Finance Terms/Glossary
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
80/20 Rule: A "rule of thumb" that 80 percent of resources are consumed in the process of producing 20 percent of the procedures or services.
A2K3: Seimens Medical System
(SMS) tool for accessing computerized patient information, including
census, registration, and billing data.
AARP: Insurance for the American Association of
Retired Persons. This plan offers supplementary coverage for retired
persons on Medicare.
Account ID (PeopleSoft Account ID): A four-digit
number that is one of the valid general ledger accounts, e.g., 2220 is
Staff Salary.
Accrual-basis Accounting: A system of accounting in
which revenues and expenses are recorded as they are earned and
incurred, not necessarily when cash is received or paid.
Admission Date: The date in which a patient is checked
into the hospital for care.
Administrators: The top business/operations managers
over clinical areas such as the Heart Center, Cancer Center, and the
Women's Place.
Adobe Acrobat Reader: Computer software that allows
you to open and view Portable Document Format files (or PDF
files).
Advanced Beneficiary Notice (ABN): A notice given to a
Medicare beneficiary to sign in the following cases:
A doctor gives a patient a service that the doctor believes Medicare does not consider medically necessary; and
A doctor gives a patient a service that the doctor believes Medicare will not pay for.
If a patient does not get an ABN to sign before receiving the service and Medicare does not pay for it, then the patient does not have to pay for it. If the doctor does give the patient an ABN that is signed before receiving the service and Medicare does not pay for it, then the patient will have to pay for it.
"Agencies": This is when insurance coverage for a specific category of people is offered through a special agency, such as CSS/Children's Specialty Services or Western State.
A-Gram: Arterial Gram
Allocation: The process of taking costs from one
area or cost objective and allocating them to others.
Amortization: The process of cost allocation that assigns the
original cost of an intangible asset to the periods benefited.
Ancillary Services: Additional services performed
related to patient care, such as lab work, x-ray and anesthesia.
APC (Ambulatory Payment Classification): A prospective
payment system developed by HCFA for hospital outpatient services in
which CPT codes are assigned to specific APC groups based on similar
resource utilization. These groups are assigned relative payment
weights based on the median costs of the services.
APS: Acute Pain Service
Average Cost or Unit Cost: Cost divided by
volume.
Audited Financials: The official fiscal year end financial
reports such as the income statement, balance sheet, and cash flow
statement that have been scrutinized by an independent auditor and
judged to be in accordance with generally accepted accounting
principles.
Authorization System: An organized set of controls used by managed care plans to ensure appropriate utilization of resources; can be referrals, pre-authorizations or pre-certifications.
Authorized Signatory: A legal guardian or an
individual who has "Power of Attorney" for another individual. This
person can sign legal documents on behalf of the individual. Some
people might have an authorized signatory because they are disabled, or
illiterate. The signatory may sign below an "X" that the illiterate or
disabled person has marked on the signature area of a document.
Bad Debt: An uncollectible
account receivable.
Balance Billing: A provider's billing of a covered
person for charges above the amount reimbursed by the health plan. For
example, the difference between billed charges and the amount paid.
This procedure may or may not be appropriate, depending upon the
contractual arrangement between the parties.
Balance Sheet (Statement of Financial Position): The
financial statement that reports a company's assets, liabilities, and
owners' equity at a particular date.
Blue Cross/Blue Shield Plans: An insurance company
that offers both indemnity and managed care plans. Blue Cross is the
hospital portion of the coverage; Blue Shield is the outpatient
portion.
Budget: A plan that provides a formal, quantitative
expression of management's plans and intentions or expectations.
Budget Amendment: A formal revision or update to a
department's budget.
Capital Reports: The Capital
Reports follow the expenditures of capital funds for ongoing projects
throughout the Medical Center by administrative area. The Capital
Reports present expenses, committed funds and project balances.
