Glossary
Last Updated on August 15, 2023
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1. Accounts Receivable (AR)
Money owed to a healthcare provider by patients or insurers after services have been delivered.
2. Appeal
A request to a payer to reconsider a denied or underpaid claim.
3. Automation
The use of technology to perform tasks like coding, claims processing, and AR follow-up with minimal human input.
4. Base Payment Rate
Base payment rate is the predetermined amount established by payers for specific healthcare services, serving as the starting point for reimbursement calculations.
5. Benchmarking
Benchmarking is the process of comparing an organization's performance metrics against industry standards to identify areas for improvement.
6. Beneficiary
Beneficiary is an individual or entity who receives healthcare services and is eligible to receive benefits from a health insurance plan or government program.
7. Benefit period
Benefit period is the specific timeframe during which an insurance policyholder is eligible to receive benefits for covered healthcare services.
8. Bundled payment
Bundled payment is a reimbursement model where healthcare providers receive a single payment for a group of services related to a specific episode of care.
9. Bundling
Bundling is the process of grouping multiple healthcare services or procedures together and billing them as a single unit for reimbursement purposes.
10. Charge Capture
Recording of services provided so they can be billed accurately.
11. Claim Denial
A payer’s refusal to reimburse a claim in full or in part.
12. Compliance
Adherence to regulations and payer requirements (e.g., HIPAA, CMS).
13. Days in AR
Average time taken to collect payments after claim submission.
14. Denial Management
Prevention, identification, and resolution of denied claims.
15. Documentation
Provider notes and clinical records supporting billed services.
16. Eligibility Verification
Confirming patient insurance coverage before treatment.
17. EHR (Electronic Health Record)
Digital version of a patient’s medical history and clinical information.
18. Explanation of Benefits (EOB)
Statement from a payer showing claim outcomes and patient responsibility.
19. First-Pass Resolution Rate (FPRR)
Percentage of claims paid without resubmission or appeal.
20. Fee-for-Service (FFS)
Traditional model where providers are reimbursed per service delivered.
21. Front-End
Revenue cycle activities before care is provided (registration, eligibility, authorization).
22. Guarantor
Person responsible for paying a patient’s bill (often the patient or parent/guardian).
23. Gap Analysis
Identifying performance shortfalls between current and desired outcomes.
24. HCC (Hierarchical Condition Category)
Risk adjustment model for predicting healthcare costs.
25. HIPAA
Law governing patient privacy and data protection.
26. Healthcare Analytics
Use of data insights to optimize clinical and financial outcomes.
27. ICD-10-CM
International Classification of Diseases, 10th Edition, Clinical Modification used for diagnosis coding.
28. Integrity Audits
Reviews ensuring coding, billing, and documentation accuracy.
29. Insurance Verification
Checking coverage details with a payer before services.
30. Justification of Services
Documentation that proves services are medically necessary.
31. J-Codes
Part of the HCPCS coding system used for injectable drugs.
32. Key Performance Indicators (KPIs)
Metrics measuring RCM success, such as denial rate and net collection rate.
33. Knowledge Management
Sharing institutional expertise to improve RCM efficiency.
34. Lag Days
Time between patient discharge and claim submission.
35. Lean Six Sigma
Process improvement methodology applied to RCM to reduce errors and waste.
36. Ledger Balance
Total outstanding charges owed by a patient.
37. Mid-Cycle
The stage involving coding, documentation, and charge capture.
38. Medical Necessity
Services deemed reasonable and necessary for patient care and reimbursement.
39. Modifier
Code used to provide additional information about a procedure or service.
40. Net Collection Rate
Percentage of expected reimbursement actually collected.
41. NPI (National Provider Identifier)
Unique ID for healthcare providers in the U.S.
42. No-Show
Patient who misses a scheduled appointment, often impacting billing cycles.
43. Out-of-Pocket Costs
Patient’s direct payment responsibility (deductibles, co-pays, coinsurance).
44. Outsourcing
Contracting external vendors for RCM services.
45. Outstanding Claims
Claims submitted but not yet paid or denied.
46. Patient Access
The entry point of RCM, including scheduling, registration, and financial counseling.
47. Prior Authorization
Payer approval before delivering certain services.
48. Point-of-Service (POS) Collections
Collecting patient payments at the time of care.
49. Quality Reporting
Submitting clinical and operational data to CMS or payers for incentives.
50. Query (Coding Query)
A request for clarification from clinicians to ensure accurate coding.
51. Revenue Cycle Management (RCM)
Process of managing financial aspects of patient care, from scheduling to payment.
52. Risk Adjustment
Method for aligning payment with patient risk levels.
53. Remittance Advice (RA)
Explanation from a payer about claim payment decisions.
54. Self-Pay
Payments made directly by patients without insurance involvement.
55. Secondary Insurance
Additional insurance that covers costs not paid by primary insurance.
56. Scrubber (Claim Scrubber)
Software that checks claims for errors before submission.
57. Telehealth
Remote delivery of healthcare services using digital platforms.
58. Transparency in Billing
Providing patients clear, upfront cost and billing details.
59. Transaction Code Set
Standardized codes for healthcare transactions.
60. Utilization Review
Evaluating necessity and efficiency of healthcare services.
61. Underpayment
Payment received that is less than the contracted rate.
62. Upcoding
Assigning a higher-level code than documentation supports (compliance risk).
63. Value-Based Care
Model focusing on outcomes and cost efficiency rather than service volume.
64. Verification of Benefits (VOB)
Confirming specific coverage details of a patient’s plan.
65. Virtual Assistant (RCM)
AI-powered tools that assist with claim processing or AR tasks.
66. Write-Off
Adjustment of charges deemed uncollectible or contractually disallowed.
67. Work Queue
Digital workflow management for claims, denials, or follow-ups.
68. Workforce Optimization
Strategies to maximize efficiency and productivity of RCM staff.
69. X12 Transactions
Electronic data interchange (EDI) standards for healthcare claims (e.g., 837 claim file).
70. X-Mod (Experience Modifier)
Insurance rating factor used to calculate premiums (sometimes referenced in employer healthcare costs).
71. Year-to-Date (YTD)
Cumulative measure of financial or operational performance.
72. Yield Rate
The ratio of successful claims processed vs. total submitted.
73. Zero-Balance Account
Patient account where all balances have been resolved.
74. Z-Codes
ICD-10 codes used for social determinants of health and other factors influencing care.
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