Insurance claim that an insurance company refused to pay but may pay in the future.

Sales drive carried out to enroll eligible individuals who are not covered into an existing group insurance plan. Also called recanvass .

Expense used by a physician to render a service or procedure that includes the doctor’s time and effort and the expenses of nonphysician time and effort.

Administration of the health care product in a cost-effective manner and maintaining quality of health care and contributing to the goals of the organization.

Patient classification system that obtains patients’ medical data and health status information from the minimum data set (MDS) to assign each patient to a resource group for Medicare reimbursement. The RUG-III system has seven major categories of patient types: rehabilitation, extensive services, special care, clinically complex, impaired cognition, behavior problems, and reduced physical function. These categories are further broken down into 44 specific patient groupings.

System of national uniform relative values for all physicians’ services. It ranks physician services and procedures by units that provide a formula to determine an annual Medicare fee schedule. Relative value units (RVUs) are based on the physicians’ work RVU, practice expense RVU, and cost of professional liability insurance RVU (see Figure R-1 ). RVUs are adjusted for each Medicare local fiscal agent by geographical practice cost indices. A conversion factor is used to convert a geographically adjusted relative value into a payment amount. Also called resource-based relative value unit (RBRVU) and synonymous with Medicare fee schedule . Formula used to calculate the fee for a specific procedure using the resource-based relative value scale system. CPT, Current Procedural Terminology; GPCI, geographical practice cost indices; HCPCS, Healthcare Common Procedure Coding System; RVUs, relative value units.

Body structures involved consist of the nose, pharynx, larynx, trachea, bronchi, bronchioles, and lungs.

Short-term hospice inpatient stay that may be necessary to give temporary relief to the person (primary health care giver) who regularly assists with home care of a patient. This temporary or periodic care may be provided in a nursing home, assisted living residence, or other type of long-term care program. Also known as short-term assisted living care .
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Respite care is a benefit to family members of a patient whereby the family is provided with a break or respite from caring for the patient. The patient is confined to a nursing home for needed care for a short period of time.