Healthcare Payer & Providers Glossary

Healthcare fraud can be committed by patients, providers, or payers who intentionally deceive the healthcare system, implicating false claims, actions, or documents to obtain financial gain or unauthorized benefits.

The global payment method involves a lump sum amount paid to physician groups per patient for a specific period, regardless of the actual care provided.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that offers provisions for data privacy and security to safeguard sensitive patient medical information and prevent it from being disclosed without the patient's consent or information.

The ICD-10 Coordination and Maintenance Committee (C&M) is a federal interdepartmental group that maintains and updates ICD-10-CM and ICD-10-PCS code sets.

Limitation refers to the lack of capacity or restrictions imposed that may hinder the performance of revenue cycle management (RCM) processes in healthcare.

A Major Complication and Comorbidity (MCC) is essentially any serious secondary diagnosis that increases the complexity of a patient's condition. As a result, it also increases the resources required to treat it.

Medicaid is a collaborative federal and state program that covers medical costs for people with limited income and resources.

Comprehensive medical billing guide. Learn all the essential tips needed handcrafted by medical billing experts.

A medical billing clearinghouse improves claim processing speed and accuracy. Learn everything you need to know about a medical billing clearinghouse here.

Learn about denials in medical billing, including denial codes, effective management, and prevention techniques.

Get an in-depth understanding on medical coding. Learn all the essential tips needed handcrafted by medical coding experts.

Explore how medical coding automation enhances accuracy, reduces costs, and streamlines RCM processes for healthcare providers.

Outsourcing medical coding streamlines revenue cycle management, reduces costs, improves accuracy, and ensures compliance. Learn how outsourcing enhances overall efficiency.

Medical coding software changes how coders work. Learn everything you need to know about medical coding software here.

The Beveridge Model of Health Care is a system in which the government provides healthcare to all citizens through income tax payments.

An open enrollment period refers to the window of time that occurs once a year when you can sign up for health insurance, modify your current plan, or cancel your plan.

A Participating Physician (PAR) is a healthcare provider who has entered into an agreement with an insurance company to accept the insurer’s approved amount as full payment for covered services. This essentially means PAR physicians agree to the reimbursement rates set by the insurer and typically handle claims submission directly.

Patient registration is the process of enrolling a patient's name and identity into the hospital records to keep track of services provided to each patient.

A physician query is an official request made by a medical coder for additional information from the provider.

Healthcare reimbursements incorporate the process of compensating providers or physicians for the care provided by insurance payers.

A revenue code is a numeric code that is used in medical billing. It indicates the type of service or department that provided care to a patient. It is also assigned on the UB-04 (CMS-1450) claim form and helps payers gain clarity about the services rendered and other associated details.

Explore how revenue cycle flowchart helps streamline processes, improves collaboration, and clarifies interdependencies.

Looking for detailed information on healthcare RCM? This comprehensive guide has everything you need to know about revenue cycle management.

Learn how automation in RCM can improve efficiency and productivity for healthcare providers in this guide.

Learn everything about outsourcing RCM in this guide. Healthcare providers get answers to all their questions.

Enacted in 1935, the Social Security Act provides benefits for old-age retirees, dependent mothers and children, the jobless, victims of work-related accidents, blind people, and people who have physical disabilities.

A third-party payer is an entity, such as a private insurance company or a government-funded program like Medicaid or Medicare, that is responsible for reimbursing providers for care provided to patients.

Unbundling in healthcare refers to the process of separating and billing different healthcare service components that are bundled together.

The Veterans Health Administration (VHA) is the largest government agency that offers specialized care, primary care, and related social and medical support services to the U.S. veterans.

The waiting period in healthcare is the duration for which you have to wait before getting benefits, which begins from the date of policy commencement.