Finance

The distribution of a healthcare organization patient volume and revenue across different insurance payer categories including commercial insurance, Medicare, Medicaid, self-pay, and other government programs. Payer mix is a critical financial planning metric because different payer types reimburse at dramatically different rates — commercial payers typically reimburse at 120 to 160 percent of Medicare rates while Medicaid reimburses at 60 to 80 percent of Medicare for most services. A payer mix shift toward lower-paying government payers or self-pay patients directly reduces net revenue even when patient volumes remain stable. Healthcare data teams analyze pyr_mix trends over time by facility, service line, and physician to identify shifts that affect financial performance, model the revenue impact of payer mix changes in financial planning, compare payer mix to market benchmarks using state discharge data, and evaluate the profitability of service line expansion or contraction decisions.

The systematic processes and technologies used by health plans to identify and prevent improper payments including fraud, waste, and abuse detection, clinical editing for medically unlikely or inappropriate billing, duplicate claim detection, coordination of benefits verification, and post-payment audit and recovery programs. Payment integrity programs generate significant return on investment through prevented and recovered overpayments, and payment integrity metrics including detection rates and recovery amounts are tracked as key financial performance indicators.

The revenue cycle process of recording insurance payments, patient payments, contractual adjustments, and denial information received from payers and patients into the provider billing system to update account balances and identify remaining amounts owed. Accurate and timely payment posting is essential for revenue cycle performance — posting errors create incorrect account balances that misdirect collection efforts, delay identification of underpayments, and produce inaccurate financial reports. Electronic remittance advice processing through the HIPAA 835 transaction enables automated payment posting that eliminates manual data entry errors and accelerates the posting process. Healthcare data teams measure payment posting performance through metrics including days from payment receipt to posting completion, electronic versus manual remittance processing rates, posting error rates, and unapplied payment aging to identify workflow bottlenecks and automation opportunities in the cash posting function.

The unique account identifier associated with pediatric specialty services for patients typically under 18 years of age. Used in billing, claims, and clinical systems to track encounters, referrals, and financial transactions specific to pediatric care delivery and specialty cost center reporting.

The total expense incurred for pediatric specialty care services delivered to patients under 18 years of age. Captured in claims and hospital cost accounting systems to support budgeting, department-level financial analysis, and reimbursement tracking for pediatric service lines.

A fixed daily payment rate paid to hospitals or skilled nursing facilities for each inpatient day of care, regardless of the specific services provided during that day, used as an alternative to DRG-based payment or fee-for-service billing. Per diem rates may be differentiated by service intensity level such as medical/surgical, intensive care, and step-down rates, and by day of stay with declining per diem rates for longer lengths of stay in some contract designs that create incentives for efficient discharge planning.

A normalized healthcare cost or utilization metric calculated by dividing total expenditures or utilization events by the total member months of enrollment during a defined period, enabling meaningful comparison of costs and utilization rates across populations of different sizes and time periods. PMPM is the foundational financial metric in health plan analytics used for pricing actuarial models, tracking medical cost trends, benchmarking against market competitors, and measuring the financial impact of care management program interventions.

A reference standard or target value representing the expected level of performance against which actual healthcare cost, quality, or utilization results are compared to determine payment adjustments in value-based care contracts, shared savings programs, and quality bonus arrangements. Performance benchmarks may be established based on historical expenditure trends adjusted for risk and market factors, regional or national peer comparisons, absolute performance thresholds defined in contract terms, or improvement targets measuring progress from a baseline period. CMS establishes Medicare Shared Savings Program benchmarks using three years of historical Medicare expenditure data for assigned beneficiaries, adjusted for risk score changes and national trend factors. Healthcare data teams model perf_bnchmark_amt calculations using CMS methodology and commercial contract terms, track actual performance against benchmark throughout the measurement period, analyze the drivers of benchmark deviation including care pattern changes and risk score shifts, and project final benchmark performance to support proactive care management interventions that improve the likelihood of achieving shared savings.

The administrative fee paid by a health plan to a pharmacy benefit manager for prescription drug benefit administration services including formulary development, pharmacy network contracting, drug utilization review, prior authorization processing, and claims adjudication. PBM fees are one component of the total cost of pharmacy benefit administration, with the net cost to the health plan also affected by drug rebate pass-through rates, spread pricing between ingredient costs and reimbursement, and dispensing fee arrangements.