Capitation: A set amount of money received or paid out
as prepayment for services. It takes into account expected costs in
defined categories. It is based on membership, rather than on services
delivered. It is often expressed in units of "PMPM"- Per Member Per
Month. It may be varied by such factors as age and sex to accommodate
differences in average utilization patterns in those categories. In
managed care, PCP payments may be capitated; specialist payments are
usually discounted fee-for-service.
Case: A case is established to record, manage, and bill services that relate to the same episode of care. It includes such information as registration/admit date, discharge date, attending physician, service area, whether or not the visit is accident related, whether it's inpatient or outpatient, etc. Only information for insurance/s that provide coverage for services related to the care episode is included with each case. Each case is assigned a unique UVAH Account Number.
Case Management: A process whereby covered persons
with specific health care needs are identified and a plan which
efficiently utilizes health care resources is formulated and
implemented to achieve the optimum patient outcome in the most
cost-effective manner.
CCU: Coronary Care Unit
CDM Number: Charge Description Master number, an
8-digit number (7-digit service code with a check 1-digit check digit)
that identities specific medical supplies and procedures.
CDMvsREV3: A report that combines CDM and revenue data
by year-to-date and month.
Centers for Medicare & Medicaid Services (CMS): The
federal agency that runs the Medicare program. In addition, CMS works
with the States to run the Medicaid program.
Center ID (or GL Key): A four-digit general ledger
number that corresponds to a particular department, e.g., 2002 is the
Delivery Room.
Charge: Rate or fee for a service.
Charge Capture System: A computer information system
that is used to record revenue activities such as the use of medical
supplies or the occurrence of a surgical procedure.
Charge Description Master (CDM): A table within SMS
which houses the GL Key, Charge Description, Price, Service Code, CPT
Code, Revenue Code, and whether a code is Active or Inactive (see CDM
Number).
Check Digit: (See CDM Number)
Claim: A claim is a request made to insurance carriers
for payment for services and benefits you received.
Claim Edits: These are checkpoints programmed into the
system to catch certain claim errors before they go out the door to the
insurance companies.
"Clean Claim": A clean claim is a claim that goes
out to the insurance company without any mistakes or missing
information.
CMC: Children's Medical Center
Code Manager: Computer software tool to assist in identifying
appropriate CPT and HCPCS codes.
Co-insurance: The percentage of the insurance-approved
amount that you have to pay after you pay any deductible.
Commercial Insurance Plans: Traditional indemnity
plans where patients have the freedom to choose whatever provider they
wish to see. The insurance usually pays a certain percentage of the
charges, with the patient paying the remainder.
Consult: A communication from one physician to another concerning a patient's medical condition and/or recommendations or requests for further consultation or treatment.
Contra Account: An account that is offset or deducted from another account.
Contractual Adjustment: The difference between the insurance contracted amount and the charge amount.
COPATH: Pathology charge-capture and information system.
Copay: A pre-determined flat fee that the patient pays for certain health care services at the time of service. It does not vary with the cost of the service.
Cost: The amount spent to acquire an asset. Costs have two stages: acquisition cost and expired cost. When some asset or service is purchased, the resources given in exchange represent the acquisition cost. Once the asset is fully consumed, it becomes an expired cost, or an expense.
Cost Accounting: An accounting subset that involves a mixture of management and financial accounting to measure costs and generate cost information for reporting and making management decisions. Cost accounting derives its information from internal sources. Cost Accounting provides decision support information aimed at reducing costs, increasing productivity, enhancing revenue and increasing profit.
Cost Center: An organizational unit, recognized in the chart of accounts, for which relevant expenses and revenues are accumulated. Also known as Department Number or GL Key.
Cost Driver: Any factor having an effect on cost.
Cost Object: Any item for which a cost measurement is need to help decision-making.
Coverage Type: This refers to what kind of service is covered. Some examples of different coverage types are hospital, physician, Major Medical, surgical, dental, vision, and prescription.
Covered Benefit: A health service or item that is included in your health plan and is paid for either fully or partially.
CPT Codes: Physician's Current Procedural Terminology codes are a list of medical services and procedures performed by physicians and other providers. Each service or procedure is identified by its own unique 5-digit code.
