Billing and Review Perspectives in Healthcare

Billing and Review Perspectives in Healthcare

Joel Fredrickson
Copyright: © 2020 |Pages: 50
DOI: 10.4018/978-1-7998-2310-0.ch002
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The relatively recent and more pervasive retention of electronic healthcare data has provided new opportunities for the advancement of analytics and business intelligence tools within healthcare. The tasks comprising the delivery process for healthcare provide numerous points for data capture, and associated analyses to improve efficiencies and quality of care. In general, healthcare data is extracted from transaction-based systems designed for billing, scheduling, and workflow. However, data characterizing medical events can be further leveraged to assist in the diagnosis and treatment of patients. In fact, healthcare information technology (HIT) to improve patient diagnosis and treatment is remarkably neglected. This chapter outlines the process flow for healthcare delivery, describes the data extracted during this process flow, details the enablers and inhibitors of HIT and accompanying analytics, presents concerns about data integrity and quality, and provides some methods for data cleansing and staging.
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Healthcare Process Overview

Revenue Cycle Management

The healthcare delivery process is structured according to a “revenue cycle” and related management systems. The revenue cycle entails all facets of a patient’s account, from its inception to payment. It integrates every aspect of a healthcare provider’s clinical and financial operations. Specifically, healthcare revenue cycle management is the financial process used by providers to administer functions associated with patient care, from scheduling and account creation to billing and final payment. Figure 1 shows the primary process steps in the healthcare “revenue cycle”.

Figure 1.

Healthcare revenue cycle management



The process of healthcare delivery consists of numerous stakeholders. The behavior of each stakeholder impacts other stakeholders, and the efficiency and outcomes of the revenue cycle. Roughly, there are four major groups of stakeholders in the healthcare delivery process. They are policy makers, patients, providers/facilities and payers. Each of these stakeholders is described below.

Key Terms in this Chapter

NCHSR: National Center for Health Services Research and Healthcare Technology Assessment.

ANP: Adult Care.

HITECH: Health Information Technology for Economic and Clinical Health Act.

ACG: Adjusted Clinical Groups.

PM-DRG: Pediatric Modified DRG.

CPT: Current Procedural Terminology.

CRNA: Certified Registered Nurse Anesthetists.

FNP: Primary Care Provider in Family Medicine.

HER: Electronic Health Record.

ADG: Adjusted Diagnosis Groups.

HCC: Hierarchical Condition Category.

HIT: Health Information Technology.

MACRA: Medicare Access and CHIP Reauthorization Act.

LPN: Licensed Practical Nurse.

PNP: Pediatrics.

DO: Doctor of Osteopathic Medicine.

DMEPOS: Durable Medical Equipment, Prosthetics, Orthotics and Supplies.

Cc: Condition Categories.

FHIR: Fast Healthcare Interoperability Resources.

OHDSI: Observational Health Data Sciences and Informatics.

NDC: National Drug Code.

ICD: International Classification of Diseases.

FFS: Fee For Service.

ANSI: American National Standards Institute.

ONC: Office of the National Coordinator for Health Information Technology.

SNOMED: Systematized Nomenclature of Medicine.

WHO: World Health Organization.

HIC: Hierarchical Ingredient Code.

EMR: Electronic Medical Record.

TAM: Technology Acceptance Model.

HMO: Health Maintenance Organization.

MEG: Medstat Episode Grouper or Medical Episode Grouper.

CMS: Centers for Medicaid and Medicare Services.

PA: Physician Assistant.

NAHCRI: National Association of Children’s Hospitals and Affiliated Institutions.

PPACA: Patient Protection and Affordable Care Act.

MS-DRG: Medicare Severity Diagnosis Related Group.

NP: Nurse Practitioner.

DRG: Diagnosis Related Group.

CAH: Critical Access Hospitals.

ACHILLES: Automated Characterization of Health Information at Large-scale Longitudinal Exploration System.

HIE: Health Insurance Exchange.

PCP: Primary Care Provider.

HCPCS: Healthcare Common Procedure Coding System.

OMOP: Observational Medical Outcomes Partnership.

PMPM: Per Member Per Month.

HL7: Health Level Seven International.

AMA: American Medical Association.

RCM: Revenue Cycle Management.

HIPAA: Health Insurance Portability and Accountability Act.

AP-DRG: All-Payer DRG.

CNM: Certified Nurse Midwife.

PHI: Protected Health Information.

MIPS: Merit-Based Incentive Payment System.

RN: Registered Nurses.

HMO: Managed Care (Health Maintenance Organizations).

GNP: Geriatrics.

CNS: Clinical Nurse Specialists.

NCQA: National Committee for Quality Assurance.

pps: Prospective Payment System.

APR-DRG: All Payer Refined DRG.

NTIS: National Technical Information Service.

OB/GYN: Obstetrician/Gynecologists.

ETG: Episode Treatment Groups.

MMA: Medicare Modernization Act.

PPO: Preferred Provider Organizations.

ACA: Affordable Care Act.

DCG: Diagnostic Cost Groups.

ARRA: American Recovery and Reinvestment Act.

FDA: Food and Drug Administration.

MPC: Major Practice Category.

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