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Glossary of EMR, EHR, HIT and HIPAA Terms

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See Glossary References. Updated 03-Nov-2009. Protected under a Creative Commons license: you may share and edit, please give credit to Dennis Leister, PMP, Ph.D. (LinkedIn profile: http://www.linkedin.com/in/dennisleister).

Phrase Acronym Definition Reference
24-Hour CoverageA plan under which an employer\'s group health plan, disability plan, and workers\' compensation program are merged, integrated, or coordinated (depending on state regulations) into a single health benefit plan that covers employees 24 hours a day. [39] Has been proposed as a type of health care system reform that integrates the health coverage and benefits currently offered by public and private insurance programs, state workers\' compensation systems, and automobile insurance. [40]39, 40
24-Hour Managed CareThe application of managed care principles to 24-hour coverage.39
A Key Contributor PlanIs a performance-based incentive program created for the sole purpose of attracting, motivating and retaining key individuals or small groups.2
Academic Medical CenterA group of related institutions including a teaching hospital, a medical school and its affiliated faculty practice plan, and other health professional schools.2
AccessThe ability to obtain medical care. The ease of access is determined by components such as the availability to the patient, availability of insurance, the location of health care facilities, transportation, hours of operation, affordability and cost of care. [39] Potential and actual entry of a population into the healthcare delivery system. [47]39, 47
Accountable Care OrganizationsACOSee Accountable Health Plan.
Accountable Health PartnershipAn organization of doctors and hospitals which provides care for people organized into large groups of purchasers.2
Accountable Health PlanAHPA plan that would offer a nationally defined package of specified benefits and provide consumers with a report card on the quality and services offered by the plan. [2] Under the Managed Care Act, providers and insurance companies would be encouraged (through tax incentives) to form AHPs, similar to Health Maintenance Organizations, Preferred Provider Organizations, and other group practices. Accountable health plans would compete on the basis of offering high-quality, low-cost care and would offer insurance and health care as a single product. They would be responsible for looking after the total health of members and reporting medical outcomes in accordance with Federal guidelines. [40]2, 40
Accounting Perspectives (Evaluation)Perspectives underlying decisions on which categories of goods and services to include as costs or benefits in an analysis.2
Accounts ReceivableAssets arising from services provided or the sales of goods to patients on credit.47
AccreditationAn evaluative process in which a health care organization undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality. [39] Approval by an authorizing agency for institutions and programs that meet or exceed a set of pre-determined standards. [40] A process of evaluating an institution to see if it meets standards set by the accrediting body. Generally refers to the evaluation by the Joint Commission on Accreditation of Health Care Organizations. See Joint Commission On Accreditation Of Healthcare Organizations. [47]39, 40, 47
Accreditation Manual For HospitalsA Joint Commission On Accreditation Of Healthcare Organizations publication published annually, consisting of policies and procedures relating to hospital accreditation surveys, hospital standards and scoring guidelines used to determine levels of compliance with the standards. See Joint Commission On Accreditation Of Healthcare Organizations.47
AccreteThe addition of new enrollee to a health plan, usually used in reference to Medicare.40
Acquired Immunodeficiency SyndromeAIDSA disease of the human immune system caused by the human immunodeficiency virus (HIV).13
AcquisitionThe purchase of one organization by another organization.39
Activities of Daily LivingADLBasic self-care activities, including eating, bathing, dressing, transferring from bed to chair, bowel and bladder control and independent ambulation. ADLs are widely used as a measure of evaluating independent functional status.47
Activity-Based CostingABCDefines costs in terms of an organization\'s processes or activities and determines costs associated with significant activities or events. ABC relies on the following three step process: Activity mapping, which involves mapping activities in an illustrated sequence; Activity analysis, which involves defining and assigning a time value to activities; and Bill of activities, which involves generating a cost for each main activity.2
Activity-Based ManagementABMSupports operations by focusing on the causes of costs and how costs can be reduced. It assesses cost drivers that directly affect the cost of a product or service, and uses performance measures to evaluate the financial or nonfinancial benefit an activity provides. By identifying each cost driver and assessing the value the element adds to the healthcare enterprise, ABM provides a basis for selecting areas that can be changed to reduce costs. 2
Actual ChargeThe amount a physician or other provider actually bills a patient for a particular medical service, procedure or supply in a specific instance. The actual charge may differ from the Usual, Customary and Reasonable Charge.40
Actuarial AnalysisThe statistical calculations used to determine the managed care company\'s rates and premiums charged their customers based on projections of utilization and cost for a defined population.40
Actuarial Cost Of CoverageThe expected dollar value of a health plan\'s benefits. The method of determining this value may be based entirely on a plan\'s provisions, or may adjust for the geographic location and demographic characteristics of enrollees, the actual health care utilization level by plan participants, or the type of plan under which the benefits are provided.40
Actuarial SoundnessThe requirement that the development of capitation rates meet common actuarial principles and rules.40
ActuaryAn insurance professional who perform the mathematical analysis necessary for setting insurance premium rates.39
Acute CareHospital care given to patients who generally require a stay of up to seven days and that focuses on a physical or mental condition requiring immediate intervention and constant medical attention, equipment and personnel. [40] Generally refers to inpatient hospital care of a short duration as opposed to ambulatory care or long-term care for the chronically ill. [47]40, 47
Acute Care Bed Need MethodologyA formula used to determine hospital bed needs.40
Acute Long-Term Care1) A hospital that specializes in caring for critically ill patients who have many complications and need specialized treatment over a long period, typically several weeks or longer. 2) Care of critically ill patients who have many complications and need specialized treatment over a long period, typically several weeks or longer (a Key Service).8
Ad Hoc CommitteesCommittees that are convened to address specific management concerns. Also called Special Committees.39
AddendumText that is added to a document after it has been finalized.77
Additional Drug Benefit ListSee Drug Maintenance List.
AdequacyThe extent to which a network offers the appropriate types and numbers of providers in the appropriate geographic distribution according to the needs of the plan\'s members.39
Adjusted AdmissionsA measure of all patient care activity undertaken in a hospital, both inpatient and outpatient. Adjusted admissions are equivalent to the sum of inpatient admissions and an estimate of the volume of outpatient services. This estimate is calculated by multiplying outpatient visits by the ratio of outpatient charges per visit to inpatient charges per admission.2
Adjusted Average Per Capita CostAAPCC(1) Actuarial projections of per capita Medicare spending for enrollees in fee-for-service Medicare. Separate AAPCCs are calculated - usually at the county level - for Part A services and Part B services for the aged, disabled, and people with end stage renal disease. Medicare pays risk plans by applying adjustment factors to 95 percent of the Part A and Part B AAPCCs. The adjustment factors reflect differences in Medicare per capita fee-for-service spending related to age, sex, institutional status, Medicaid status, and employment status.; (2) A county-level estimate of the average cost incurred by Medicare for each beneficiary in fee for service. Adjustments are made so that the AAPCC represents the level of spending that would occur if each county contained the same mix of beneficiaries. Medicare pays health plans 95 percent of the AAPCC, adjusted for the characteristics of the enrollees in each plan. See Medicare Risk Contract, U.S. Per Capita Cost.2
Adjusted Community RateACREstimated payment rates that health plans with Medicare risk contracts would have received for their Medicare enrollees if paid their private market premiums, adjusted for differences in benefit packages and service use. Health plans estimate their ACRs annually and adjust subsequent year supplemental benefits or premiums to return any excess Medicare revenue above the ACR to enrollees. See Adjusted Average Per Capita Cost, Medicare Risk Contract.2
Adjusted Community Rate ProposalACR1) A process by which a health plan contracting with Medicare estimates the cost of providing services to its Medicare enrolles based on costs and revenues from its commercial business. Health plans estimate their ACRs annually and adjust the subsequent year\'s supplemental benefits or premiums offered so that they do not receive a higher rate of return on Medicare enrollees than they do on their commercial business.; 2) A process by which a health plan with a Medicare risk contract estimates the cost of providing services to its Medicare enrollees based on costs and revenues from its commercial business. Health plans estimate their ACRs annually and adjust the subse quent year\'s supplemental benefits or premiums offered so that they do not receive a higher rate of return on Medicare enrollees than they do on their commercial business. See also Adjusted Average Per Capita Cost, Medicare Risk Contract.2
Adjusted Community RatingACRA rating method under which a health plan or Managed Care Organization divides its members into classes or groups based on demographic factors such as geography, family composition, and age, and then charges all members of a class or group the same premium. The plan cannot consider the experience of a class, group, or tier in developing premium rates. Also called Modified Community Rating.40
Adjusted Patient DayAPDAn accounting method for modifying the definition of inpatient days to include outpatient revenues.47
Adjusted Payment RateAPRThe Medicare capitated payment to risk-contract Health Maintenance Organizations. For a given plan, the APR is determined by adjusting county-level AAPCCs to reflect the relative risks of the plan\'s enrollees. [2] The Medicare capitated payment to risk-contract Health Maintenance Organizations. For a given plan, it determined by adjusted county-level AAPCCs to reflect the relative risks of the plan\'s enrollees. [40] See Adjusted Average Per Capita Cost.2
Administration On AgingAoAThe principal federal agency responsible for programs authorized under the Older Americans Act of 1965. It serves as an advocate for older persons at the national level, advises Congress and federal agencies on the characteristics and needs of older people, and develops programs designed to promote the health and well-being of the older population. It provides advice, funding, and assistance to achieve community-based systems of comprehensive social services for older people.40
Administrative CostsCosts related to utilization review, insurance marketing, medical underwriting, agents\' commissions, premium collection, claims processing, insurer profit, quality assurance activities, medical libraries and risk management. [2] Costs related to activities such as utilization review, marketing, medical underwriting, commissions, premium collection, claims processing, insurer profit, quality assurance, and risk management for purposes of insurance. [40]2
Administrative Costs SavingsReductions in expenditures related to changes in the administrative costs associated with the provision of health care coverage and services.40
Administrative Law JudgeALJIn the United States is an official who presides at an administrative trial-type hearing to resolve a dispute between a government agency and someone affected by a decision of that agency.13
Administrative LoadingThe amount added to the prospective actuarial cost of the health care services (pure premium) for administrative, marketing expenses and profit.40
Administrative ReformReducing paperwork though simplified universal forms or electronic filing and processing of claims.40
Administrative Services OnlyAn agency that delivers administrative services to an employer group. This type of arrangement usually requires the employer to be at risk for the cost of health care services provided.40
Administrative Services Only ContractA contract under which a third party administrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee.39
Administrative Services OrganizationASOAn entity which only provides administrative services (including claims adjudication, member services, and management information reporting).40
Administrative SupervisionA situation in which a Managed Care Organization\'s operations are placed under the direction and control of the state commissioner of insurance or a person appointed by the commissioner.39
Admissions/1000, Admissionts Per 1,000APTThe number of hospital admissions per 1.000 health plan members during a given period.40
Adult Day CareA program of social and health-related services provided during the day in a community group setting. The purpose of the program is to support frail or impaired elderly, or other disabled adults who can benefit from care in a group setting outside the home. [40] A program that provides a combination of health, recreational and social services to older adults during the day. Services may include comprehensive assessment, health monitoring, occupational therapy, personal care, a noon meal and trans- portation. Some programs also provide primary healthcare and rehabilitation services. [47]40
Adult Foster CareAFCAn elderly person\'s placement with another family when independent living is no longer possible, but nursing care is not necessary. See also Family Rest Residential.40
Adult Protective ServicesAPSSocial service interventions for impaired adults at risk of abuse, neglect or exploitation.40
Advanced DirectiveSee Living Will.