Crystal: A computer program used to generate reports from a data source.
Date of Service/DOS: The date that a patient receives service/s (the date of a patient's appointment).
Deductible: The amount an individual must pay for health care expenses, in a given year, before insurance begins to cover the costs.
Demographic Information: This is comprised of applicable information pertaining to the patient such as name, address, phone numbers, employer and emergency contact.
Depreciation: The process of cost allocation that assigns the original cost of plant and equipment to the periods benefited.
Diagnosis Related Groups (DRG): A way to pay hospitals for health care based on diagnosis, age, gender, and complications. An inpatient classification system where patients using similar resources are grouped together in specific DRG categories. Payment is made based on the relative weight assigned to the DRG.
Direct Costs: Costs that are directly attributable to providing patient care and clearly traceable to a unit of activity or cost center (e.g., nurse salaries, medical supplies and drugs). These costs are generally under the control of the manager.
Discharge Date: The date in which a patient is released from the hospital.
Durable Medical Equipment (DME): Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds.
ECG: Electrocardiograph. An instrument used in the detection and diagnosis of heart abnormalities that measures electrical potentials on the body surface and generates a record of the electrical currents associated with heart muscle activity. Also called cardiograph.
ECMO: Extracorporeal Membrane Oxygenation
Effective Date: The date a contract becomes in force.
EKG: Electrocardiogram
Emancipated Minor: An emancipated minor is a patient
under the age of 18 who is listed as his or her own guarantor. This
might be due to marriage or divorce; living independently and being
self-supporting; or being on active duty in the military.
EMG: Electromyogram. A graphic record of the
electrical activity of a muscle as recorded by an
electromyograph.
Encounter Form: Documentation of a face-to-face
meeting between a patient and a health care provider where services are
provided. This is the form that the bill will be derived from.
ENT: Ear Nose and Throat
EOB (Explanation of Benefits): Explanation of payment
sent by the insurance company.
Essbase: Sometime during FY2003, Hyperion Essbase and
Analyzer software will be available to service center administrators.
Essbase is a data warehouse, and Analyzer is a web-based front-end
which will give administrators additional data analysis and drill down
capabilities on financial and decision support reports.
Expense: The cost of services provided; expired cost.
(See Cost)
Faculty Effort: A financial
report detailing where physicians spent their time during a fiscal
year. The Reimbursement department uses this report.
Federal HMO Act of 1973: An act that enabled managed
medical care plans to increase in numbers and expand enrollments
through health care plans financed by grants, contracts, and
loans.
Fellow: A physician who has completed his or her
residency and has chosen to go on and study a specialized medical
subject.
Financial Assistance: When a guarantor for an account
qualifies for a percentage adjustment based on a completed
financial assistance application (pdf link) and established
financial guidelines.
Financials: The financial reports such as the balance
sheet, income statement, and cash flow statement.
Fiscal Intermediary: A private company that has a contract
with Medicare to pay Part A and some Part B bills. (Also called
"Intermediary" and "FI".)
Fixed Costs: Resources that are not expected to change
as volume increases or decreases. Fixed costs are often associated with
overhead resources such as administration, finance and buildings.
Frequency (or Volume): The number of times a good or service was used.
FTE: Full Time Employee, calculated as 2,080 work hours a year.
FTP: File Transfer Protocol
Full Cost: The total cost of a department or procedure
is the sum of direct and indirect costs.
FY: Fiscal Year (July 1 through June 30)
FYE: Fiscal Year End
GCRC: General Clinical Research
Center
Generalists: Physicians who are distinguished by their
training as not limiting their practice by health condition or organ
system, who provide comprehensive and continuous services, and who make
decisions about treatment for patients presenting with undifferentiated
symptoms. They typically include family practitioners, general
internists, and general pediatricians.
GL Key (or Center ID): A four-digit general ledger
number that corresponds to a particular department, e.g., 2002 is the
Delivery Room.
Group Practice: The provision of medical services by
three or more physicians formally organized to provide medical
care.
