Common Terminologies in Medical Billing

Payer: Insurance

Provider: Hospital or Physician

SSN: Social Security Number

PCP: Primary Care Physician

PCL: Professional Courtesy Letter

HMO: Health Maintenance Organization

PPO: Preferred Provider Organization

POS: Point of Service

EPO: Exclusive Provider Organization

EOB: Explanation of Benefits

ABN: Advance Beneficiary Notice

CMS: Center for Medicare and Medicaid Services

COBRA: Consolidated Omnibus Budget Reconciliation Act

DME: Durable Medical Equipment

ESRD: End Stage Renal Disease

ERA: Electronic Remittance Advice

EFT: Electronic Fund Transfer

LGHP: Large Group Health Plan

EGHP: Employer Group Health Plan

GEP: General Enrollment Period

HCFA: Health Care Financing Administration

HIPAA: Health Insurance Portability and Accountability Act

IEP: Initial Enrollment Period

MSP: Medicare Secondary Payer

NP: Nurse Practitioner

IP: Inpatient

OP: Outpatient

PA: Physician Assistant

PSO: Provider Sponsored Organization

QMB: Qualified Medicare Beneficiary

SNF: Skilled Nursing Facility

HHA: Home Health Agency

WC: Workers Compensation

VA: Veterans Administration

CHAMPUS: Civilian Health and Medical Program of the Uniformed Services

Comments

What is QMB / MQMB stands for?

In Medical billing or Healthcare industry The term QMB stands for Qualified Medicare Beneficiary & MQMB stands for Medicare Qualified Medicare Beneficiary. The term "QMB" or "MQMB" on the form indicates the client is a Qualified Medicare Beneficiary (QMB) or a Medicaid Qualified Medicare Beneficiary (MQMB). The Medicare Catastrophic Coverage Act of 1988 requires Medicare premiums, deductibles, and coinsurance payments to be paid for individuals who meet the following criteria: Important: Clients limited to QMB are not eligible for THSteps or THSteps-CCP Medicaid benefits. Note: Clients eligible for STAR+PLUS who have Medicare and Medicaid are MQMBs. Medicaid reimburses for the coinsurance and deductibles as well as Medicaid-only services for the MQMB client. QMBs do not receive Medicaid benefits other than Medicare deductible and coinsurance liabilities. MQMBs do qualify for Medicaid benefits not covered by Medicare in addition ...

Key Performance Indicators (KPIs) for Successful Revenue Cycle Management (RCM) in Healthcare Organizations

Revenue Cycle Management (RCM) is an essential process for healthcare organizations to ensure that they receive timely and accurate payments for the services they provide. Here are some of the key performance indicators (KPIs) metrics that healthcare organizations should track as part of their RCM process: Gross Collection Rate (GCR): This metric measures the percentage of charges that a healthcare organization collects from patients and insurance companies. It is calculated by dividing the total payments received by the total charges billed. Net Collection Rate (NCR): The NCR measures the percentage of expected payments received by the healthcare organization after accounting for contractual adjustments, bad debts, and other adjustments. It is calculated by dividing the total payments received by the total expected payments. Days in Accounts Receivable (DAR): This metric measures the average number of days it takes fo...

What is W-9 form? Why it is required for Medical Billing.

W-9 Form W-9 is Internal Revenue Services (IRS) request for Tax Payers identification number, mainly its used for third parties to collect ID information like Name, Address to help file information returns with IRS. Also its is used to help payee avoid backup withholding. It is required for your name, Address and SSN number or employer identification number. When your giving out W-9 form be caution, because W-9 form contains sensitive information’s. Why Insurance Company ask W-9 Form from hospital or clinic etc., Because medical billing is cycle indirectly or directly insurance company’s are working for hospital or clinic etc., for them we need to report SSN number / business tax id. As far as W-9 is form is concern it is straight forward with the all the above mentioned information, also they need to pay to address, or to update their records, or to check / update records. Note: W-4 Form is used by employer ...

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