Advanced Encrytion StandardAESAn encryption standard adopted by the U.S. government. This is the approach recommended by the HIT Standards and Policy Committees. 13
Adverse EventAny harm a patient suffers that is caused by factors other than the patient\'s underlying condition.39
Adverse SelectionAdverse selection occurs when a larger proportion of persons with poorer health status enroll in specific plans or insurance options, while a larger proportion of persons with better health status enroll in other plans or insurance options. Plans with a subpopulation with higher than average costs are adversely selected. Plans with a subpopulation with lower than average costs are favorably selected.2
AftercareServices following hospitalization or rehabilitation individualized for each patient\'s needs. Aftercare gradually phases the patient out of treatment while providing follow-up attention to prevent relapse.40
Age/Sex FactorA measurement used in insurance underwriting. It represents the age and sex risk of medical costs of one population relative to another. For example, a group with an age/sex factor of 1.05 would be expected to incur medical costs 5% greater than the average.40
Age/Sex RatesASRSet of rates for a grouping based on age and sex categories used to calculate premiums. This type of premium structure is often preferred over single and family rating in small groups because it automatically adjusts to demographic changes in the group. Also called table rates.40
Age-At-Issuance RatingA method for establishing health insurance premiums whereby an insurer\'s premium is based on the age of individuals when they first purchased health insurance coverage.2
Age-Attained RatingA method for establishing health insurance premiums whereby an insurer\'s premium is based on the current age of the beneficiary. Age-attained-rated premiums increase as the purchaser grows older.2
Agency For Health Care Policy And ResearchAHCPRA Federal agency within the Public Health Service responsible for research on quality, appropriateness, effectiveness and cost of health care.40
Agency For Healthcare Research And QualityAHRQPart of the U.S. Department of Health and Human Services dedicated to advancing quality in healthcare.10
AgentA person who is authorized by an Managed Care Organization or an insurer to act on its behalf to negotiate, sell, and service managed care contracts.39
Aggregate MarginA margin that compares revenues to expenses for a group of hospitals, rather than a single hospital. It is computed by subtracting the sum of expenses for all hospitals in the group from the sum of revenues and dividing by the sum of revenues. See also PPS Inpatient Margin, PPS Operating Margin, Total Margin.2
Aggregate PPS Operating MarginSee Aggregate Margin.
Aggregate Stop-Loss CoverageA type of stop-loss insurance that provides benefits when a group\'s total claims during a specified period exceed a stated amount.39
Aggregate Total MarginSee Aggregate Margin.
Aging In PlaceProcess allowing seniors to remain in their current residence despite changes in their needs by adjusting the degree and type of services provided. This can occur at home or in a facility offering multiple levels of care.40
Aging NetworkA highly complex and differentiated system of federal, state, and local agencies, organizations and institutions which are responsible for serving and/or representing the needs of older persons. The network is involved in service systems development, advocacy, planning, research, coordination, policy development, training and education, administration, and direct service provision. The core structures in the network include the Administration on Aging (AoA), State Units on Aging (SUA), Area Agencies on Aging (AAA), and local service provider agencies.40
Aid To Families With Dependant ChildrenAFDCA program established by the Social Security Act of 1935 and eliminated by welfare reform legislation in 1996. AFDC provided cash payments to needy children (and their caretakers) who lacked support because at least one parent was unavailable. Families had to meet income and resource criteria specified by the state to be eligible. AFDC has been replaced by a new block grant program, but AFDC standards are retained for use in Medicaid. [2] A federally supported, state-administered program established by the Social Security Act of 1935 that provides financial support for children under the age of 18 (and their caretakers) who have been deprived of parental support or care because of the parent\'s death, continued absence from the home, unemployment, or physical or mental illness. [40] See Temporary Assistance for Needy Families.2, 40
AIDSSee Acquired Immunodeficiency Syndrome.47
AIDS-Related ConditionsARCOther medical conditions related to HIV/AIDS infection.73
Alcoholics AnonymousAAAlcoholics Anonymous® is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism. The only requirement for membership is a desire to stop drinking. There are no dues or fees for AA membership; we are self-supporting through our own contributions. AA is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy, neither endorses nor opposes any causes. Our primary purpose is to stay sober and help other alcoholics to achieve sobriety.\'74
AlertsPop-ups or reminders. An automated warning system such a clinical alerts, preventive health maintenance, medication interactions etc.77
Algorithm A formula or set of steps for solving a particular problem 77
Alien Insurance CompanyAn insurance company that operates under the laws of another country.40
All Patient Diagnosis Related GroupsAPDRGAn enhancement of the original Diagnostic Related Groups, designed to apply to a population broader than that of Medicare beneficiaries, who are predominately older individuals. The APDRG set includes groupings for pediatric and maternity cases as well as of services for HIV-related conditions and other special cases.40
AlliancesOrganizations consisting of large groups of purchasers of health care. The buying power of Alliances is expected to force competitive marketing among providers. Also called Health Insurance Purchasing Cooperatives.2
Allied HealthGeneral term referring to a variety of non-physician and non-nursing clinicians, practitioners, therapists, technologists and technicians working in the health field.40
Allied Health PersonnelSee Allied Health Professional.
Allied Health ProfessionalAHPProfessionally educated and certified non-physician healthcare providers, including nurse practitioners, certified registered nurse anesthetists, respiratory therapists, physicians\'s assistants and others.47
Allowable ChargeGeneric term referring to the maximum fee that a third party will use in determining reimbursement for a given service or supply. An allowable charge may not always be the same as the actual charge.40
Allowable CostsCharges for services rendered or supplies furnished by a health care provider, which qualify as covered expenses for insurance purposes.40
Allowed ChargeThe amount Medicare approves for payment to a physician. Typically, Medicare pays 80 percent of the approved charge and the beneficiary pays the remaining 20 percent. The allowed charge for a nonparticipating physician is 95 percent of that for a participating physician. Nonparticipating physicians may bill beneficiaries for an additional amount above the allowed charge. See Balance Billing, Participating Physician, Supplier Program.2
All-Payer SystemA system by which all payers of health care bills - the government, private insurers, big companies and individuals - pay the same rates, set by the government, for the same medical service. This system does not allow for cost-shifting. [2] A plan to impose uniform prices on medical services, regardless of who\'s paying. [40]2
Alternative DeliveryRefers to alternatives to Fee-For-Service systems for delivering healthcare. Examples include Health Maintenance Organizations, Independent Practice Associations and Preferred Provider Organizations.47
Alternative Delivery And Financing SystemsADFSSee Alternative Delivery System.
Alternative Delivery SitesSubstitute for traditional inpatient sites for care such as ambulatory care centers, surgicenters, home care, hospice care, or alternative delivery and financing systems such as Health Maintenance Organizations or Preferred Provider Organizations.40
Alternative Delivery SystemProvision of health services in settings that are more cost-effective than an inpatient, acute-care hospital, such as skilled and intermediary nursing facilities, hospice programs, and in-home services. [2] An alternative to traditional inpatient care such as ambulatory care, home health care and same day surgery. [40]2, 40
Alternative Health CareAHCSee Alternative Medicine.
Alternative Levels Of CareAlternatives to traditional acute impatient care, such as ambulatory care centers, surgicenters, home care, skilled nursing facilities, and hospices.40
Alternative MedicineAs used in the modern Western world, it encompasses any unproven healing practice \'that does not fall within the realm of conventional medicine\'. Commonly cited examples include naturopathy, chiropractic, herbalism, traditional Chinese medicine, Unani, Ayurveda, meditation, yoga, biofeedback, hypnosis, homeopathy, acupuncture, and diet-based therapies, in addition to a range of other practices. It is frequently grouped with complementary medicine, which generally refers to the same interventions when used in conjunction with mainstream techniques, under the umbrella term complementary and alternative medicine, or CAM. Some significant researchers in alternative medicine oppose this grouping, preferring to emphasize differences of approach, but nevertheless use the term CAM, which has become standard.13
Ambulance RestockingThe practice of hospital replenishing certain drugs and supplies used by an ambulance service during transport of a patient to the hospital.40
AmbulatoryAble to get from one place to another independently (even if using assistive devices such as manual wheelchairs, canes or walkers).40
Ambulatory CareHealth care services provided to patients on an ambulatory basis, rather than by admission to a hospital or other health care facility. The services may provided at a hospital or a free-standing facility. [1] Services may include diagnosis, treatment, surgery, and rehabilitation. [2]1, 2
Ambulatory Care FacilityACFA medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility. Also called a medical clinic or medical center.39
Ambulatory Patient ClassificationsAPCA system for classifying outpatient services and procedures for purposes of payment. The APC system classifies some 7,000 services and procedures into about 300 procedure groups.2
Ambulatory Patient GroupAPGSA payment system that pays a fixed price for certain types of outpatient procedures.40
Ambulatory Payment ClassificationAPCThis is the method used by Centers For Medicare And Medicaid Services to implement prospective payment for ambulatory procedures. APC clusters many different ambulatory procedures into groups for purposes of payment.1
Ambulatory SettingAn institutional health setting in which organized health services are provided on an outpatient basis, such as surgery center, clinic or other outpatient facility. Ambulatory care settings also may be mobile units of services, e.g., mobile mammography, Magnetic Resonance Imaging.40
Ambulatory Surgery CenterASCSurgery performed on an outpatient basis, either hospital-based or performed in an office or surgicenter. [1] A free-standing facility certified by Medicare that performs certain types of types of procedures on an outpatient basis. [2] Freestanding centers that perform surgeries which do not require an overnight stay. [40]1
Ambulatory Utilization ManagementReview prior to service against established standards to determine the medical necessity and appropriateness of the care to be provided in an ambulatory setting. The selection of treatment plans subject to pre-service review may be based upon criteria such as proposed care that would require frequent visits, expensive therapy, an extended course of therapy, or costly technology. Concurrent review would be applied as appropriate.40
Ambulatory Utilization ReviewAURUtilization Review in an Ambulatory Setting.