Guarantor: The person responsible for paying the
bill. A person over the age of 18 is usually his or her own
guarantor.
HBSI: Healthcare Benchmarking
System, International
HCFA 1500 Claim Form: A universal form, developed by
the Health Care Financing Administration, for providers of services to
bill professional fees to health carriers.
HCPCS: (Pronounced "hick-picks) The acronym for the
HCFA (HealthCare Financing Administration) Common Procedure Coding
System. This system is a uniform method for health care providers and
medical suppliers to report professional services, procedures, and
supplies. There are three HCPCS levels; each has its own unique coding
system.
HCPCS (Level I): Level I is the American Medical
Association's (AMA) Current Procedural Terminology (CPT), which was
developed and is maintained by the AMA. CPT lists five-digit codes with
descriptive terms for reporting services performed by health care
providers and is the country's most widely accepted coding reference.
CPT was created in 1966 and is published annually.
HCPCS (Level II): HCPCS National codes are required
for reporting most medical services and supplies provided to Medicare
and Medicaid patients. The codes begin with a sing letter (A through V)
followed by four numeric digits. They are grouped by the type of
service or supply they represent and are updated annually by HCFA with
input from private insurance companies.
HCPCS (Level III): These are codes that are assigned
and maintained by individual state Medicare carriers. These codes begin
with a letter (W through Z) followed by four numeric digits.
Health Care Financing Administration/ HCFA: The
Federal agency responsible for administering Medicare and overseeing
states' administration of Medicaid.
HIF Date: The date the Historical Interface File is
run. During the first week of the month that begins with a Monday, the
HIF date is that week's Saturday.
HMO/Health Maintenance Organization: An HMO is an
organized system for providing comprehensive health care to large
groups of voluntarily enrolled members in a specific geographic area.
HMOs provide comprehensive care with no deductibles, and with limited
out-of-pocket costs such as low copays. Patients on HMO plans will
always have PCPs, and need referrals to see specialists or receive
services outside of the PCP's office. They will also need to see
in-network providers, or receive special plan authorization to seek
care outside of the network. Claims for non-referred covered specialty
services are not paid for by the plan, (unless the patient signed a
waiver form) and the member usually cannot be billed in such cases.
Hospice: A facility or program engaged in providing
palliative and supportive care of the terminally ill, and licensed,
certified or otherwise authorized pursuant to the law of jurisdiction
in which services are received.
Hyperion: A computer software company that provides
the UVA Medical Center with a software platform for budgeting (Hyperion
Pillar - maintained by the UVA Medical Center Budget Office) and
reporting (Hyperion Essbase and Analyzer- maintained by the UVA Medical
Center Finance Office of Internal Reports).
ICD-9 Diagnosis Codes:
International Classification of Diseases, 9th Edition codes. These are
standardized codes that physicians use in the diagnosis of
disease.
Income Statement: The Income Statement reports income
and expenditures at an institutional level for current year, budget,
and prior year.
Indemnity Insurance: Coverage offered by insurance
companies in which individual insured persons are reimbursed for
medical expenses by the company. Payments may be made to the individual
incurring the expense, or directly to the provider. These plans were
the traditional type of insurance before the advent of managed care.
The individual pays a pre-determined percentage of the cost of health
care services, and the insurance company pays the other percentage. A
typical split has the individual paying 20%, with insurance paying 80%.
The fees for services are defined by the providers, and vary from
physician to physician. The individual has the freedom to choose his or
her own physicians.
Indirect Costs: Costs that are associated with
providing support to patient care or other operations that do not
produce patient revenue (e.g., housekeeping, finance, information
systems, medical records, meals and laundry). Also called Allocated
Costs or Overhead.
Inpatient: (also abbreviated as Inpt or IP): A person
admitted to the hospital as a bed patient for more than a specific
number of hours. Care rendered to a patient that requires that the
patient be formally admitted to the hospital and confined to the
hospital during care. Inpatient designation usually requires 24 hours
of patient care or more. (Compare to Outpatient)
Inpatient Profitability Report: This is a SAS report,
which measures various revenue related fields for inpatient services.
