Revenue Cycle Management Terms definition and
summary
Revenue Cycle Management/Accounts Receivable Management - The process by
which health care facilities and providers ensure their financial viability by increasing
revenue, improving cash flow, and enhancing the patient's experience.
Claims Rejections - Unpaid claims that fail to meet certain data.
Claims Denials - Unpaid claims that contain beneficiary identification errors, coding
errors, diagnoses that do not support medical necessity of procedures/services
performed, duplicate claims, global days of surgery E/M coverage issues, national
correct coding initiative edits and outpatient code editor issues, and other patient
coverage issues.
Quarterly Provider Updates (QPUs) - Regulations and major policies implemented or
cancelled, new and revised manual instructions, regulations that establish or modify the
way CMS administers its programs.
Utilization Management/Utilization Review - Method of controlling healthcare cost and
quality of care by reviewing the appropriateness and necessity of care provided to
patients prior to the administration of care or after care has been provided.
Prospective Review - Prior to the administration of care.
Retrospective Review - After care has been provided.
Preadmission Certification (PAC)/Preadmission Review - Review for medical
necessity of inpatient care prior to the patient's admission.
Preauthorization/Precertification/Prior Approval/ Prior Authorization - Review by
health plans to grant prior approval for reimbursement of health care services.
Concurrent Review - Review for medical necessity of tests and procedures ordered
during an inpatient hospitalization.
Discharge Planning - Arranging appropriate healthcare services for the discharged
patient.
Revenue Cycle Monitoring - Assessing the revenue cycle to ensure financial viability
and stability using metrics.
, Metrics - Standards of measurement
Revenue Cycle Auditing - An assessment process that is conducted as a follow-up to
revenue cycle monitoring so that areas of poor performance can be identified and
corrected.
Resource Allocation - Distribution of financial resources among competing groups.
Resource Allocation Monitoring - Uses data analytics to measure whether a health
care provider or organization achieves operational goals and objectives within the
confines of the distribution of financial resources, such as appropriately expending
budgeted amounts as well as conserving resources and protecting assets while
providing quality patient care.
Data Analytics - Tools and systems that are used to analyze clinical and financial
data, conduct research, and evaluate the effectiveness of disease treatments.
Data Warehouses - Databases that use reporting interfaces to consolidate multiple
databases, allowing reports to be generated from a single request.
Data Mining - Extracting and analyzing data to identify patterns, whether predictable
or unpredictable.
Encounter Form/Superbill - Financial record source document used by health care
providers and other personnel to record treated diagnoses and services rendered to the
patient during the current encounter.
Chargemaster/Charge Description Master (CDM) - Document that contains a
computer-generated list of procedures, services, and supplies with charges for each.
Revenue Code - A four-digit code preprinted on a facility's chargemaster to indicate
the location or type of service provided to an institutional patient.
Chargemaster Maintenance - Process of updating and revising key elements of the
chargemaster to ensure accurate reimbursement.
Chargemaster Team - Jointly shares the responsibility of updating and revising the
chargemaster to ensure its accuracy and consists of representatives of a variety of
departments, such as coding compliance financial services, health information
management, information services, other departments, and physicians.
Clearinghouse - An agency or organization that collects, processes, and distributes
claims.
Accept Assignment - The provider agrees to accept what the insurance company
approves as payment in full for the claim.
summary
Revenue Cycle Management/Accounts Receivable Management - The process by
which health care facilities and providers ensure their financial viability by increasing
revenue, improving cash flow, and enhancing the patient's experience.
Claims Rejections - Unpaid claims that fail to meet certain data.
Claims Denials - Unpaid claims that contain beneficiary identification errors, coding
errors, diagnoses that do not support medical necessity of procedures/services
performed, duplicate claims, global days of surgery E/M coverage issues, national
correct coding initiative edits and outpatient code editor issues, and other patient
coverage issues.
Quarterly Provider Updates (QPUs) - Regulations and major policies implemented or
cancelled, new and revised manual instructions, regulations that establish or modify the
way CMS administers its programs.
Utilization Management/Utilization Review - Method of controlling healthcare cost and
quality of care by reviewing the appropriateness and necessity of care provided to
patients prior to the administration of care or after care has been provided.
Prospective Review - Prior to the administration of care.
Retrospective Review - After care has been provided.
Preadmission Certification (PAC)/Preadmission Review - Review for medical
necessity of inpatient care prior to the patient's admission.
Preauthorization/Precertification/Prior Approval/ Prior Authorization - Review by
health plans to grant prior approval for reimbursement of health care services.
Concurrent Review - Review for medical necessity of tests and procedures ordered
during an inpatient hospitalization.
Discharge Planning - Arranging appropriate healthcare services for the discharged
patient.
Revenue Cycle Monitoring - Assessing the revenue cycle to ensure financial viability
and stability using metrics.
, Metrics - Standards of measurement
Revenue Cycle Auditing - An assessment process that is conducted as a follow-up to
revenue cycle monitoring so that areas of poor performance can be identified and
corrected.
Resource Allocation - Distribution of financial resources among competing groups.
Resource Allocation Monitoring - Uses data analytics to measure whether a health
care provider or organization achieves operational goals and objectives within the
confines of the distribution of financial resources, such as appropriately expending
budgeted amounts as well as conserving resources and protecting assets while
providing quality patient care.
Data Analytics - Tools and systems that are used to analyze clinical and financial
data, conduct research, and evaluate the effectiveness of disease treatments.
Data Warehouses - Databases that use reporting interfaces to consolidate multiple
databases, allowing reports to be generated from a single request.
Data Mining - Extracting and analyzing data to identify patterns, whether predictable
or unpredictable.
Encounter Form/Superbill - Financial record source document used by health care
providers and other personnel to record treated diagnoses and services rendered to the
patient during the current encounter.
Chargemaster/Charge Description Master (CDM) - Document that contains a
computer-generated list of procedures, services, and supplies with charges for each.
Revenue Code - A four-digit code preprinted on a facility's chargemaster to indicate
the location or type of service provided to an institutional patient.
Chargemaster Maintenance - Process of updating and revising key elements of the
chargemaster to ensure accurate reimbursement.
Chargemaster Team - Jointly shares the responsibility of updating and revising the
chargemaster to ensure its accuracy and consists of representatives of a variety of
departments, such as coding compliance financial services, health information
management, information services, other departments, and physicians.
Clearinghouse - An agency or organization that collects, processes, and distributes
claims.
Accept Assignment - The provider agrees to accept what the insurance company
approves as payment in full for the claim.
