Healthcare revenue terms, defined

Plain-English definitions for terms you'll hear around revenue leakage, care programs and EHR integration.

APCM: Advanced Primary Care Management: monthly Medicare codes (G0556, G0557, G0558) for primary care practices that provide ongoing, team-based care management.
BAA: Business Associate Agreement: the HIPAA contract between a covered entity and a vendor that handles protected health information. Security
Baseline: How often each step of care completed in about two years of your own history, by location and service line, before Nuvory flagged anything.
BHI: Behavioral Health Integration: care management for behavioral health conditions delivered within a medical practice.
Bulk FHIR ($export): The FHIR Bulk Data Access standard for exporting data for a whole patient population in one asynchronous request, used for historical loads.
Care gap: A difference between the care a patient should receive under a guideline or care plan and the care recorded.
CCM: Chronic Care Management: Medicare-covered care management for patients with two or more chronic conditions expected to last at least 12 months. Care management candidates
Clearinghouse: A company that routes and checks claims, remittances and eligibility transactions between providers and payers.
Closed-loop referral: A referral tracked until the patient is seen and the consult note is returned to the referring provider. Closed-loop referral management
Done elsewhere: An open item closed because the patient received the care from another provider, recorded by staff with a reason or matched through claims or HIE data.
FHIR: Fast Healthcare Interoperability Resources, the HL7 standard for exchanging healthcare data through APIs. FHIR R4 is the version required for certified EHR APIs in the US.
Healthcare revenue leakage intelligence: Software that connects to a practice's EHR, finds patients and revenue lost between referral, visit, procedure, follow-up and longitudinal care, explains why each one is open, ranks the next action and verifies when care is completed. It works before a claim exists, unlike revenue cycle management. Also called leakage intelligence. About revenue leakage intelligence
HL7 v2: An older messaging standard still widely used for admissions (ADT) and scheduling (SIU) feeds.
Network leakage: Care for services your organization offers that patients receive from outside providers. It overlaps with referral leakage when the patient was referred to you. Also called outmigration or outflow. Network leakage
Next-best action: The single most valuable action to take for a patient now, chosen from all their open items.
No-show: A scheduled appointment the patient did not attend and did not cancel. No-show recovery
Patient leakage: Another name for network leakage: patients receiving care you offer from outside providers. Network leakage
Patient opportunity intelligence: Software that combines a patient's open items, such as an unscheduled referral, an overdue recall or an open order, explains why each exists, estimates its value and ranks the next action. Patient opportunity intelligence
PCM: Principal Care Management: care management focused on one complex chronic condition.
Procedure leakage: A procedure or test a provider ordered that never happened: never scheduled, canceled without a new date, or scheduled and never completed. Procedure recovery
Recall: A reminder in the EHR that a patient is due for a visit or procedure by a set date, such as a surveillance colonoscopy. A recall is overdue when the date passes with nothing booked. Patient recall software
Recovered value: Care completed after Nuvory flagged an opportunity, valued with your own visit and procedure values and reported against your baseline. It shows correlation with outreach, not proof of cause.
Referral leakage: A referred patient who never completes the care they were referred for: never scheduled, scheduled and lost, or seen by another organization. Referral leakage software
Revenue leakage: Revenue a practice should have earned but didn't, because a patient dropped out between steps of care: a referral never scheduled, a procedure ordered and never completed, a follow-up past due. Healthcare revenue leakage software
RPM: Remote Physiologic Monitoring: Medicare-covered monitoring of physiologic data, such as blood pressure or weight, collected by a device at home.
RTM: Remote Therapeutic Monitoring: monitoring of non-physiologic data such as therapy adherence or musculoskeletal status.
Service line: A group of related services managed as one business, such as cardiology or gastroenterology.
SMART on FHIR: A standard for apps that launch inside an EHR with the user's context, such as the open patient, and that authorize securely against the EHR's FHIR API. EHR integrations
SOC 2 Type II: An independent audit report on how well a service organization's security controls operated over a period of time. Security
Unresolved order: A test, imaging study, procedure or referral that was ordered but has no matching scheduled or completed service, and no documented reason it was closed. Unresolved order tracking
US Core: The set of FHIR profiles that define the minimum data US EHRs expose, such as patients, conditions and procedures.
X12 835: The electronic remittance advice that tells a provider what a payer paid and why.
X12 837: The electronic claim format sent from providers to payers through a clearinghouse.

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