AmendedAmA designation sometimes found before a House or Senate bill number showing that formal changes have been made to an introduced piece of legislation during the legislative process.40
AmendmentSee Rider.
American Accreditation Healthcare CommissionAAHC/URACFormerly known as the Utilization Review Accreditation Commission, this is an independent, not-for-profit corporation which develops national standards for Utilization Review and Managed Care Organizations.40
American Health Information CommunityAHICThe Office of the National Coordinator also provides management of and logistical support this group. It is a federally-chartered advisory committee that makes recommendations to the Secretary of HHS on how to make health records digital and interoperable, encourage market-led adoption and ensure that the privacy and security of those records are protected at all times.9
American Recovery and Reinvestment ActARRAOn Feb.17, 2009, President Obama signed this act into law.
American With Disabilities ActADAA Federal law which prohibits employers of more than 25 employees from discriminating against any individual with a disability who can perform the essential functions, with or without accommodations, of the job that the individual holds or wants.40
Amount, Duration And ScopeHow a Medicaid benefit is defined and limited in a state\'s Medicaid plan. Each state defines these parameters, thus state Medicaid plans vary in what is actually covered.40
Analysis Of VarianceANOVAA collection of statistical models, and their associated procedures, in which the observed variance is partitioned into components due to different explanatory variables. In its simplest form ANOVA gives a statistical test of whether the means of several groups are all equal, and therefore generalizes Student\'s two-sample t-test to more than two groups.13
Ancillary CareA term used to describe additional services performed related to care, such as lab work, X-ray and anesthesia.40
Ancillary ChargeAlso called hospital \'extras\' or miscellaneous hospital charges. They are supplementary to a hospital\'s daily room and board charge. They include such items as charges for drugs, medicines and dressings; laboratory services; x-ray examinations; and use of the operating room.40
Ancillary ServicesServices provided to hospital patients in the course of care, other than room, board, medical and nursing services, such as laboratory, radiology, pharmacy and rehabilitation therapy services.47
AnnotatorA system function that allows an explanatory note or diagram to be added to an image.77
Annual And Lifetime Maximum Benefit AmountsMaximum dollar amounts set by Managed Care Organizations that limit the total amount the plan must pay for all healthcare services provided to a subscriber per year or in his/her lifetime.39
Anti-Kickback StatuteA Federal law that prohibits the paying or receiving of remuneration in exchange for the referral of patients or businesses paid by a Federal health care program.40
AntiselectionThe tendency of people who have a greater-than-average likelihood of loss to seek healthcare coverage to a greater extent than individuals who have an average or less-than-average likelihood of loss. Also called Adverse Selection.39
AntitrustA situation in which a single entity, such as integrated delivery system, controls enough of the practices in any one specialty in a relevant market to have monopoly power (i.e., the power to increase prices).40
Antitrust LawsLegislation designed to protect commerce from unlawful restraint of trade, price discrimination, price fixing, reduced competition, and monopolies. See also Sherman Antitrust Act, Clayton Act, Federal Trade Commission Act.39
Any Willing ProviderA term used to describe legislation that requires a health plan to accept on its provider panels every physician, hospital or other practitioner that wants to participate in the health plan\'s products.40
Appeals Review CommitteeThe Managed Care Organization committee that reviews member appeals related to medical management or coverage determinations.39
Application Service ProviderASPA business that provides computer-based services to customers over a network. Software offered using an ASP model is also sometimes called On-demand software or Software as a Service. The most limited sense of this business is that of providing access to a particular application program (such as customer relationship management) using a standard protocol such as HTTP.13
Approved ChargeThe maximum fee Medicare will pay in a given area for a covered service.40
Approved Health Care Facility Or ProgramFacility or Program that is licensed, certified or otherwise authorized pursuant to the laws of the state to provide health care and which is approved by a health plan to provide the care described in a contract.40
ArbitrationA process in which the parties to a dispute submit their dispute to an impartial third party for a final, binding decision.39
Architecture The structure or structures of the system, which comprise software elements, the externally visible properties of those elements, and the relationships among them. 77
Area Agency On AgingAAAA public or private nonprofit organization designated by the state to develop and administer the area plan on aging within a sub-state geographic planning and service area. AAAs advocate on behalf of older people within the area and develop community-based plans for services to meet their needs. AAAs administer Federal, State, local and private funds through contracts with local service providers. In Delaware the State Unit on Aging also services as the state\'s sole Area Agency on Aging.40
ARRA 8Reference to 8 elements of the HITECH component of ARRA: 1) Technologies that protect the privacy of health information, i.e. common data transport, auditing, authentication, authorization; 2) A nationwide health information technology infrastructure, i.e. enveloping and delivery standards; 3) The utilization of a certified electronic record for each person in the US by 2014, i.e. standards in support of meaningful use; 4) Technologies that support accounting of disclosures made by a covered entity i.e. standards similar to audit trails that also include disclosures made to third party; 5) The use of electronic records to improve quality, i.e. aspects of meaningful use that enhance safety and standards which support quality measurement; 6) Technologies that enable identifiable health information to be rendered unusable/unreadable, i.e. encryption; 7) Demographic data collection including race, ethnicity, primary language, and gender i.e. standards which support demographic exchange; 8) Technologies that address the needs of children and other vulnerable populations, i.e. standards supporting immunization registries.82
ASC-Approved ProcedureA procedure that has been approved by Medicare for payment in the Ambulatory Surgical Center. A procedure is approved if it can be performed safely in the outpatient setting, if it was performed in the inpatient setting at least 20 percent of the time when it was approved, and if it is performed in physicians\' offices no more than 50 percent of the time. 2
ASO ContractSee Administrative Services Only Contract.39
AssessmentThe regular collection, analysis and sharing of information about health conditions, risks, and resources in a community. The assessment function is needed to identify trends in illness, injury, and death, the factors which may cause these events, available health resources and their application, unmet needs, and community perceptions about health issues.2
AssetsAll items of value that a company owns. [39] Medicaid term referring to resources such as savings, stocks, bonds, and certain possessions that are considered in determining financial eligibility. [40]39, 40
AssignmentA process under which Medicare pays its share of the allowed charge directly to the physician or supplier. Medicare will do this only if the physician accepts Medicare\'s allowed charge as payment in full [guarantees not to balance bill]. Medicare provides other incentives to physicians who accept assignment for all patients under the Participating Physician and Supplier Program. [2] An agreement by a physician to bill Medicare or other third-party payers directly and accept “reasonable charge” as full payment for his or her services. If the physician does not accept assignment, the patient is billed for the difference between the Medicare charge and his or her usual charge. [40] See also Balance Billing, Nonparticipating Physicians, Participating Physician, Participating Physician, Supplier Program.2, 40
Assignment Of BenefitsA method under which a claimant requests that his/her benefits under a claim be paid to some designated person or institution, usually a physician or hospital.40
Assistance With Government ServicesHelps eligible patients enroll in public health insurance programs, Medicaid, local and state programs, and other government aid programs.8
Assisted Living FacilityALFHome-like residential option that provides personal care and scheduled nursing care as needed.40
Assistive Devices Or TechnologyAny tools that are designed, fabricated, and/or adapted to assist a person in performing a particular task, e.g., cane, walker, shower chair, computer speech recognition, communication device.40
AssuranceMaking sure that needed health services and functions are available.2
Asymmetric Digital Subscriber LineADSLA form of DSL, a data communications technology that enables faster data transmission over copper telephone lines than a conventional voiceband modem can provide. It does this by utilizing frequencies that are not used by a voice telephone call.[1] A splitter - or microfilter - allows a single telephone connection to be used for both ADSL service and voice calls at the same time. ADSL can generally only be distributed over short distances from the central office, typically less than 4 kilometres (2 mi),[2] but has been known to exceed 8 kilometres (5 mi) if the originally-laid wire gauge allows for farther distribution.13
Asynchronous Transfer Mode ATMA network technology based on transferring data in cells or packets of a fixed size. 77
At-RiskTerm used to describe a provider organization that bears the insurance risk associated with the healthcare it provides. [39] Having to assume the financial liability for a loss that occurs when premiums paid are less than the cost of services provided. [40]39
AttendantTerm used most often by the disability community to refer to an aide who provides personal assistance in the community. See also Personal Care.40
Attrition RateDisenrollment or fall-out rate expressed as a percentage of total membership. Off-open enrollment terminations are generally due to subscriber\'s employment or relocation outside of the Managed Care Organization\'s service area, and cannot be controlled. Open enrollment terminations are sometimes due to subscriber dissatisfaction and thus may be controllable.40
Audit Of Provider TreatmentReview of the patient\'s medical record and charges and claims for services to assure that the services provided were consistent with the patient\'s diagnosis(es) and that documentation in the medical record supports the submitted charges.40
Audit TrailSecurity system that tracks a user’s access, deletion or modification of data. The term used in healthcare information security refers to a chronological record of system resource usage. This includes user login, file access, other various activities, and whether any actual or attempted security violations occurred, legitimate or unauthorized.77
AuthenticationThe verification of the identity of a person or process.77
AuthorizationA health plan\'s system of approving payment of benefits for services that satisfy the plan\'s requirements for coverage. [39] As it applies to managed care, authorization is the approval of care, such as hospitalization. Pre-authorization may be required before a patient is admitted or care is given by (or reimbursed to) non-HMO providers. [40]39, 40
Auto-AssignmentA term used with Medicaid mandatory managed care enrollment plans. Medicaid recipients who do not specify their choice for a contracted plan within a specified time frame are assigned to a plan by the state. Can also refer to assignment to primary care physicians.40
Automatic Call DistributorACDA device that answers calls with a recorded message and then routes calls to the appropriate department or unit.39
AutonomyAn ethical principle which, when applied to managed care, states that Managed Care Organizations and their providers have a duty to respect the right of their members to make decisions about the course of their lives.39
AuxilianMember of a hospital auxiliary who may or may not be an in-service volunteer within the affiliated hospital.47
Average Adjusted Per Capita CostAAPCCPayment rates used by the Health Care Financing Administration to reimburse managed care organizations for care delivered to Medicare enrollees. [40] The formula used is 95 percent of Medicare Part A and B costs per person by county. [47]40, 47
Average BenefitSee Average Cost.
