any necessary changes in the definition of the procedure. CPT codes have numeric modifiers, while HCPCS codes have alphanumeric modifiers. Modifiers are added at the end of a code with a hyphen. It provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code.
National Committee for Quality Assurance (NCQA)
An organization that works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation.
National Practitioner Data Bank (NPDB)
A web-based repository of reports containing information on medical malpractice payments and certain adverse actions related to health care practitioners, providers, and suppliers.
A group of health care providers that form an affiliation and contract as a group with an insurer.
A health care provider who is not under contract with an insurer.
Nurse practitioner (NP)
A registered nurse specially educated and licensed to provide primary and/or specialty care.
Office of Inspector General (OIG)
The Office of Inspector General (OIG) for the U.S. Department of Health & Human Services has created the educational materials to assist in teaching physicians about the Federal laws designed to protect the Medicare and Medicaid programs and program beneficiaries from fraud, waste, and abuse.
Health care providers who are under contract with an insurer or HMO.
Physician assistant (PA)
A specially trained individual who provides medical care usually provided by a physician.
Health care that focuses on healthy behavior and providing services that help prevent health problems. This includes health education, immunizations, early disease detection, health evaluations and follow-up care.
Health services usually provided by physicians or other practitioners in general practice or in fields such as family practice, obstetrics, pediatrics, and internal medicine.
Primary Source Verification or Provider Credentialing
The process by which a health plan or hospital checks an individual provider’s reported credentials and qualifications. Primary source verification of healthcare providers is required for confirming that an individual possesses a valid license, certification, or registration to practice medicine. Primary sources include medical school diplomas; specialty training or residency certificates; licenses to practice; registration with a medical or dental council; or any other credential required by law, regulation, or hospital policy.
The authorizing by an appropriate authority, such as a governing body, of a health practitioner to provide specific treatment, care, or services at a health facility subject to limits based on factors that include license, education, training, experience, competence, health status, and specialized skill.
A person or an institution that provides health care services.
A contract between providers and payers that makes the provider responsible for all the costs incurred in the care of empaneled health plan members.
Periodic review and reverification of all education, licenses, certificates, insurance and liability or claims history to support the qualifications of any Healthcare Provider and to ensure provider is in good standing to provide quality care to patients.
Relative Value Unit (RVU)
This term is used to describe formulas produced by Medicare.
A complete and thorough re-verification of the information contained in your Medicare and Medicaid enrollment record to ensure it is still accurate and compliant with Medicare and Medicaid regulations. Revalidation is re-enrollment.
Revenue Cycle Management (RCM)
Revenue Cycle Management (RCM) is the process of managing the financial transactions that occur in the healthcare industry. It involves the administration of financial transactions from the point of patient registration, through the provision of services, and up to the final payment of the balance due.
Risk Adjustment Factor (RAF)
Risk Adjustment Factor (RAF) is a methodology used in healthcare financing to adjust payments to healthcare plans based on the predicted healthcare expenses of their members. RAF is used to calculate the relative risk of healthcare expenditures for individuals with specific health conditions or demographic characteristics.
A program for providing group health care coverage with benefits paid entirely by the employer rather than by an insurance company.
Upcoding and Downcoding
Upcoding is coding or reporting for a higher-level service or procedure than what is actually done, to increase the reimbursement rate. At the same time, downcoding is using a code that is of less dollar value than the actual procedure performed.
A leading nationwide accrediting organization setting the highest standards of care and continually define and write standards that elevate health care.
URAC’s accreditation programs require organizations to demonstrate how they meet standards set by experts in health care in the areas of patient management, pharmacy product handling, patient communications, credentialing of providers, review timelines, and patient safety and security. In order to earn an accreditation, organizations must submit a variety of policies and procedures which are reviewed by a URAC accreditation reviewer. Following this review, applications are blinded and given to URAC’s Accreditation Committee for review.
Value-Based Contract (VBC)
A written contractual arrangement between parties in which the payment for health care goods and services is tied to predetermined, mutually agreed upon terms that are based on clinical circumstances, patient outcomes, and other specified measures of the appropriateness and effectiveness of the services rendered.1 In other words, rather than payment being solely dependent on the amount of services rendered, it is instead influenced or determined by value of care delivered to a population or specified group of patients.
When used right, Z codes can improve claims accuracy and specificity, and help to establish medical necessity for treatment. These codes, found in Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) of the ICD-10-CM code book, can be used in any healthcare setting. Z-codes describe circumstances outside of injury or disease that cause a patient to visit a health professional.
The Z codes (Z00-Z99) provide descriptions for a situation wherein the symptoms a patient displays do not point to a specific disorder but still warrant treatment.