It can be split out by Operational Service Center, physician, payor,
DRG and many other modalities.
Inpatient Repository Reports: The Inpatient Repository
Reports contain service center patient population data reported at
various summary levels (e.g., physician, payor and DRG).
Inpt: Inpatient (See Inpatient).
Insurance Carrier: An entity that may underwrite or
administer a range of health benefit programs.
Insurance Denial: Insurance has reviewed the claim and denied it for payment for a particular reason. It has made a determination not to pay on the claim. Some denials can be overturned, some cannot.
Insurance ID Number Suffix: Many insurance
companies will have a two digit suffix on the end of the member's ID
number that Identifies the relationship of the member to the
subscriber. They usually identify a status of self, spouse, or child.
Suffixes and what they mean vary by carrier.
Intern: A first year resident who has already
completed medical school.
Interns & Residents: A financial report detailing where interns and
residents spent their time during a fiscal year. This report is used
the Cost Accounting and Reimbursement departments.
IP: Inpatient (See Inpatient).
KCRC: Kluge Children's
Rehabilitation Center
Labels/Stickies for the Encounter
Form: Our system uses two kinds of sticky labels. Our larger
label contains the patient's demographic, insurance and encounter
information. The smaller sticker is billing-related information for
ancillary service requests. These are printed and applied to the
encounter form.
Late Charge Report: This report is generated by
Patient Financial services and measures those charges which have been
submitted in excess of the standard timeframe from patient encounter.
Access to the Q: drive is required to view this report.
Laundry & Linen: A statistical report that records
the pounds of laundry/linen used by departments. The Cost Accounting
and Reimbursement departments use this report.
LTS/Long Term Signature Card: The signing of this card
provides authorization to file claims and release medical information
to a patient's insurance plan.
Managed Care Plans: Plans
where patients must either seek services from selected networks of
providers or use a primary care physician gatekeeper to oversee and
coordinate their health care in order to receive their best benefit, as
an attempt at keeping plan costs down. These plans all have
authorization systems involving referrals and/or pre-authorizations.
They may be HMO, POS or PPO plans.
Mapping: Assigning revenue to a different
department.
Meals: A statistical report that records the pounds of
meals eaten by patients by department. The Cost Accounting and
Reimbursement departments use this report.
Medicaid: A government-run health insurance program
for low income and indigent people.
Medicaid CMM: A mandatory utilization control and case management program that Medicaid recipients are placed in when it is believed they have a pattern of using Medicaid services inappropriately. It is a managed care plan; patients must have PCPs and obtain referrals for all specialty care. They also have a designated pharmacy that they must use for all prescriptions.
Medicaid Medallion: A mandatory managed care program that Medicaid recipients are placed in when they fall within the following categories: those receiving aid from Temporary Assistance for Needy Families, or Low Income Families with Children; the blind; and the disabled. Patients must have PCPs and obtain referralsfor all specialty care.
Medical Necessity: Those covered services required
to preserve and maintain the health status of a member or eligible
person in accordance with the area standards of medical practice in the
medical community where services are rendered.
Medicare: A nationwide, federally-administered health
insurance program that covers the costs of hospitalization, medical
care, and some related services for persons over age 65, or any age
disabled person. Part A covers inpatient costs, Part B covers
outpatient costs.
Medicare+Choice: A program created by the Balanced
Budget Act of 1997 to replace the existing system of Medicare risk and
cost contracts. Beneficiaries will have the choice during an open
season each year to enroll in a Medicare+Choice plan or remain in
traditional Medicare. Medicare+Choice plans may include coordinated
care plans (HMOs, PPOs, or plans offered by provider-sponsored
organizations); private fee-for-service plans; or plans with medical
savings accounts.
Medicare Part A: Hospital insurance that pays for
inpatient hospital stays, care in a skilled nursing facility, hospice
care and some home health care.