Average CostThe average cost (or benefit) for a unit of output (e.g., one day in a hospital for one patient) is the total cost (or benefit) of the total units of output delivered by the total units of output.40
Average Daily CensusADCAverage number of people served on an inpatient basis on a single day during the reporting period. Calculated by dividing the total number of inpatient days by the number of days in the reporting period.4
Average Length Of StayALOSA standard hospital statistic used to determine the average amount of time between admission and discharge for patients in a diagnosis related group (DRG), an age group, a specific hospital or other factors.40
Average Manufacturer\'s PriceAMP\"Average price paid by wholesalers for drugs distributed to the retail class of trade, net of
customary prompt pay discounts.\"5
Average Wholesale PriceAWPAverage Wholesale Price of brand-name pharmaceuticals, as stated by the manufacturer, is used as a basis for determining discounts and rebates.1
Backbone The term is often used to describe the main network connections composing the Internet. 77
Balance BillThe fee amount remaining after patient co-payments.40
Balance Billing[1] Physician charges in excess of Medicare-allowed amounts, for which Medicare patients are responsible, subject to a limit. In Medicare and private fee-for-service health insurance, the practice of billing patients in excess of the amount approved by the health plan. In Medicare, a balance bill cannot exceed 15 percent of the allowed charge for nonparticipating physicians. [2] A provider\'s billing of a covered person directly for charges above the amount reimbursed by the health plan (i.e., difference between billed charges and the amount paid). This may or may not be allowed, depending upon the contractual arrangements between the parties. [40] See Allowed Charge, Nonparticipating Physicians.1, 2, 40
Balance SheetThe financial statement that shows an Managed Care Organization\'s financial status on a specified date. [39] Statement of assets and liabilities. [47]39, 47
Balanced Budget Act Of 1997BBAThis law made sweeping changes in the Medicare and Medicaid programs. Several of the significant provisions of the BBA were payment reductions to health care providers, new prospective payment systems for health care providers, and reduction of coverage of health care services by the Medicare and Medicaid programs.40
BandwidthA data transmission rate; the maximum amount of information (bits/second) that can be transmitted along a channel.77
Bar CodeA printed horizontal strip of vertical bars which represent decimal digits used for identification. Bar codes must be read by a bar code reader.77
Bariatric/Weight Control ServicesOffers advice and customized programs of weight loss.8
BaseA set dollar amount to cover the cost of health care per covered person excluding mental health/substance abuse services, pharmacy and administrative charges.40
Base CapitationA stipulated dollar amount to cover the health care per covered person less mental health/substance abuse services, pharmacy and administrative charges.40
Basic Benefits PackageA core set of health benefits that everyone in the country should have either through their employer, a government program, or a risk pool.40
Basic DRG Payment RateThe payment rate a hospital will receive for a Medicare patient in a particular Diagnosis-Related Group. The payment rate is calculated by adjusting the standardized amount to reflect wage rates in the hospital\'s geographic area [and cost of living differences unrelated to wages] and the costliness of the DRG. See also Standardized Amount, Diagnosis-Related Groups2
Basic Health PlanWashington\'s state-sponsored health insurance plan for children and adults not eligible for the standard Medicaid program or who do not otherwise receive employment-based coverage. The plan pays all costs for children in families with incomes up to 200% of the federal poverty level, and part of insurance costs for adults up to 200% of the federal poverty level. Individuals or families above the income cutoff can purchase BHP coverage at unsubsidized rates.2
Bed ConversionAllocation of beds from one level of care to another, as in converting acute-care beds to long-term care beds.47
Bed Days/1000The number of impatient days per 1000 health plan members for a fixed period of time.40
Bed Reservation BenefitIn some long-term care policies, a benefit paid to maintain the enrollee\'s space in a nursing home facility when the enrollee must be hospitalized temporarily.40
Before-And-After Design (Evaluation)A reflexive design in which only a few before-intervention and after-intervention measures are taken.2
Behavioral HealthcareThe provision of mental health and chemical dependency (or substance abuse) services.39
Behavioral OffsetSee Volume Offset2
Behavioral Risk Factor Surveillance SystemBRFSSAnnual telephone survey of state residents aged 18 and over that measures a variety of behaviors that affect health, such as diet, smoking, and use of preventive health services.2
BenchmarkingA method of planning and implementing quality management programs that consists of identifying the best practices and best outcomes for a specific process and emulating the best practices to equal or surpass the best outcomes. [39] The process of continually measuring products, services and practices against major competitors or industry leaders. [47]39, 47
BenchmarksLong-range measurable goals that speak to changing conditions. See also Benchmarking, Performance Measures, Quality Assurance, Key Indicators, Outcome Measures.40
BeneficenceAn ethical principle which, when applied to managed care, states that each member should be treated in a manner that respects his or her own goals and values and that Managed Care Organizations and their providers have a duty to promote the good of the members as a group.39
BeneficiarySomeone who is eligible for or receiving benefits under an insurance policy or plan. The term is commonly applied to people receiving benefits under the Medicare or Medicaid programs.2
Beneficiary LiabilityThe amount beneficiaries must pay providers for Medicare-covered services. Liabilities include copayments, and coinsurance amounts, deductibles, and balance billing amounts.2
BenefitAmount payable by the insurance company to a claimant, assignee, or beneficiary, when the insured suffers a loss covered by the policy.40
Benefit AmountSee Benefit Level.
Benefit CapThe lifetime dollar or day limitation of an insurance policy.40
Benefit DesignThe process an Managed Care Organization uses to determine which benefits or the level of benefits that will be offered to its members, the degree to which members will be expected to share the costs of such benefits, and how a member can access medical care through the health plan. [39] This will define scope of coverage. [40].39, 40
Benefit LevelThe limit or degree of services a person is entitled to receive based on his/her contract with a health plan or insurer.40
Benefit LimitSee Benefit Cap.
Benefit MaximumSee Benefit Cap.
Benefit PackageServices an insurer, government agency, health plan, or an employer offers under the terms of a contract.40
Benefit PackageServices covered by a health insurance plan and the financial terms of such coverage, including cost sharing and limitations on amounts of services. See Cost Sharing.2
Benefit Payment ScheduleList of the amounts an insurance plan will pay for covered health care services.40
Benefit PeriodThe maximum length of time specified in an insurance product during which benefits will be paid.40
Benefit RedesignRestructuring employee health benefit plans by providing incentives for prudent consumer behavior, such as introducing coverage for treatment in alternative settings; establishing managed care provisions such as pre-admission testing, second surgical opinions and pre-admission certification; establishing alternative financial arrangements, such as creating individual health accounts; or changing employee premium contribution, co-payment, or deductible levels.40
Benefits (Evaluation)Net project outcomes, usually translated into monetary terms. Benefits may include both direct and indirect effects.2
Benefits TaxA tax all workers would be required to pay based on the value of employer-provided health benefits which exceeds a certain level, or a limit on the tax deduction employers currently take for providing benefits.40
Benefits-To-Costs Ratio (Evaluation)The total discounted benefits divided by the total discounted costs.2
Best PracticesActual practices, in use by qualified providers following the latest treatment modalities, that produce the best measurable results on a given dimension.39
Biased SelectionThe phenomena whereby individuals or groups with atypical health risks disproportionately enroll in a specific health plan or type of health plan. Favorable selection occurs when a plan\'s enrollment predominantly consists of above-average health risks, while plans that disproportionately enroll individuals (and groups) of below-average health risks are said to experience adverse selection. Biased selection may be influenced by individual decisions in response to benefit design and plan characteristics as well as by insurer marketing and rating practices.40
Billed ClaimsThe fees or costs for health care services provided to a covered person submitted by a health care provider.40
Billing CodeSee Diagnostic and Treatment Code.
