Glossary

Workers’ Compensation Bill Review Glossary

Clear, precise explanations of the terms that determine how a workers’ comp medical bill gets priced, reduced, or paid, organized by fee schedules, facility reimbursement, and bill review. Each term goes beyond a one-line definition to explain how it actually affects reimbursement.

Fee Schedules & Pricing

How workers’ comp reimbursement amounts are calculated and where the numbers come from.

Workers’ Compensation Fee Schedule The state- or jurisdiction-specific list that sets the maximum reimbursement for medical services. Read the definition → Relative Value Units (RVU) The Medicare-style building block used to price a service based on work, practice expense, and malpractice risk. Read the definition → Conversion Factor The dollar multiplier applied to RVUs (or other units) to convert relative value into an allowed amount. Read the definition → Place of Service (POS) The code identifying where care was delivered, which can change how a service is priced. Read the definition → UCR (Usual, Customary & Reasonable) Benchmark pricing used when no fee schedule exists for a service or jurisdiction. Read the definition →

Facility Reimbursement

How hospitals, surgery centers, and other facilities are paid, which follows very different rules than professional billing.

Cost-to-Charge Ratio (RCC) A facility-pricing method that converts billed charges into an allowed amount using a hospital-specific ratio. Read the definition → ASC Fee Schedule Fixed-payment groupings used to reimburse ambulatory surgery centers for outpatient procedures. Read the definition → OPPS (Outpatient Prospective Payment System) The Medicare system that prices hospital outpatient services using Ambulatory Payment Classifications (APCs). Read the definition → IPPS (Inpatient Prospective Payment System) The Medicare system that prices hospital inpatient stays using Diagnosis-Related Groups (DRGs). Read the definition →

Bill Review & Utilization

The processes that determine whether a bill is accurate and whether the underlying treatment was appropriate.

Medical Bill Review The process of reviewing provider-submitted bills for accuracy, coding compliance, and adherence to fee schedules. Read the definition → Utilization Review (UR) The clinical process of evaluating whether treatment is medically necessary and consistent with guidelines. Read the definition → Medical Necessity The standard used to determine whether a treatment is appropriate and required for a given diagnosis. Read the definition → Prior Authorization The requirement that a payer approve certain treatment before it is rendered or reimbursed. Read the definition →

All Terms, A–Z

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