Medicare Part B: Medicare medical insurance that helps
pay for doctors' services, outpatient hospital care, durable medical
equipment, and some medical services that are not covered by Part
A.
MFPA: Managers of Financial Planning and Analysis.
Finance managers who act as liaisons and facilitators for
Administrators.
MICU: Medical Intensive Care Unit
MIS: Medical Information Services, a charge-capture
system.
Miscellaneous Revenue: Revenue that comes from activities other than a
company's normal operating activities. Miscellaneous revenue is an
offset to expenses.
MRI: Magnetic Resonance Imaging. The use of a nuclear
magnetic resonance spectrometer to produce electronic images of
specific atoms and molecular structures in solids, especially human
cells, tissues, and organs.
NICU: Neonate Intensive Care
Unit
NNICU: Nerancy Neurological Intensive Care Unit
Novius Decision Advantage (NDA): The Cost Accounting
department's computer system for allocating costs. NDA is a
windows-based Siemens/ Shared Medical Systems computer system organized
by multiple tables.
OP: (also abbreviated as Outpt)
Outpatient (See Outpatient).
Operating Margin: "Profit/loss" or revenue less
expenses.
Operating Margin Report: The Operating Margin Report combines
elements of the Income Statement and Performance Reports. It reports
income, depreciation, amortization, and bad debt at the institutional
level, and all other expenses at the administrative level.
Oracle: The University of Virginia's enterprise
resource planning system. It was implemented in FY 2001 to replace the
FAS system.
ORMIS: Operating room charge-capture and information system
that is a component of MIS.
Out-of-Network: Physicians, hospitals or other health
care providers who are considered nonparticipants in an insurance plan
(usually a managed care plan). Depending on an individual's health
insurance plan, expenses incurred by services provided by
out-of-network health professionals may not be covered, or covered only
in part.
Out-of-Pocket: The total payments toward eligible
expenses that a covered person pays for health care expenses. These
include deductibles, copays and coinsurance. Sometimes this amount is
limited, or has a cap, and once this limit is reached the plan pays
100% for the rest of the calendar year. (Some out-of-pocket costs do
not have limits.)
Outpatient: (Also abbreviated as OP or Outpt) A
patient who visits a clinic or hospital to received medical diagnosis
or treatment but does not occupy a hospital bed for a specified minimum
stay. Care rendered to a patient that does not require the patient to
be formally admitted to the hospital and confined to the hospital
during care. Inpatient designation usually requires less than 24 hours
of patient care. Outpatients typically receive care and return home the
same day. Clinics offer most outpatient care, though outpatient care
can occur in a hospital for services such as dentistry or radiology.
(Compare to Inpatient)
Outpatient Profitability Report: A SAS report which measures
various revenue related fields for outpatient services. It can be split
out by Operational Service Center, physician, payor, DRG and many other
modalities.
Outpatient Prospective Payment System: Under Medicare
Part B, the way that Medicare will pay for most outpatient services at
hospitals or community mental health centers.
Outpatient Repository Reports: The Outpatient Repository
Reports contain patient population data reported at various summary
levels (e.g., physician, payor, DRG and service center).
Outpt: (also abbreviated as OP) Outpatient (See
Outpatient).
PACU: Post Anesthesia Care
Unit
Par & Non-Par/Participating & Non-Participating
Providers: A participating provider is one who has signed a
contract to participate with the health plan. This contract obligates
the provider to accept a discounted fee rate, in exchange for an
increased volume of business. The contract also ensures cooperation
with plan policies and procedures, including medical management and
authorization systems. A non-participating provider has not signed a
contract with the plan.
PCC: Primary Care Center
PCP/Primary Care Physician or Provider: The
physician who provides primary care services. In a managed care plan
this physician acts as the gatekeeper, coordinating all of a patient's
care and overseeing how health care services are utilized.
Performance Reports: The Performance Reports measure
actual expenses against budget at a divisional, administrative and
departmental level. Both the current and the flexible budgets are
reported. Accounts measured on these reports include salaries,
supplies, purchased services, contract labor and pharmaceuticals.