BiohazardA biological or chemical agent or a condition that is harmful to humans or other living things. A term often used in biohazardous materials like used needles, bandages and other contaminated materials.47
Biomedical EthicsA term used to describe philosophical questions involving morals, values and ethics in the provision of healthcare.47
BiometricsBiometrics are automated methods of recognizing a person based on a physiological characteristic such as fingerprints, retina, voice etc.77
Blended RatingFor groups with limited recorded claim experience, a method of forecasting a group\'s cost of benefits based partly on an Managed Care Organization\'s manual rates and partly on the group\'s experience.39
Block GrantAn intergovernmental transfer of federal funds to states and local governments for broad purposes such as health, education or community development in general. A block grant holds few requirements for how the money is to be spent, instead offering state and local discretion within general guidelines established by Congress and the executive branch. Annual program plans or applications are normally required. See also Categorical Grant, Formula Grant.40
Blood PressureBPThe pressure (force per unit area) exerted by circulating blood on the walls of blood vessels, and constitutes one of the principal vital signs. The pressure of the circulating blood decreases as it moves away from the heart through arteries and capillaries, and toward the heart through veins. When unqualified, the term blood pressure usually refers to brachial arterial pressure: that is, in the major blood vessel of the upper left or right arm that takes blood away from the heart.13
Board And CareResidential option providing no direct health or personal care services. See also Foster Care, Rest Residential Care, Family Rest Residential Care, Adult Foster Care.40
Board CertifiedA physician or other health professional who has passed an examination given by a specialty board and has been certified by that board as a specialist in that subject.47
Board EligibleA term used to describe a physician who is eligible to take the specialty board examination by virtue of having graduated from an approved medical school, completed a specific type and length of training and practiced for a specified amount of time.40
Board Of DirectorsThe primary governing body of a Managed Care Organization.39
Board Of Health1) The State Board of Health (for Washington State) has ten members, nine of whom are appointed by the Governor. The tenth member is the Secretary of the State Department of Health, or designee. The membership includes people who are experienced in matters of health and sanitation, an elected city official who is a member of a local board of health, a local health officer, and two people representing consumers of health care.; [2] Local boards of health are governing bodies of at least three persons who supervise all matters pertaining to the preservation of the life and health of the people within their jurisdiction. Each local board of health enforces public health statutes and rules, supervises the maintenance of all health and sanitary measures, enacts local rules and regulations, and provides for the control and prevention of any dangerous, contagious, or infectious disease.2
Board Of Medical ExaminersBMEA body recognized by a state government, which validates a health professional\'s credentials to determine the individual\'s ability to practice medicine in a particular state; the board is also authorized to suspend, place a physician on probation, or revoke his/her license to practice medicine.86
Body Mass IndexBMIA measure of body fat based on height and weight that applies to both adult men and women.50
Body Surface AreaBSAThe measured or calculated surface of a human body.13
Bonus PaymentAn additional amount paid by Medicare for services provided by physicians in Health Professional Shortage Areas. Currently, the bonus payment is 10 percent of Medicare\'s share of allowed charges. See Allowed Charge, Health Professional Shortage Area.2
Boren AmendmentAn amendment to OBRA 80 which repealed the requirement that states follow Medicare principles in reimbursing hospitals, nursing facilities and intermediate care facilities for the mentally retarded (ICF/MR) under the Medicaidprogram. The amendment substituted language which required states to develop payment rates which were \'reasonable and adequate\' to meet the costs of \'efficiently and economically operated\' providers (Recently repealed under the Balanced Budget Act).40
Boutique HospitalA limited service hospital designed to provide one medical specialty such as orthopedic or cardiac care.40
BrandA name, number, term, sign, symbol, design, or combination of these elements that an organization uses to identify one or more products.39
BroadbandingIs the grouping of jobs and roles into fewer but wider pay ranges to encourage incentives such as management development, career ladders, and skill- and competency-based pay.2
BrokerA salesperson who has obtained a state license to sell and service contracts of multiple health plans or insurers, and who is ordinarily considered to be an agent of the buyer, not the health plan or insurer.39
BrowserShort for Web browser, a software application used to locate and display Web pages. Commonly-used browsers are Microsoft’s Internet Explorer (IE) and Mozilla’s Firefox (FF).77
Budget NeutralityFor the Medicare program, adjustment of payment rates when policies change so that total spending under the new rules is expected to be the same as it would have been under the previous payment rules.2
BudgetingA process that includes creating a financial plan of action that an organization believes will help it to achieve its goals, given the organization\'s forecast.39
Bundled BillingThe practice of charging an all-inclusive package price for all medical services associated with selected procedures.47
Bundled PaymentA single comprehensive payment for a group of related services.2
Bundled RatePayments that represent an amalgamation of services.40
Bundled ServicesA single comprehensive group of closely-related specialty and related services. Payments for bundled services have become the norm in recent years and unbundled services are investigated closely by HCFA and other payers for evidence of fraud.2, 40
BundlingThe use of a single payment for a group of related services. Also called Bundling Payment or Bundled Payment.2
Business Case An economic argument or justification for capital expenditure. A business case includes an analysis of business process performance and associated needs or problems, proposed alternative solutions, assumptions, constraints, and a risk-adjusted cost-benefit analysis. 77
Business IntegrationThe unification of one or more separate business (nonclinical) functions into a single function.39
Buy-InRefers to the arrangments states make for paying Medicare premiums on behalf of those they are required or choose to cover. See also Qualified Medicare Beneficiary, Specified Low-income Beneficiary.2
Cache A special, high-speed storage mechanism. 77
Cafeteria PlanFlexible benefit plan under which the employer provides a range of taxable and nontaxable benefits options from which each eligible employee can make a limited number of selections. Options that may be available to employees through these plans include life insurance, health programs, retirement plans, vacation time, and stock options. Nontaxable benefits can include group term life insurance up to a specified amount of coverage, disability benefits, accident and health benefits, and group legal services to the extent that such benefits are excludable from gross income. A cafeteria plan that includes taxable and nontaxable benefits must meet certain requirements under the Internal Revenue Code. The term \'Cafeteria Plan\' may also describe a health benefit program that allows employees to select among various cost, coverage, or provider options.40
Calendar YearCYThe span of time from January 1 through December 31 of a year on the Julian calendar.
Call Abandonment RateA measure of how often members hang up before receiving assistance when they make telephone calls to a company and are put on hold.39
Canadian-Style SystemA health care financing system based upon the system in place in Canada that provides tax-financed universal coverage with the government as the sole purchaser of services.40
CapacityThe ability to perform the core public health functions of assessment, policy development, and assurance on a continuous, consistent basis, made possible by maintenance of the basic infrastructure of the public health system, including human, capital, and technology resources.2
Capacity StandardsStatements of what public health agencies and other state and local partners must do as a part of ongoing, daily operations to adequately protect and promote health, and prevent disease and injury.2
CapitalThe money that a public company\'s owners have invested in the company.39
Capital CostsEquipment and physical plant costs, but not consumable supplies. Included in these costs can be depreciation, interest, leases, rentals, taxes and insurance on physical assets like plant and equipment.2, 40
CapitationCAP1) Method of payment for health services in which a physician or hospital is paid a fixed amount for each person served regardless of the actual number of nature of services provided.; 2) A method of paying health care providers or insurers in which a fixed amount is paid per enrollee to cover a defined set of services over a specified period, regardless or actual services provided; 3) A health insurance payment mechanism which pays a fixed amount per person to cover services. Capitation may be used by purchasers to pay health plans or by plans to pay providers. See also Bundling, Fee for Service, Per Diem, Rate Setting, Medicare Risk Contract, Medicare+Choice.2
Capped FeeSee Fee Schedule.39
Captive AgentsAgents that represent only one health plan or insurer.39
Cardiac Catheterization LaboratoryA facility that diagnoses and treats heart disease through a tube, or catheter, inserted through an artery and passed into the heart or its vessels.8
Cardiac Intensive CareProvides specialized support for patients who because of heart attack, open-heart surgery, or other life-threatening conditions need intense, comprehensive care.8
Care Coordination BenefitA benefit in newer long-term care policies that pays consultation fees for a professional, such as a registered nurse or a medical social worker, to periodically assess and make recommendations about the enrollee\'s care program. The purpose is to adjust services when and if the individual\'s care needs change. Also called personal care advisor or personal care advocate benefit.40
Care Management ProtocolCMPSpecify utilization and treatment standards for various diagnoses.1
CarrierAn organization, typically an insurance company, acting as an insurer for private plans or government programs.40
CarryoverThat provision in medical plans that allows individuals who have not satisfied their deductible in a given calendar year to apply expenses incurred in the last quarter of that calendar year to the next year\'s deductible.40
Carve-Out CoverageCarve-out refers to an arrangement where some benefits [e.g., mental health] are removed from coverage provided by an insurance plan, but are provided through a contract with a separate set of providers. Also, carve-out may refer to a population subgroup for whom separate health care arrangements are made.2
Case ManagementMonitoring and coordinating the delivery of health services for individual patients to enhance care and manage costs; often used for patients with specific diagnoses or who require high-cost or extensive health care services.2
Case ManagerAn experienced health professional that works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care. Often used for patients with specific diagnoses or who require high-cost or extensive health care services.40
Case MixThe mix of patients treated within a particular institutional setting, such as the hospital. Patient classification systems like DRGs can be used to measure hospital case mix. See also DRGs, Case-Mix Index.2
Case Mix IndexA measure of relative severity of medical conditions of a hospital\'s patients.40
Case RateFlat fee paid for services based on client characteristics (such as diagnosis). For this fee the provider covers all of the services the client requires for a specific period of time. Also called bundled rate, or flat fee-per-case. Very often used as an intermediate step prior to capitation. See also Diagnostic Related Groups, Risk Adjustment.40
Case-Mix AdjustmentSee Risk-Adjustment.39
Case-Mix IndexCMIThe average DRG weight for all cases paid under PPS. The CMI is a measure of the relative costliness of the patients treated in each hospital or group of hospitals. See also Diagnosis-Related Group.2
Cash & CounselingA joint Federal and Robert Wood Johnson Foundation demonstration program in which cash allowances are given to Medicaid recipients with disabilities to pay for attendants and other services.40
Catastrophic CaseA catastrophic case is any medical condition where total cost of treatment (regardless of payment source) is expected to exceed an amount designated by the Health Maintenance Organization contract with the medical group.40
Catastrophic CoverageSee Catastrophic Health Insurance.
Catastrophic Health InsuranceHealth insurance which provides protection against the high cost of treating severe or lengthy illnesses or disability. Generally such policies cover all, or a specified percentage of, medical expenses above an amount that is the responsibility of another insurance policy up to a maximum limit of liability. It is also used to describe those services covered by reinsurance in a capitated program.40
Catchment AreaGeographical region where the majority of health care providers customers are located. See also Market Area.40
Categorical GrantFederal assistance to State and local governments, institutions, agencies, organizations, and individuals to carry out specified activities in the public\'s interest. In contrast to \'block grants\' money is to be spent for a particular purpose or for the benefit of a particular class or group of individuals, such as older persons. See also Block Grant, Formula Grant.40
Categorically NeedyUnder initial Medicaid eligibility requirements, individuals who received Medicaid benefits because of their welfare status: aged, blind, or disabled (as defined under the Supplemental Security Income program - SSI) or a member of a family with dependent children where one parent is absent, incapacitated or unemployed (as defined under the Aid to Families with Dependent Children program - AFDC). 39, 40
Categorically Needy IndividualsSee Categorically Needy.
Center For Health Care StrategiesEstablished in 1995 as a non-profit, non-partisan policy and resource center affiliated with the Woodrow Wilson School of Public and International Affairs at Princeton University. The Center serves as the National Program Office for two national initiatives of the Robert Wood Johnson Foundation: Medicaid Managed Care Program and Building Health Systems for People with Chronic Illnesses. See also Robert Wood Johnson Foundation.40
Center For Independent LivingCILFederally funded non-profit agencies at the state and community level that advocate for and provide independent living services to persons with disabilities.40
Centers For Disease ControlCDCAn agency within the U.S. Department of Health and Human Services that serves as the central point for consolidation of disease control data, health promotion and public health programs. CDC is Also called the Centers for Disease Control and Prevention, and is based in Atlanta, GA.40
Centers For Medicare & Medicaid ServicesCMSA U.S. federal government agency under Health and Human Services.1
Certificate Authority CAIs a trusted third-party organization or company that issues digital certificates used to create digital signatures and public-private key pairs. 77
Certificate Of AuthorityCOAThe license issued by a state to an Health Maintenance Organization or insurance company which allows it to conduct business in that state.39
Certificate Of CoverageCOC\"This document explains what health benefits you and your dependants have under the
plan. It details the services that will and will not be covered. Services that are not covered are called Exclusions.\"16
Certificate Of NeedCONSee Certificate of Public Review.
