University of Mississippi Medical Center. Access Management. Patient Access Specialists II

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Financial Terminology

Financial Terminology

in Access Management

University of Mississippi Medical Center

Access Management

Access Management

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As a Patient Access Specialist

As a Patient Access Specialist…

• You are the FIRST STAGE in the Revenue

Cycle.

• Your job is to collect ACCURATE patient

information during registration.

I d t d thi

f ll

’ll

d

• In order to do this successfully, you’ll need an

understanding of key financial terms related

to healthcare

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What to Expect

What to Expect…

• This module will help you prepare to be an

effective and efficient Patient Access

Specialist I.

THIRTY EIGHT FINANCIAL TERMS

• THIRTY-EIGHT FINANCIAL TERMS are

presented.

• You will need to know each of them as you

• You will need to know each of them as you

register patients.

• A quiz at the end will measure what you

• A quiz at the end will measure what you

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

NOTE:

NOTE:

• Understanding the first three terms are crucial to comprehending the other thirty-five.

to comprehending the other thirty five.

• Before proceeding, make sure you know the

difference between the Payer, Beneficiary, and

Provider.

• These terms are used throughout the entire d l

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Payer- broad term describing any organization that pays medical expenses on behalf of

patients.

 For example: Blue Cross Blue Shield Aetna Medicaid For example: Blue Cross Blue Shield, Aetna, Medicaid, Medicare, etc.

• Beneficiary- the person or persons entitled to di l b fi Thi ll f h

medical benefits. This usually refers to the patient.

Provider a doctor hospital or medical

• Provider- a doctor, hospital, or medical

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Administrative Costs- any cost associated with creating and submitting a bill for services For creating and submitting a bill for services. For example: registration, utilization review,

coding, billing, and collection of expenses. These are the non-medical costs of collecting These are the non medical costs of collecting money for services rendered.

Ad i i A th i ti h

• Admissions Authorization – process where Payer accepts or rejects coverage for

Beneficiary in urgent/emergent care situations. This usually takes 24 48 hours

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Ambulatory Payment Classification (APC)- a method used to calculate payment for

outpatient services. It is made up of a system of averaging and bundling common services and of averaging and bundling common services and procedures using Current Procedural

Terminology (CPT), Healthcare Common

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Annual Maximum Benefit Amount Deductible -The maximum dollar amount set by Managed The maximum dollar amount set by Managed Care Organizations (MCO) that LIMITS the total amount the plan must pay for a subscriber in a year It’s the maximum amount an insurance year. It s the maximum amount an insurance company will pay for a patient in one year.

• Out-of-pocket maximums – This occurs in extreme cases of chronic illness where large amounts of out-of-pocket expenses add up amounts of out-of-pocket expenses add up. MCO’s set a limit to the amount of out-of-pocket expenses a member pays in a single

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Deductible - the dollar amount per year the

patient must pay before Insurance pays a dime. The maximum amount a patient will pay for

medical services in a year considering they medical services in a year, considering they don’t exceed the insurance company’s Annual Maximum.

• Assignment of Benefits- Patient gives written approval for their insurance company to pay Provider directly on their behalf. The form is usually signed at the time of registration

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Average Daily Census- the average number of inpatients maintained in the hospital each da inpatients maintained in the hospital each day for a specific length of time.

• Average Length of Stay- the average number of days of service rendered to each patient during a specific time

a specific time.

• Appeal-a complaint made when Beneficiaries or • Appeal a complaint made when Beneficiaries or

Providers disagree with decisions about health care services. This typically relates to payment issues

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Balance Billing- the practice of billing a patient for the fee amo nt remaining after the Ins rer for the fee amount remaining after the Insurer payment and Patient co-payment have been made.

– Example: Total Bill is $100 and insurance pays $80 while patient pays a $10 Co-Pay. Remaining balance to bill patient is $10.

• Claim- an itemized statement of the costs

incurred during treatment It is normally sent by incurred during treatment. It is normally sent by the Provider to the Payer to initiate

reimbursement.

Th it i d bill t t th i

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Clinical Data Repository (CDR)- the process of receiving, reviewing, adjudicating, and

processing claims.

– Also known as the Revenue CycleAlso known as the Revenue Cycle.

• Fee for Service- the traditional healthcare Fee for Service the traditional healthcare

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Benefit Period – the time period in which

Medicare covers inpatient care in hospitals and Skilled Nursing Facilities(SNF) under one

deductible The Benefit Period begins the first deductible. The Benefit Period begins the first day of a patient’s stay and ends sixty days after discharge IF the sixty days is not interrupted by another stay in a hospital or SNF.

– Patient gets as much treatment as needed with one

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Deposit - the amount of money a Provider

req ires prior to rendering service This amo nt requires prior to rendering service. This amount is typically a percentage of the patient’s

estimated total bill.

• Diagnosis Related Group (DRG)- classification system for over 490 diagnoses based on patterns system for over 490 diagnoses based on patterns of resource consumption and length of stay.

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Co-insurance – a cost sharing arrangement of many MCOs where the Payer and Patient share a percentage of medical charges.

– Example: 80/20 where Payer is responsible for paying – Example: 80/20 where Payer is responsible for paying

80% and the Patient 20%.

• Bad Debt- when a patient’s outstanding balance is regarded as uncollectible and is charged as a

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Financial Terminology In Healthcare

Financial Terminology In Healthcare

• Co-pay- a cost sharing arrangement where

the patient/guarantor is responsible for a

defined payment amount for a specific type

of service usually paid at the time of

of service, usually paid at the time of

treatment.

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• HCFA 1500 - the standard form used to submit claims for air amb lance comm nicative

claims for air ambulance, communicative disorders, Medicare Part B services, and physician clinics.

• Eligible Expenses- the agreed upon fee for health services and supplies covered under a health services and supplies covered under a health plan. This ensures reasonable and fair prices.

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Fee Schedule- a listing of accepted fees or established allowances for specific medical established allowances for specific medical procedures. As used in medical care plans, it usually represents the maximum amount the

Insurance company will pay for services such as lab and radiology.

– The Fee Schedule lists Eligible Expenses.g p

• Per Diem- a negotiated daily payment for delivery of hospital services provided This delivery of hospital services provided. This usually refers to “room and board” charges.

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Premium- a patient’s regularly scheduled

pa ment for ins rance coverage to Medicare an payment for insurance coverage to Medicare, an insurance company, or health plan.

• Out-of-Pocket- non-reimbursable expenses patients are responsible to pay for services received from Provider.

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Reimbursement - the amount of cash paid to the Provider by Patients and Payers for

the Provider by Patients and Payers for healthcare services.

R C l ll d i i i d li i l

• Revenue Cycle - all administrative and clinical functions that contribute to the collection of payment for services provided to the patient. • Self-pay - the portion of bill to be paid in part

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Financial Terminology in Healthcare

Financial Terminology in Healthcare

• Tertiary Payer – the insurer or entity with third priority of payment for a bill, after the primary and secondary payers.

• Uniform Billing Code - a federal directive requiring hospitals to follow specific billing requiring hospitals to follow specific billing

Figure

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