PMRP flashcards

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, spanning front-end access, mid-cycle coding and charge capture, and back-end billing, denials, and collections.

False Claims Act

Federal statute imposing treble damages and per-claim civil penalties on entities that knowingly submit false or fraudulent claims to government payers.

Anti-Kickback Statute

Criminal law prohibiting remuneration intended to induce referrals of items or services payable by federal health care programs; violations can lead to exclusion and penalties.

Stark Law

Civil strict-liability statute barring physician self-referral for designated health services reimbursed by Medicare, absent a regulatory exception.

EMTALA

Federal law requiring hospitals with emergency departments to provide a medical screening exam and stabilizing treatment regardless of the patient's ability to pay.

Real-time eligibility

An X12 270/271 transaction that verifies a patient's coverage, benefits, copay, deductible, and network status with the payer before service.

Prior authorization

Payer approval obtained before a service is rendered; the authorization number and effective dates must be documented on the account to prevent denial.

Advance Beneficiary Notice

A Medicare form signed before service informing the patient that an item may not be covered and that they may be financially liable.

Financial counseling

The process of estimating patient responsibility, screening for Medicaid or charity care, and establishing payment plans before or at the point of service.

MS-DRG

Medicare Severity Diagnosis Related Group; the inpatient prospective payment classification determined by principal diagnosis, secondary diagnoses, procedures, and discharge disposition.

Present on Admission

A POA indicator (Y, N, U, W, or 1) reported on inpatient claims to identify conditions present when the patient was admitted; affects HAC payment and quality reporting.

CDI query

A non-leading physician communication requesting clarification or additional documentation to support accurate diagnosis and procedure coding, based on clinical indicators.

Modifier 25

A CPT modifier appended to an evaluation and management code to indicate a significant, separately identifiable service was performed on the same day as a procedure.

Clean claim rate

The percentage of claims accepted on first submission without rejection or edit; a key front-end and coding quality indicator.

NCCI edits

National Correct Coding Initiative edits, including procedure-to-procedure and medically unlikely edits, that prevent unbundling and overutilization on claims.

CO-16 denial

A claim adjustment reason code indicating the claim lacks information or contains invalid data needed for adjudication; often caused by registration or coding errors.

Coordination of benefits

The process of determining payer order and billing primary, secondary, and tertiary payers in sequence with supporting remittance advice.

Denial rate

The percentage of submitted claims denied by payers; used to measure revenue cycle performance and prioritize root-cause improvement.

Medical necessity appeal

A formal appeal supported by clinical documentation and payer criteria challenging a denial that a service was not medically necessary.

CO-197 denial

A claim adjustment reason code indicating precertification or authorization was absent; often preventable through front-end authorization verification.

Days in A/R

A measure of how long receivables take to collect, calculated as total A/R divided by average daily charges over a period.

A/R aging

The classification of outstanding receivables into time buckets (0-30, 31-60, 61-90, 91-120, 120+ days) to prioritize collection follow-up.

Charity care

Free or discounted care provided under a hospital's financial assistance policy to patients who cannot pay; distinct from bad debt.

835 ERA

The X12 electronic remittance advice transaction that reports claim payments, contractual adjustments, patient responsibility, and denial reason codes.

Underpayment detection

The process of comparing posted allowed amounts against contracted rates to identify and recover payer shortfalls.

Credit balance

An account state in which payments exceed charges or expected reimbursement, requiring investigation and possible refund or escheatment.

Net collection rate

Payments divided by charges minus contractual adjustments; a measure of how much of the collectible revenue is actually collected.

First-pass yield

The percentage of claims paid on first submission without denial, rework, or appeal; a key efficiency and quality metric.

Cost to collect

Total revenue cycle operating cost divided by net patient revenue; measures the efficiency of the billing and collection process.

HIPAA Security Rule

Regulation requiring administrative, physical, and technical safeguards to protect electronic protected health information, including a mandatory risk analysis.

Breach notification

The HIPAA requirement to notify affected individuals within 60 days of discovering a breach and to notify HHS, with additional rules for breaches affecting 500 or more people.

FHIR

A modern HL7 interoperability standard using RESTful APIs to exchange health data, supporting patient access and health information exchange.