Certificate Of Public ReviewCPRA certificate issued by a governmental body to an individual or organization proposing to construct or modify a health facility, or to offer a new or different service. The process of obtaining the certificate is included in the term. [1] Replaced the former Certificate of Need Program. [40]1, 40
CertificationCertification is a voluntary system of standards that practitioners can choose to meet to demonstrate accomplishment or ability in their profession. Certification standards are generally set by non-governmental agencies or associations. [1] An official authorization for use of services. [40]1, 40
Certification Commission For Healthcare Information TechnologyCCHITCertification commission. CCHIT utilizes many of the standards proposed by HITSP for incorporation into the test scripts and criteria. 11
Certification Of A Comprehensive Electronic Health RecordEHR-CThis is what has been done to date. The product itself is certified, not the specific implementation at a specific site. EHR-C products should be able to meet all meaningful use criteria if implemented properly. The cost to the vendor for certification is $30,000-50,000 per product. EHR-C is for providers who seek maximal assurance of EHR compliance and capabilities.51
Certification Of A ModuleEHR-MThe Certification of a Module such as e-prescribing, lab ordering/resulting, clinical charting and data exchange. A clinician could assemble multiple modules and be certified regarding the specific functions they perform. Integration of data between modules is the clinician\'s responsibility. Meaningful use may be possible, but depends upon how the modules are used together. The cost to the vendor for certification is $5000-$35,000 per module. EHR-M is for providers who prefer to integrate technologies from multiple certified sources.51
Certification Of SiteEHR-SCertification of Site for the functionality that can be achieved using the software installed there. A screen capture function is used to document capabilities and this capture will be reviewed by an expert remotely. The cost is $150-300 per licensed provider. EHR-S is for providers who self- develop or assemble EHRs from non-certified sources.51
Certified Health PlanA managed health care plan, certified by the Health Services Commission and the Office of the Insurance Commissioner to provide coverage for the Uniform Benefits Package to state residents.2
ChargesThe posted prices of provider services.2
Charity CareFree or reduced fee care provided due to financial situation of patients.2
ChartMedical record77
Chart NoteA document, written by the clinician or provider, which describes the details of a patient’s encounter. Sometimes referred to as a progress note.77
Cherry PickingThe practice of seeking only healthy customers.40
Chief Executive OfficerCEOThe manager responsible for an organization\'s overall operation, general administration, and public affairs.39
Chief Financial OfficerSee Finance Director.
Chief Information OfficerCIOThe manager responsible for the plan\'s computer hardware and software systems, its telephone and electronic communication systems, and its electronic commerce capabilities.39
Chief Marketing OfficerSee Marketing Director.
Chief Medical OfficerSee Medical Director.
Chief Operations OfficerSee Director Of Operations.
Children\'s Health Insurance ProgramCHIPA federal program initiated in 1998 and jointly funced by states and the federal government, which allows states to expand health coverage to uninsured low income children not previously eligible for Medicaid.2, 40
Chronic CareCare and treatment rendered to individuals whose health problems are of a long-term and continuing nature. Rehabilitation facilities, nursing homes, and mental hospitals may be considered chronic care facilities.40
Chronic DiseaseA disease which has one or more of the following characteristics: (1) is permanent, leaves residual disability; (2) is caused by nonreversible pathological alternation; (3) requires special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care.40
Chronic IllnessSee Chronic Disease.
Citrix ServerA server solution, similar to Microsoft Terminal Services that provides remote access to clients via the web or to dummy terminals in a network.78
Civilian Health And Medical Program of the Uniformed ServicesCHAMPUSA program that provides funds to pay for the treatment in private institutions for members of the uniformed services and their families. See also TRICARE.40
ClaimAn itemized statement of healthcare services and their costs provided by a hospital, physician\'s office, or other provider facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.39
Claim FormAn application for payment of benefits under a health plan.39
ClaimantThe person or entity submitting a claim.39
Claims AdministrationThe process of receiving, reviewing, adjudicating, and processing claims.39
Claims AnalystSee Claims Examiner.39
Claims AuditReview of health care claims for the purpose of determining the liability of the payer, eligibility of the beneficiary and provider, and the accuracy of the amounts involved.40
Claims ExaminersEmployees in the claims administration department who consider all the information pertinent to a claim and make decisions about the Managed Care Organization\'s payment of the claim. Also called claims analysts.39
Claims InvestigationThe process of obtaining all the information necessary to determine the appropriate amount to pay on a given claim.39
Claims ReviewThe method by which an enrollee\'s health care service claims are reviewed before reimbursement is made. The purpose of this monitoring is to validate the medical appropriateness of the provided service and to be sure the cost of the service is not excessive.40
Claims SupervisorEmployee in the claims administration department who oversee the work of several claims examiners.39
Classification of Data CentersThe Telecommunication Industry Association (TIA) published the TIA-942 standard which classifies data center capabilities into four tiers: 1) Tier 1- Basic: 99.671% Availability (annual downtime of 28.8 hrs) Tier 2- Redundant Components: 99.741% Availability (22.0 hrs); 3) Tier 3- Concurrently Maintable: 99.982% Availability (1.6 hrs); 4) Tier 4- Fault Tolerant: 99.995% Availability (0.4 hrs).75
Clayton ActA federal act which forbids certain actions believed to lead to monopolies, including (1) charging different prices to different purchasers of the same product without justifying the price difference and (2) giving a distributor the right to sell a product only if the distributor agrees not to sell competitors\' products. The Clayton Act applies to insurance companies only to the extent that state laws do not regulate such activities. See also Antitrust Laws.39
ClearinghouseAn agency that accepts claims from providers and resubmits them to the carrier in the carrier\'s desired format and to meet the carrier\'s data requirments. [40] Some of the more popular clearinghouses include Emdeon/WebMD, McKesson and THIN. [78]40, 78
Client/Server architectureAn information-transmission arrangement, in which a client program sends a request to a server. When the server receives the request, it disconnects from the client and processes the request. When the request is processed, the server reconnects to the client program and the information is transferred to the client. This usually implies that the server is located on site as opposed to the Application Server Provider architecture.77
Clinic ModelSee Consolidated Medical Group.
Clinic Without WallsSee Group Practice Without Walls.
Clinical Data RepositoryA real-time database that consolidates data from a variety of clinical sources to present a unified view of a single patient. It is optimized to allow clinicians to retrieve data for a single patient rather than to identify a population of patients with common characteristics or to facilitate the management of a specific clinical department.77
Clinical Decision SupportCDSIteractive computer programs, which are designed to assist physicians and other health professionals with decision making tasks. A working definition has been proposed by Dr. Robert Hayward of the Centre for Health Evidence; \'Clinical Decision Support systems link health observations with health knowledge to influence health choices by clinicians for improved health care\'. This definition has the advantage of simplifying Clinical Decision Support to a functional concept.13
Clinical Decision Support SystemCDSSA system (typically software) designed to aid clinicians in decision making by matching individual patient characteristics to computerized knowledge bases for the purpose of generating patient-specific assessments or recommendations.77
Clinical Document ArchitectureCDAAn XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. CDA is part of the HL7 version 3 standard. Akin to other parts of the HL7 version 3 standard it was developed using the HL7 development Framework (HDF) and it is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 Data Types. CDA documents are persistent in nature. The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part relies on coding systems (such as from SNOMED and LOINC) to represent concepts.13
Clinical GuidelinesClinical guidelines are recommendations based on the latest available evidence for the appropriate treatment and care of a patient’s condition. See also Evidence-Based Order Sets.77
Clinical Information SystemCISSee Patient Medical Record.
Clinical IntegrationA type of operational integration that enables patients to receive a variety of healthcare services from the same organization or entity, which streamlines administrative processes and increases the potential for the delivery of high-quality health-care.39
Clinical Laboratory Improvement Act/AmendmentsCLIAA Federal law designed to set national quality standards for laboratory testing. The law covers all laboratories that engage in testing for assessment, diagnosis, prevention or treatment purposes.40
Clinical MessagingCommunication of clinical information within the electronic medical record to other healthcare personnel.77
Clinical Observations Recording and EncodingCORESee CORE Problem List.
Clinical Performance MeasuresCPMAny measure of the quality of the performance or outcome of medical procedures.15
Clinical Personal Health ServicesHealth services generally provided one-on-one in a medical clinical setting.2
Clinical Practice GuidelineCPGA utilization and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific clinical case.39
Clinical Practice ManagementThe development and implementation of parameters for the delivery of health-care services to plan members.39
Clinical Preventive ServicesHealth care services delivered to individuals in clinical settings for the purpose of preventing the onset or progression of a health condition or illness.2
Clinical Revenue Cycle ManagementCRCMSee Revenue Cycle.
Clinical StatusA type of outcomes measure that relates to biological health outcomes.39
Closed AccessA provision which specifies that plan members must obtain medical services only from network providers through a primary care physician to receive benefits. See also Closed Panel.39, 40
Closed FormularyThe provision that only those drugs on a preferred list will be covered by a PBM or Managed Care Organization.39
Closed PanelMedical services delivered in the Health Insuring Corporation owned health center or satellite clinic by physicians who belong to a specially formed, but legally separate, medical group that only serves the HIC.40
Closed PHOA type of physician-hospital organization that typically limits the number of participating specialists by type of specialty.39
Closed PlansAccording to the National Association of Insurance Commissioners\' Quality Assessment and Improvement Model Act, managed care plans that require covered persons to use participating providers.39
Closed-Panel HMOAn Health Maintenance Organization whose physicians are either direct employees or belong to a group of physicians that contract with it.39
Cloud ComputingA style of computing in which dynamically scalable and often virtualized resources are provided as a service over the Internet. Users need not have knowledge of, expertise in, or control over the technology infrastructure in the \'cloud\' that supports them. The concept generally incorporates combinations of the following: 1) Infrastructure as a Service (IaaS); 2) Platform as a Service (PaaS); and 3) Software as a Service (Saas).13
Code Of Federal RegulationsCFRA publication of the Federal government that consists of all regulations of Federal departments and agencies.40
CodingA mechanism for identifying and defining physicians\' and hospitals\' services. Coding provides universal definition and recognition of diagnoses, procedures and level of care. Coders usually work in medical records departments and coding is a function of billing. Medicare fraud investigators look closely at the medical record documentation which supports codes and looks for consistency. Lack of consistency of documentation can earmark a record as \'upcoded\' which is considered fraud.40
Coding ErrorsDocumentation errors in which a treatment is miscoded or the codes used to describe procedures do not match those used to identify the diagnosis.39
Cognitive ImpairmentA loss of mental capacity demonstrated by a person\'s inability to think, perceive, reason or remember. Such impairment results in a person\'s inability to care for him or herself without ongoing supervision from another person and is due to a mental or nervous condition with an organic cause.40
Cognitive Impairment Reinstatement ProvisionA provision in some long-term care policies that allows a policy that has lapsed because the enrollee did not pay the premium to be reinstated for full benefits, if the premiums are paid within six months after the lapse. Typically, the enrollee\'s physician must certify that the enrollee suffered a cognitive impairment that presumably caused the individual to fail to pay the premium on time.40
CoinsuranceA type of cost sharing where the insured party and insurer share payment of the approved charge for covered services in a specified ratio after payment of the deductible by the insured. For example, for Medicare physicians\' services, the beneficiary pays coinsurance of 20 percent of allowed charges. See Allowed Charge, Copayment, Cost Sharing, Deductible.2
Collective BargainingCollective bargaining refers to bargaining by union members, which is authorized by the NLRA, or non-unionized physicians\' attempts to obtain the right to bargain collectively.1
Commission On Accreditation Of Rehabilitation FacilitiesCARFNationally recognized independent review organization that accredits disability service organizations.40
Commission On Health Care QualityCHCQNational Commission charged with improving health care quality.40
Communication ChannelA person, location, or device furnished by a company to deliver information or services to customers.39
Community Based CareThe blend of health and social services provided to an individual or family in their place of residence (or nearby) for the purpose of promoting, maintaining, or restoring health or minimizing the effects of illness and disability.40
Community Care NetworksCCNSystems of health care providers organized to provide access to a comprehensive range of personal health services to members of a geographic area. The \'network\' may act as a health insurance plan offering its services for a specified premium. In this setting, primary care physicians and mid-level professionals are usually used as the entry and referral point for services and a range of services tailored to the needs of the specific community.40
Community Health CenterCHCAn ambulatory health care program usually serving a geographic area which has scarce or nonexistent health services or a population with special health needs (also called Neighborhood Health Center). Community Health Centers attempt to coordinate Federal, state, and local resources into a single organization capable of delivering both health and related social services to a defined population. While such a center may not directly provide all types of health care, it usually takes responsibility to arrange all medical services needed by its patient population.40
Community Health Information NetworkCHINA community-based Health Information Network.