Period: Equivalent to a month. During the fiscal year,
each month is a period with July being period 1, December being period
6, and June being period 12. There are 12 periods in a year.
Period 13: A temporary accounting period used for
audit adjustments and year-end close processing. This is referred to as
Period 998 in PeopleSoft. It is the equivalent to a 13th month for the
year with only Accounting posting data to it.
PeopleSoft: The University of Virginia's enterprise
resource planning system. It includes Accounting, Accounts Payable,
Asset Management, Human Resources, Inventory, Payroll and
Purchasing.
PETC: Preanesthesia Evaluation and Testing
Center
Physician Gatekeeper: The physician who decides whether or not a
patient will be referred to a specialist for further care. Also called
the Primary Care Provider or Physician (PCP).
PICU: Pediatric Intensive Care Unit
Pillar: A budgeting software package produced by the
software company Hyperion. This is the software used by the UVA Medical
Center's Budget Office.
POS/Point-of-Service Plan: A health plan allowing the
covered person to choose to receive services from a participating or
non-participating provider, with different benefit levels associated
with how access is obtained. Patients have PCPs but are not required to
use them as gatekeepers for referrals to other physicians, however,
benefits are higher when they do and cost-share is lower. The highest
benefit level will be paid when patients seek services through the PCP
and obtain referrals for specialty care. An intermediate level benefit
is paid when patients bypass the PCP and go straight to a network
specialist without referral. The lowest benefit is paid when patients
bypass the PCP and seek care directly from a non-network physician
without referral.
PPO/Preferred Provider Organization: A plan that receives health insurance premiums from enrolled members or employer groups, and contracts with independent physicians or group practices to provide care at a discounted rate. There will be a financial incentive for the member to seek care within the network, higher benefits and lower cost-shares. Patients do not have to have PCPs and do not need to obtain referrals for specialty services.
Pre-auth: Reimbursement-related permission from insurance to perform certain specific procedures or services.
Pre-certification: A formal approval obtained from the insurance company prior to delivery of medical services. Many insurance companies require mandatory pre-certification for specific medical services.
Pre-Cert Write-Off Report: This report is also generated by Patient Financial Services and measures accounts from which attainable revenue has been deemed uncollectible because they lack the appropriate precertification required by the payor. Access to the Q: drive is required to view this report.
Premium: The amount of money that is paid to the insurance company by the insured, and/or the insured's employer, to obtain the insurance coverage.
Price: The amount of monetary value asked for in exchange for a good or service.
Primary Insurance: This is the insurance that the claim will be sent to first. It may be the only insurance, or there may be other insurances that the claim may be sent to subsequently.
Primary Payer: An insurance policy, plan, or program that pays first on a claim for medical care.
Profitability Report: The Profitability Report summarizes patient revenue and costs by service center, discharge service and payor for current year, YTD and for the prior two fiscal years. The report contains both inpatient and outpatient data, and it includes case counts, patient days, and average length of stay information in addition to cost/charges/profit data.
Pro Forma: An internal financial report or financial information for a specific purpose.
Program Memorandum: An official notice from Medicare about changes to Medicare.
Provider: A physician, hospital, group practice, nursing home, pharmacy or any individual or group of individuals that provides a health care service.
Provider Network: A group of providers, typically linked through contractual arrangements, which provide a defined set of benefits. They are formed by a managed care plan to contain costs and ensure contractual cooperation. Providers sign on and agree to discounted rates and compliance with authorization and medical management systems.
Ratio of Cost to Charges (RCC): A costing method used to convert charges from a patient bill to costs by applying the ratio of departmental full cost to total charges.
Referral: An approval from your primary care physician (PCP) for you to see a specialist or get certain services. In many managed care plans, you need to get a referral before you get care from anyone except your primary care physician. If you do not get a referral first, the plan may not pay for your care.
Reimbursement: To pay back or compensate (another party) for money spent.
Relative Value Units (RVUs): A unit of scale/number that is assigned based on the relative costs of different procedures.
