A/R - is an abbreviation for accounts receivable and means those accounts that are owed to you. In the medical office that means all the charges on the patients accounts.
Adjustment - generally this is referring to a contractual adjustment to the patient accounts that reduces the balance per your office agreement with certain insurance companies. For instance, when you participate with Medicare you are required to reduce the patient's charges for each visit to the allowed amount. Some companies may refer to this amount as a "Discount" on their EOB but it is a contractual adjustment.
Advance Directives - What kind of medical care would you want if you were too ill or hurt to express your wishes? Advance directives are legal documents that allow you to convey your decisions about end-of-life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion later on.
A living will tells how you feel about care intended to sustain life. You can accept or refuse medical care.
A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions if you are unable to do so.
American Hospital Association (AHA) -
The American Hospital Association (AHA) is the national organization that represents and serves all types of hospitals, health care networks, and their patients and communities. Close to 5,000 hospitals, health care systems, networks, other providers of care and 37,000 individual members come together to form the AHA.
AHCA - Agency for Healthcare Administration - Our mission is Better Health Care for All Floridians, and together we are responsible for the administration of the Medicaid program, for the licensure and regulation of health facilities and for providing information to Floridians about the quality of the health care they receive in Florida. They have a wealth of information for providers as well as consumers
on their website.
Allowed Amount - that is the amount agreed to be charge for each procedure, test or visit type to the patient per the insurance company you have a contract with. For instance, your company charges $100 for a basice doctors office visit. The contract amount for a basic doctors office visit is $80 then you must write off $20 from the patient's account for that visit.
Authorizations - Also known as Precertifications is the the process of contacting the patient's insurance carrier for permission do the test, treat the patient, or allow the admission to the hospital. The insurance carrier will generally give you a reference number to attach to the claim in question for processing.
Balance Billing - The practice of billing the patient the remaining balance after the insurance has paid their payment without discounts or adjustments. Any insurance plans that your company participates with frowns on this practice and there can be stiff penalties when done.
Black Lung Benefits - The Black Lung Benefits Act (BLBA) is administered by the Office of Workers’ Compensation Programs (OWCP). The Act provides for monthly payments to and medical treatment for coal miners totally disabled from pneumoconiosis (black lung disease) arising from employment in or around the nation's coal mines. Visit the Black Lung Homepage:
http://www.dol.gov/owcp/dcmwc/regs/compliance/blbene.htm
CHIP - Children's Health Insurance Programs - The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA or Public Law 111-3) reauthorized the Children's Health Insurance Program (CHIP). CHIPRA finances CHIP through FY 2013. It will preserve coverage for the millions of children who rely on CHIP today and provides the resources for States to reach millions of additional uninsured children.
Coinsurance - This is the percentage amount of the allowed charges due by the patient. Usually the patient will have an out-of-pocket limit per year. Once that limit has been reached then the coinsurance due from the patient goes to zero. These amounts are almost always hard to compute at the time of service. So, unless you have only a few billing codes and procedures you will generally have to wait for the claims to process before you can inform the patient what he or she owes on the remaining balance of that service.
Copays - This is a set amount due for specific services and is set by the patient's insurance policy. This amount is separate from deductibles, c0-insurances and generally will always be due whether the patient reaches his or her out-of-pocket limits or not. For instance the patient owes $10 copay to see his or her primary care physician, $25 for a specialists visit, $100 for every Emergency Room visit and $45 for every urgent care center visit. These amounts vary by patient coverage and should always be collected before the patient leaves. They are almost always listed on the front of the patient's insurance card and are no surprise.
CPT - Current Procedural Terminology - These are the codes used in billing a procedure or office visit. They are determined by the American Medical Associated and grouped by type of procedure. They are also grouped by categories. Category I is the basic five digit codes dealing with the procedure and a description, Category II is intended to Measure Performance and Category III is for Emerging Technology. A full description of these categories is offered at the AMA CPT CATEGORY ARTICLE.
Deductible - The amount set by the patient's insurance that he or she must pay first before any claims will be paid by the insurance company. This amount is applied, generally, to the first claims received in the year per patient and is reduced by the allowed amount for that service. For instance, the patient has a $100 calendar year deductible, receives services at an emergency room on January 1st, the claim is for the total amount of $500 but the allowed amount for that service is only $100. In this case the entired allowed amount will be applied to the patient's deductible so that the next claim received by the insurance company for this patient will be processed at the percentage amount of allowed charges.
Discount - Generally referring to an agreed upon amount to reduce the patient's balance. Many medical offices and hospitals as well will offer a discount to self-pay patients who pay the bill up-front or make a set amount deposit for the type of services rendered. This is different from a "Contractual Adjustment" in that the agreement is between the patient and the medical facility itself. It should be coded differently in your Accounts Receivable system for accounting purposes as it is important to know the difference between insurance adjustments and patient discounts.
EOB - is an abbreviation for Explaination of Benefits. It is the form that is sent to your office along with the payment (if any) that lists the amount of the claim you sent on your patient's visits, the amount allowed (if any) of those charges, the adjustment due, and the amount paid for that service (if any). This form will give a reason if the claim is denied, has been applied toward the patient's deductible and a course of action if the claim can be reconsidered for payment.