Community Health Purchasing AllianceCHPAEstablished by the Health Care and Insurance Reform Act of 1993. CHPAs are responsible for assisting their members and particularly small employers to be prudent purchasers of health care by analyzing and disseminating data on prices, quality and patient satisfaction. CHPAs annually solicit bids for a variety of state mandated insurance products.40
Community InclusionSee Community Integration.
Community IntegrationTerm used in the disability community to refer to an individual\'s ability to share in community life including physical, cultural and social integration as well as self-determination.40
Community Nursing OrganizationCNOA Federal demonstration program that capitates home health and durable medical equipment costs using nurses as care managers.40
Community Rating1) A system of setting health insurance premiums based on the average cost of providing medical services to all people in a geographic area, without adjusting for an individual\'s medical history.; 2) A method for establishing health insurance premiums whereby an insurer\'s premium is the same for everyone in a premium class within a specific geographic area; 3) A method of determining an insurance premium structure that reflects expected utilization by the population as a whole, rather than by specific groups. Federally qualified Health Maintenance Organizations must community rate. See also Premium, Experience Rating.2, 39, 40
Community Rating By ClassCRCModifies Community Rating principles to establish different premiums based upon the age, sex, marital status, or industry of the individual group. The 1981 amendments to the Federal HMO Act allowed Federally qualified HMOs to community rate by class. Defined under the Tax Equity and Fiscal Responsibility Act of 1982, a Competitive Medical Plan (CMP) resembles a Health Maintenance Organization but is not qualified under the Federal HMO Act; it must be state-licensed; to be eligible to participate in Medicare, the CMP must be Federally approved.40
Co-MorbidityPresence of a second disease or condition influencing the care or treatment of a patient, and in the hospital setting is expected to increase the length of stay by at least one day for most patients.40
ComparabilityRequirement that the state must ensure that the same Medicaid benefits are available to all people who are eligible. Exceptions include benefits approved under Medicaid waiver programs for special sub populations of Medicaid eligibles.40
Comparative EffectivenessSee Comparative Effectiveness Research.
Comparative Effectiveness ResearchCERResearch that provides information on the relative strengths and weakness of various medical interventions.27
Compensation CommitteeThe Managed Care Organization committee that addresses issues related to compensation of the CEO and it\'s general compensation and benefit policies.39
Competency-Based PayIs compensation based on the development of those attributes that distinguish exceptional performers, such as customer orientation, team commitment and conflict resolution.2
Competitive AdvantageA factor, such as the ability to demonstrate quality, that helps organizations to compete successfully with other Managed Care Organizations for business.39
Competitive BiddingComparing one proposal to another based on price, services offered, quality, or other factors. Also refers to the process of offering reduced rates to health plans to obtain exclusive contracts from payers.40
Competitive Medical PlanCMPA mechanism created in TEFRA to enable organized provider groups, in addition to Federally qualified Health Maintenance Organizations, to participate in Medicare; these may be hospitals, medical group practices, Preferred Provider Organizations, non-Federally qualified Health Maintenance Organizations or other entities that meet certain financial solvency requirements. The CMP must be Federally approved to participate in Medicare.40
ComplaintA health plan member\'s expression that his expectations regarding the product or the services associated with the product have not been met.39
Complementary and Alternative MedicineCAMSee Alternative Medicine.
ComplicationA medical condition that arises during treatment and in the hospital setting that is expected to increase the length of stay by at least one day for most patients.40
Composite RateGrouping covered individuals from separate health insurance plans into a single group for medical underwriting purposes. For example, a composite rate would be established for all those eligible to participate in a multiple option plan regardless of the delivery and financing coverage elected by the plan participants. The number of covered individuals and the projected number and cost of claims under each plan option are considered.40
Comprehensive Health OrganizationCHOIn Canada, a joint venture formed by community and provider interests operating a nonprofit corporation; these agencies combine the existing elements of the health care system into a unified whole and provide a range of health promotion and treatment services to a defined roster population.18
Comprehensive Major Medical CoverageA health insurance plan that combines basic health benefits with higher benefit maximums to help cover the costs of major claims. The maximum benefit may range up to $500,000 or have no limit. This coverage usually includes a deductible and coinsurance.40
Comprehensive Outpatient Rehabilitation FacilityCORFMedicare term used to designate providers that offer a defined set of outpatient rehabilitation services that can be reimbursed through Medicare.40
Computer/Telephony IntegrationCTIA technology that unites a computer system with a telephone system so that the two technologies function seamlessly.39
Computer-Based Patient RecordSee Electronic Medical Record.
Computerized Medical RecordCMRSee Electronic Medical Record.
Computerized Patient RecordCPRSee Electronic Medical Record.
Computerized Physician Order EntryCPOEAn electronic prescribing system. With CPOE, physicians enter orders into a computer rather than on paper. Orders are integrated with patient information, including laboratory and prescription data. The order is then automatically checked for potential errors or problems.1
Computerized Provider Order EntryCPOESuggest \'providerer\' instead of \'physician\' since PA, nurses, etc. may use this as well.13
Conceptual Utilization (Evaluation)Long-term, indirect utilization of the ideas and findings of an evaluation.2
Concurrent ReviewA screening method by which a health care provider reviews a procedure performed or hospital admission authorized by a colleague to assess its necessity.40
Congregate HousingHousing for older and disabled people. Provides for private living quarters and shared eating and living areas.40
Congregate MealsProgram authorized under Title II-C-1 of the Older Americans Act which provides, five or more days a week, a hot or other appropriate meal per day in a group setting. Congregate nutrition programs also include nutrition education and other appropriate services for older people.40
Consolidated Medical GroupA large single medical practice that operates in one or a few facilities rather than in many independent offices. The single-specialty or multi-specialty practice group may be formed from previously independent practices and is often owned by a parent company or a hospital. Also called a medical group practice or clinic model.39
Consolidated Omnibus Budget Reconciliation ActCOBRAA federal act which requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage. Qualifying events include reduced work hours, death or divorce of a covered employee, and termination of employment.39
ConsolidationA type of merger that occurs when previously separate providers combine to form a new organization with all the original companies being dissolved.39
Consumer Directed CareSee Participant Driven Supports.
Consumer Directed ServicesSee Participant Driven Supports.
Consumer PreferenceSeveral interrelated capabilities including, but not limited to the ability: 1) for a consumer to define permissions for who is permitted to access information in their electronic health record (EHR) and under what circumstances this access is appropriate; 2) for consumers to express preferences regarding how and under what circumstances their health information should or should not be made available to others by their healthcare providers; 3) for consumers to authorize the release of their health information to another provider or third party; and 4) to establish various types of consumer preferences including but not limited to consents, advance directives, etc.98
Consumer Price IndexCPIA measure of changes in prices for various commodities. The medical CPI analyzes price changes which have occurred in hospitals, physician services, drugs and other related items.40
Continuing Care Accreditation CommissionCCACThe nation\'s only accreditation program for CCRCs. The commission accredits communities meeting strict criteria in the areas of finance, governance and administration, resident life and health care.40
Continuing Care Retirement CommunityCCRCPrepaid long term care plan that provides a continuum of residential options from independent living to nursing home care. Usually requires a substantial entrance fee and monthly charges.40
Continuing EducationCEWithin the domain of Continuing Education, professional continuing education is a specific learning activity generally characterized by the issuance of a certificate or continuing education units (CEU) for the purpose of documenting attendance at a designated seminar or course of instruction. Licensing bodies in a number of fields impose continuing education requirements on members who hold licenses to practice within a particular profession. These requirements are intended to encourage professionals to expand their knowledge base and stay up-to-date on new developments.13
Continuing Medical EducationCMEThe continuing education of practicing physicians through refresher courses, medical journals and texts, educational programs and self-study courses. In some states CME is required for continued licensure.40
Continuity of Care DocumentCCDAn XML-based markup standard intended to specify the encoding, structure and semantics of a patient summary clinical document for exchange. The CCD specification is a constraint on the HL7 Clinical Document Architecture (CDA) standard. The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part is based on the HL7 Reference Information Model (RIM) and provides a framework for referring to concepts from coding systems such as from SNOMED and LOINC.13
Continuity Of Care RecordCCRA patient health summary standard. It is a way to create flexible documents that contain the most relevant and timely core health information about a patient, and to send these electronically from one care giver to another. It contains various sections such as patient demographics, insurance information, diagnosis and problem list, medications, allergies and care plan.13
Continuous Quality ImprovementCQIA process to continuously make everything better each day. The initiative is customer focused and requires that processes be analyzed, measured, improved and evaluated on an ongoing basis.40
Continuum Of CareA range of clinical services provided to a patient that may reflect the treatment rendered during a single hospitalization or may include care for multiple conditions spanning the patient\'s lifetime.40
Contract Management SystemAn information system that incorporates membership data and provider reimbursement arrangements and analyzes transactions according to contract rules.39
Contractual AllowanceA practice of setting rates that are higher than actual costs to recover unreimbursed costs from government, uninsured, underinsured, and other payers.40
Contributory ProgramA method of payment for group coverage in which part of the premium is paid by the employee and part is paid by the employer or union.40
Convalescent CareTerm often used for short-term custodial care and refers to a \'recovery\' period after an illness or injury when some assistance may be needed that does not require skilled care.40
ConversionIn group health insurance, the opportunity given the insured and any covered dependents to change his or her group insurance to some form of individual insurance, without medical evaluation upon termination of his or her group insurance.40
Conversion Factor UpdateAnnual percentage change to the conversion factor. For Medicare, the update is set by a formula to reflect medical inflation, changes in enrollment, growth in the economy, and changes in spending due to other changes in law.2
Conversion FactorsThe dollar amount that, when multiplied by Relative Value Scale (RVS) unit values, estimate the average cost per service. The unit values vary by medical procedure according to the relative complexity or cognitive value of the different procedures. Conversion factors can be used to measure physician fee levels and they may be by area and the period being used for experience. The term also is used for any factor which is multiplied by a standard value to adjust payments. See also Relative Value Scales, Conversion Factor, Sustainable Growth Rate, Sustainable Growth Rate System, Volume Performance Standard System.40
Conversion PrivilegeSee Conversion.