Repository: A vast warehouse of inpatient and outpatient patient data composed primarily of data from the SMS files.
Resident: A physician who has completed medical school and at least one year in a residency program.
Rev 3: The Rev 3 reports quantities and total charges by transaction code for inpatient and outpatient. It contains both YTD and MTD information.
Revenue: An increase in a company's resources from the sale of goods and services.
Referral: Documents reimbursement-related PCP approval for the patient to see a specialist, or receive services outside of the PCP's office
RIMS: Radiology charge-capture and information system.
Secondary Insurance: This is the second insurance that the claim will be sent to, following submission to the primary insurance. Usually secondary coverage has the responsibility for payment of any eligible charges not covered by the primary coverage.
Secondary Payer: An insurance policy, plan, or program that pays second on a claim for medical care.
Self-Refer: When a patient goes straight to a
specialist without referral from another physician.
Special Discounts: These are special reductions in the
price of services for reasons such as professional courtesy or
grants.
Specialist: A physician who sees patients with a particular health condition, or for a particular organ system.
Stat Summary Report: The Stat Summary Report includes many different tabs measuring various patient and revenue-related fields such as admissions, discharges, births, OP visits, ER visits, revenue percents by major payor, beds available, occupancy rates, discharges by residence and the top 20 localities from which patients originate.
Step-Down Allocation: A method of cost allocation in which nonrevenue centers allocate their costs to all cost centers, both revenue and nonrevenue, that have not yet allocated their costs. Once a nonrevenue center allocates its costs, no costs can be allocated to it.
STICU: Surgical Trauma Intensive Care Unit
Subscriber/Policyholder: The person responsible for payment of premiums or whose employment is the basis for eligibility for membership in a health plan.
SUNQUEST: Clinical laboratory charge-capture and information system.
TES (Transaction Edit System): Physician charge suspense module capable of routing charges to the hospital.
Third Party Administrator/TPA: An independent person or corporate entity (third party) that administers group benefits, claims and administration for a self-insured company or group.
Third Party Payer: A public or private organization that pays for or underwrites coverage for health care expenses for another entity, usually an employer.
Transaction Code: Refers to the CDM number or service code.
Transfers: The shifting of direct costs from one cost center to another.
Tricare: Health insurance for military families, including active duty personnel, their dependents and retirees. The government runs this program.
TSO: IBM software that allows a user to interact with the IBM mainframe.
TCV: Thoracic Cardiovascular Unit
TCV-PO: Thoracic Cardiovascular Post Op
UB-92 and 1500 Forms: Federally mandated forms used to bill health care services to insurance companies.
UMA: University Medical Associates
United Mine Workers Association/UMWA: A health insurance plan that covers the health care costs of mine workers. Union members' health costs are covered by "The Funds." This plan pays the outpatient costs, with Medicare Part A paying the inpatient costs.
Units of Service (UOS): On the performance reports or in HBSI, UOS is a departmental-specific statistic, which measures volume/workload for that department. Some examples are: patient days for inpatient units, clinic visits for outpatient clinics, number of procedures or RVUs for procedural areas. Administrative or overhead departments, which largely have fixed costs, often use an institutional measure such as adjusted discharges or a generic measure such as calendar days as their UOS.
Variable Costs: Resources that are expected to change as volume increases or decreases. Variable costs are often associated with direct resources such as labor, supplies and drugs.
VASC: Virginia Ambulatory Surgical Center
View: A report-delivery tool that allows users to view mainframe reports on a terminal screen.
Volume (or Frequency): The number of times a good or service was used.
Waiver Form: In most cases, a patient signs a waiver form to acknowledge responsibility for paying the bill for services they are about to receive.
Weighted Average: The average cost of each transaction code is "weighted" by the number of units at a particular cost point.
Worker's Comp: A state-governed system designed to address work-related injuries. Under the system, employers assume the cost of medical treatment and wage losses arising from a worker's job-related injury or disease, regardless of who is at fault. In return, employees give up the right to sue employers, even if injuries stem from employer negligence.