HCPCS or Healthcare Common Procedure Coding System numbers are the codes used by Medicare (CMS: Centers for Medicare and Medicaid Services). There are two sets of codes. The first set, HCPCS Level I, are based on and identical to the CPT codes. Level II HCPCS codes are used by medical suppliers other than physicians, such as ambulance services or durable medical equipment.
Look Up HCPCS Here!
HFMA - Healthcare Financial Management Association - To define, realize, and advance the financial management of health care by helping members and others improve the business performance of organizations operating in or serving the healthcare field.
Their website has lots of educational material as well as information on certification exams.
HIPAA - Health Insurance Portability and Accountability Act 1996 - A major goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being. The Rule strikes a balance that permits important uses of information, while protecting the privacy of people who seek care and healing. Given that the health care marketplace is diverse, the Rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed (
taken directly from the HHS Health Information Privacy website.)
Home Health Agency or HHA - Agencies/Providers that offer care to patients in their homes. Most insurances separate out coverage for home visits or may not cover them at all. Medicare and Medicaid plans have specialized billing and coverage requirements to learn more visit the website:
https://www.cms.gov/center/hha.asp
Hospice - Facilities that cater to individuals that are terminally ill. There are special insurance coverages for these facilities and have special billing and authorizations requirements. To find out more check out the government website:
http://www.cms.gov/Hospice/
ICD-9 or the International Classification of Diseases is the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States. Created and Sponsored by the World Health Organization. These are second part of the billing codes which must be chosen correctly in order to maximize the reimbursement for the doctors and medical facilities.
Medicaid - State Sponsored insurance plans for those who qualify under each states guidelines. Mostly, the insurance is for those under the povery guidelines, pregnant, children under a certain age and/or critical illness. The guidelines for each state is available on the federal website at: www.cms.gov
Medicare - Federal Government sponsor insurance program for retirees, those who are disabled, has Black Lung or Kidney Failure. There is a wealth of information on the website for providers and consumers. Go to
www.medicare.gov
NAHAM - National Association of Healthcare Access Management - The
national professional organization dedicated to promoting excellence in the management of patient access services in all areas of the healthcare delivery system. They have created two Certifications for Healthcare Access Personnel. The Certified Healthcare Access Associtate (CHAA) and the Certificed Healthcare Access Management (CHAM) tests. Visit their website for more information.
Out-of-Pocket Limit - An amount set by the terms of the patient's insurance contract. This usually based on the amount of coinsurance that the patient has paid. For instance, the patient has an out-of-pocket limit of $1,500 per year. The patient must pay a percentage of the allowed amount after meeting his/her yearly deductible untul the payments reach $1,500 then all claims will be paid at 100%.
Participation Discount - This is an agreed percentage adjustment to a patient's balance for being a member of a certain group. These are voluntary adjustments in that your medical facility has agreed to give these members a discount on services. This is not an insurance agreement and all payments are being made by the patient. You are giving the discount because the group has promised to refer their members to your practice and in return you agreed to apply a discount. The patients should have proof of membership through a card of some type and many look like insurance cards however on the back should be the words, "THIS IS NOT AN INSURANCE".
Patient Protection and Affordable Care Act (PPACA) is a federal statute that was signed into United States law by President Barack Obama on March 23, 2010. This Act and the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010) made up the health care reform of 2010. The laws focus on reform of the private health insurance market, provide better coverage for those with pre-existing conditions, improve prescription drug coverage in Medicare and extend the life of the Medicare Trust fund by at least 12 years. To get a better understanding of this piece of legislation try this website:
http://www.healthcare.gov/law/introduction/index.html
Red Flag Rules - A new law in effect that states, even healthcare providers, any business that extends credit to it's clients must have a system in place to ensure that the person seeking services is who they say they are. To find out more read through the
Federal Trade Commissions website about Red Flag Rules
Referrals - Generally a form filled out by the Primary Care Physician of a patient who has an HMO insurnance that allows the patient to receive treatment at a specialists office. These forms have a reference number that should be included on the billing form of the specialist.
Registrar - Another name for Front Office Clerk, Admission Clerk, Patient Access Specialist, etc. This is the person who first encounters the patient in a medical facility. They are responsible for checking the patient in for their services. They are also responsbile for making sure all demographic and insurance information is correct in the system. Usually, they are the ones that will collect copays, update information and schedule return visits (in the case of doctors offices).
Skilled Nursing Facilities (SNF) - A nursing home, convalescent home, Skilled Nursing Unit (SNU), care home or rest home provides a type of care of residents: it is a place of residence for people who require constant nursing care and have significant deficiencies with activities of daily living. Residents include the elderly and younger adults with physical or mental disabilities. Residents in a skilled nursing facility may also receive physical, occupational, and other rehabilitative therapies following an accident or illness. The insurance coverage for these types of facilities are generally sited as separate coverage. Check out the CMS website for more information at:
https://www.cms.gov/center/snf.asp