The total pharmacy benefit expenditure divided by total member months, used as the primary financial metric for tracking pharmacy cost trends, benchmarking pharmacy benefit management performance, and projecting future pharmacy expenditures in premium rate development. Rx PMPM is analyzed by therapeutic class, brand/generic mix, specialty versus traditional drugs, and formulary tier to identify cost drivers and target pharmacy benefit management interventions including formulary changes, prior authorization policies, and step therapy requirements.

Revenue received by health plans and pharmacy benefit managers from pharmaceutical manufacturers as contractual payments tied to formulary placement, market share, and utilization volume for brand-name and specialty drugs. Pharmacy rebates are a significant revenue component for health plans and PBMs, with total industry rebate volumes exceeding tens of billions of dollars annually. Rebate accounting requires careful timing recognition and allocation between the plan and the PBM, and CMS requires Medicare Part D plans to pass a defined percentage of rebates through to point-of-sale price reductions.

The unique account identifier linked to a physical examination encounter or preventive health visit. Used in billing and claims systems to track wellness exams, annual physicals, and pre-employment screenings for financial reconciliation, scheduling systems, and population health reporting purposes.

The total expense associated with physical examination services, including preventive wellness visits and routine health assessments. Captured in claims and cost accounting systems to support reimbursement analysis, value-based care reporting, and preventive service utilization tracking across patient populations.

A two-digit code used on professional claims to identify the setting where a healthcare service was delivered to the patient, directly affecting the applicable fee schedule rate and facility versus non-facility payment determination under Medicare and commercial payer contracts. CMS maintains the Place of Service code set used on CMS-1500 professional claims, with common codes including 11 for physician office, 21 for inpatient hospital, 22 for hospital outpatient department, 23 for emergency room, 24 for ambulatory surgical center, 31 for skilled nursing facility, and 02 for telehealth in the patient home. The same procedure code carries different payment amounts depending on place of service — non-facility rates for office-based services exceed facility rates for the same service delivered in a hospital outpatient setting because the facility bills separately for overhead. Healthcare data teams analyze pos_cd distributions to track care setting migration, identify place of service billing errors that affect reimbursement accuracy, and measure telehealth service volumes by place of service code.

The unique account identifier assigned to a specific health benefit plan structure within member enrollment and claims systems. Used to associate members, premium payments, and claims activity to a defined coverage tier, enabling accurate benefits administration, eligibility verification, and plan-level financial reporting.

The total expense attributed to a specific health benefit plan structure, including claims paid, administrative fees, and care management costs. Used in actuarial analysis, financial forecasting, and plan performance reporting to evaluate cost trends across benefit designs and enrolled member populations.

The dollar amount of patient financial obligations collected by healthcare organizations at the time of service delivery, before the patient leaves the clinical setting. Point-of-service collection represents the most effective and lowest-cost method of collecting patient balances — research consistently demonstrates that collection rates decline sharply as time passes after the date of service, with point-of-service collection rates of 50 to 70 percent compared to post-service collection rates of 20 to 35 percent for the same balance type. Best practice revenue cycle organizations collect copays, prior-visit balances, and estimated patient responsibility amounts at registration and checkout. Healthcare data teams track pos_coll_amt by service type, facility, and registration staff to measure point-of-service collection performance, benchmark against industry standards, calculate the revenue impact of improving collection rates at the point of service, and evaluate the effectiveness of staff training and scripting programs designed to increase patient payment at time of service.

The unique account identifier tied to an individual or group insurance coverage agreement between the policyholder and the health plan. Used in enrollment, billing, and claims systems to link covered members to their contractual benefits, premium obligations, and coverage terms for administrative processing.

The total expense associated with an insurance coverage agreement, including premiums, claims liability, and administrative costs tied to a specific policy. Used in underwriting, actuarial, and financial systems to evaluate policy profitability, renewal pricing, and cost performance against coverage obligations.

The advance approval obtained from a health insurance payer before delivering specific non-emergency healthcare services, procedures, or medications to confirm the payer will provide coverage and reimbursement for the planned care. Pre-authorization is required by most health plans for elective surgeries, inpatient admissions, advanced imaging including MRI and CT scans, specialty medications, durable medical equipment, and certain outpatient procedures. The pre-authorization process requires submitting clinical documentation supporting medical necessity to the payer for clinical review within defined response timeframes. CMS issued regulations in 2024 requiring Medicare Advantage plans to implement electronic prior authorization APIs using FHIR standards to reduce administrative burden. Healthcare data teams build pre-authorization tracking systems that monitor authorization request status, approval and denial rates by service type and payer, authorization expiration dates, and the revenue impact of services delivered without required authorization that result in claim denials.