CHBME flashcards
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32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Revenue cycle
- The end-to-end financial process from patient scheduling through final payment, including registration, coding, charge capture, claim submission, denial management, and collections.
- Net revenue
- Gross charges minus contractual adjustments, discounts, bad debt, and charity care; the amount an organization actually expects to collect for services rendered.
- Days in A/R
- Total accounts receivable divided by average daily gross charges; measures how long receivables remain outstanding and signals collection efficiency.
- Clean claim rate
- The percentage of claims accepted on first submission without edits or rejection; a core front-end and coding accuracy indicator.
- Denial rate
- The proportion of submitted claims that payers deny; commonly segmented into front-end, clinical, and coding denial categories for targeted correction.
- Net collection ratio
- Payments received divided by net allowed revenue after contractual adjustments; a value near 95-100% indicates effective collection of collectible balances.
- Gross collection ratio
- Payments received divided by gross charges billed; lower than the net ratio because it includes contractual write-offs and discounts.
- Point-of-service collection
- Collecting copays, coinsurance, and deductible estimates at or before the visit, reducing later bad debt and patient balance follow-up.
- Charge capture
- The process of recording all services, supplies, and procedures delivered so they can be coded and billed; missed charges are typically unrecoverable.
- Prior authorization
- Payer approval obtained before certain services; missing or expired authorization is a common cause of front-end denials.
- Eligibility verification
- Confirming coverage, benefits, and cost-sharing before service to prevent denials and to set accurate patient financial expectations.
- Contractual adjustment
- The difference between billed charges and the payer-allowed amount under a contracted rate; written off and not billed to the patient.
- Claim scrubber
- Software that edits claims for coding, modifier, and payer-specific rules before submission, improving first-pass acceptance rates.
- Explanation of benefits
- Payer document showing allowed amounts, payments, adjustments, and patient responsibility; used to post payments and identify denials.
- Appeal
- A formal request to reconsider a denied claim, often requiring clinical documentation and adherence to payer deadlines and levels.
- Write-off
- Removing an uncollectible or non-billable balance from accounts receivable, such as contractual adjustments, charity care, or small balances.
- Aged A/R report
- A report grouping outstanding receivables by age buckets (0-30, 31-60, 61-90, 90+ days) to prioritize follow-up.
- Medical necessity denial
- A payer determination that a service was not clinically justified; overturned with documentation supporting the service and diagnosis.
- Bundling edit
- A rule that combines component services into one payable code, such as NCCI edits; unbundling without justification causes denials.
- Modifier
- A two-character code appended to a CPT or HCPCS code to clarify circumstances, such as distinct service, laterality, or reduced service.
- Copayment
- A fixed dollar amount the patient pays at the time of service, separate from deductible and coinsurance obligations.
- Coinsurance
- The patient's percentage share of allowed charges after the deductible is met, such as 20% under many plans.
- Deductible
- The amount a patient must pay out of pocket before insurance begins paying for covered services.
- Allowed amount
- The maximum amount a payer will recognize for a covered service under its fee schedule or contract; basis for payment calculations.
- EOB versus remittance advice
- The EOB explains benefits to the patient; the remittance advice (ERA/835) transmits payment and adjustment details to the provider.
- Front-end denial
- A denial caused by registration, eligibility, or authorization errors rather than clinical or coding issues; preventable before service.
- Coding denial
- A denial due to incorrect, missing, or inconsistent codes or modifiers; corrected by reviewing documentation and resubmitting.
- Underpayment
- Payment below the contracted allowed amount; identified by comparing remittance to contract terms and pursued through reconsideration.
- Charity care
- Free or discounted care provided to eligible low-income patients under financial assistance policy; excluded from collectible revenue.
- Bad debt
- Unpaid patient balances deemed uncollectible after reasonable collection efforts; distinct from contractual adjustments and charity care.
- Cost-to-collect
- The total expense of billing and collection operations divided by total collected revenue; a measure of revenue cycle efficiency.
- First-pass resolution rate
- The percentage of claims paid on initial submission without denial or rework; a leading indicator of revenue cycle health.