Coordinated Care PlansCCPsThe Medicare+Choice delivery option that includes Health Maintenance Organizations (with or without a point-of-service component), Preferred Provider Organization, and provider-sponsored organizations (PSOs).39
Coordinated CoverageMethod of integrating benefits payable under more than one health insurance plan [for example, Medicare and retiree health benefits]. Coordinated coverage is typically orchestrated so that the insured\'s benefits from all sources do not exceed 100 percent of allowable medical expenses. Coordinated coverage may require beneficiaries to pay some deductibles or coinsurance.2
Coordination Of BenefitsCOBAn insurance provision whereby responsibility for primary payment for medical services is allocated among carriers when a person is covered by more than one employer-sponsored health benefit program. This prevents beneficiaries from being reimbursed for more than 100% of allowable charges.40
Coordination Of CoverageSee Coordination Of Benefits.
Copayment1) A fixed dollar amount paid for a covered service by a health insurance enrollee; 2) Amount that a member of a health plan has to pay for specific health services, such as visits to a physician. See also Coinsurance, Deductible.2
Co-PaymentA type of cost-sharing which requires the insured or subscriber to pay a specified flat dollar amount at the time the service is rendered, usually on a per-unit-of-service basis, with the third-party payer reimbursing some portion of the remaining charges.39, 40
Core FunctionsThree basic functions of the public health system: assessment, policy development, and assurance. State and local public health agencies must perform these functions in order to protect and promote health, and prevent disease and injury.2
CORE Problem List Subset of SNOMED CTThe primary purpose of this Subset of SNOMED CT is to facilitate the use of SNOMED CT for coding of problem list data in Electronic Health Records (EHRs) and to enable more meaningful use of EHRs to improve patient safety, health care quality, and health information exchange. A crosswalk from is provide72
Coronary Care UnitCCUA hospital ward specialized in the care of patients with heart attacks, unstable angina and (in practice) various other cardiac conditions that require continuous monitoring and treatment. Also called Cardiac Care Unit.13
Coronary Intensive Care UnitCICUSee Coronary Care Unit.
Corporate Compliance CommitteeThe Managed Care Organization committee that monitors and guides all compliance activities, including appointment of a corporate compliance officer, approval of compliance program policies and procedures, review of the organization\'s annual compliance plan, evaluation of internal and external audits to identify potential risks, and implementation of corrective and preventive actions.39
Corporate Compliance DirectorAn executive level health plan manager who is responsible for overseeing the plan\'s compliance with state and federal laws.39
CorporationAn organization that is recognized by the authority of a governmental unit as a legal entity separate from its owners.39
Cost ContainmentControl or reduction of inefficiencies in the consumption, allocation, or production of health care services that contribute to higher than necessary costs. (Inefficiencies in consumption can occur when health services are inappropriately utilized; inefficiencies in allocation exist when health services could be delivered in less costly settings without loss of quality; and, inefficiencies in production exist when the costs of producing health services could be reduced by using a different combination of resources.) [2] Efforts by purchasers and by providers to control health care costs through mechanisms such as benefit design, pre-admission certification, pre-admission testing, and concurrent review programs; second opinion programs; discharge planning; claims audits, case management, and employee education. [40]2, 40
Cost ContractAn arrangement between a managed health care plan and HCFA under Section 1876 or 1833 of the Social Security Act, under which the health plan provides health services and is reimbursed its costs. The beneficiary can use providers outside the plan\'s provider network. [2] Arranges for the provision of health services to plan members based on reasonable cost or prudent buyer concepts. The plan receives an interim capitated amount derived from an estimated annual budget that may be periodically adjusted during the course of the contract to reflect actual cost experience. The plan\'s expenses are audited at the end of the contract to determine the final rate the plan should have been paid. The AAPCC may be a factor in establishing the final payment rate. [40] See also Health Care Prepayment Plan, Medicare Cost Contract, Risk Contract.2, 40
Cost EffectivenessUsually considered as a ratio, the cost effectiveness of a drug or procedure, for example, relates the cost of that drug or procedure to the health benefits resulting from it. In health terms, it is often expressed as the cost per year per life saved or as the cost per quality-adjusted life-year saved.40
Cost ManagementSee Cost Containment.
Cost OutlierAn individual whose service costs are significantly higher than the average. In Medicare, it refers to a patient who is more costly to treat compared with other patients in a particular diagnosis related group. See also Day Outlier.40
Cost ReimbursementMethod of provider reimbursement based on actual costs incurred.40
Cost SharingA general term referring to payments made by health insurance enrollees for convered services. Examples of cost sharing include deductibles, coinsurance, and copayments. See Balance Billing, Coinsurance, Copayment, Deductible.2
Cost SharingFinancing arrangements whereby the member of a health plan must pay some of the costs to receive care.40
Cost Shifting1) When the cost of uncompensated care provided to the uninsured is passed onto the insured; 2) Increasing revenues from some payers to offset losses and lower net payments from other payers.2
Cost Shifting, EmployerInitiating or increasing employee financial participation in the health benefit cost through premium sharing, co-payments, co-insurance, or deductibles.40
Cost Shifting, MedicareA provision of COBRA, shifting primary coverage for eligible claims from Medicare to employer health plans for employees and their spouses.40
Cost Shifting, ProviderCharging some patients, or classes of patients, more than others for the same services in order to recover unreimbursed costs from government and other payers.40
Cost-Based ReimbursementA method of paying hospitals for actual costs incurred by patients. Those costs must conform to explicit principles defined by third-party payers.40
Cost-Benefit AnalysisA comparison of the cost of an action and the economic benefits it produces through elimination of other direct and indirect costs.40
Cost-Effectiveness AnalysisCEAAform of economic analysis that compares the relative expenditure (costs) and outcomes (effects) of two or more courses of action. Cost-effectiveness analysis is often used where a full cost-benefit analysis is inappropriate e.g. the problem is to determine how best to comply with a legal requirement. Typically the CEA is expressed in terms of a ratio where the denominator is a gain in health from a measure (years of life, premature births averted, sight-years gained) and the numerator is the cost of the health gain. The most commonly used outcome measure is Quality-Adjusted Life Years.13
Costs (Evaluation)Inputs, buth direct and indirect, required to produce an intervention.2
Council on Graduate Medical EducationCOGMEAuthorized by the U.S. Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues and financing policies and to recommend appropriate Federal and private-sector efforts to address identified needs.70
CoveragePromise by a third party to pay for all or a portion of expenses incurred for specified health care services.40
Coverage DecisionA decision by a health plan whether to pay for or provide a medical service or technology for particular clinical indications.2
Covered PersonAn individual who meets eligibility requirements and for whom premium payments are paid for specified benefits of the contractual agreement.40
Covered ServiceThe specified scope of services and the units of each service to be included as benefits under an insurance policy.40
CredentialingThe review and verification process used to determine the current clinical competence of a provider and whether the provider meets the Managed Care Organization\'s pre-established criteria for participation in the network.39
Credentialing CommitteeThe Managed Care Organization committee that establishes and updates credentialing processes and criteria and reviews provider credentials during the credentialing and recred-entialing processes.39
CredibilityA measure of the statistical predictability of a group\'s experience.39
Critical Loss AnalysisA two step analysis is used to perform a critical loss analysis. The first step identifies, for any given price increase, the amount of sales that can be lost before the price increase becomes unprofitable. The second step considers whether or not the actual level of sales lost due to the price increase will exceed this amount.1
Critical PathsFocus on a patient and document essential steps in the diagnosis and treatment of a condition or the performance of a condition. They document a standard pattern of care to be followed for each patient and are developed primarily as a nursing tool specific to a healthcare organization and its unique system. They consist of practice guidelines/parameters, clinical guidelines/protocols/algorithms, care tracks, care maps, care process models, case care coordination, collaborative case management plans, collaborative care tracks, collaborative paths, coordinated care, minimum standards, patient pathways, quality assurance triggers, reference guidelines, service strategies, recovery routes, target tracks, standards of care, standard treatment guidelines, total quality management, key processes, anticipated recovery paths. Also called Care Paths.2
Critical PathwayStandardized specifications for care developed by a formal process that incorporates the best scientific evidence of effectiveness with expert opinion.40
Cross Enterprise Document SharingXDSA profile created by Integrating the Healthcare Enterprise to facilitate the sharing of clinical documents between institutions. XDS re-uses ebXML registry methodology to provide a centralised method of indexing documents.13
Cure ProvisionA provider contract clause which specifies a time period (usually 60-90 days) for a party that breaches the contract to remedy the problem and avoid termination of the contract.39
Current Population SurveyU.S. Census Bureau survey conducted nationally to measure employment, health insurance status, income, and other variables.2
Current Procedural TerminologyCPTThe coding system for physicians\' services developed by the CPT Editorial Panel of the American Medical Association; basis of the HCFA Common Procedure Coding System. [2] The coding system provides a uniform language that accurately describes medical, surgical, and diagnostic services and is used to determine Medicare reimbursement rates. [40]2, 40
Custodial CareThe medical or non-medical services, which do not seek to cure, are provided during periods when the medical condition of the patient is not changing, or do not require the continued administration by medical personnel. 40
Customary ChargeSee Reasonable And Customary Fee.
Customary, Prevailing, And ReasonableCPRThe method of paying physicians under Medicare from 1965 until implementation of the Medicare Fee Schedule in January 1992. Payment for a service was limited to the lowest of [1] the physician\'s billed charge for the service, [2] the physician\'s customary charge for the service, or [3] the prevailing charge for that service in the community. Similar to the usual, customary, and reasonable system used by private insurers. See Medicare Fee Schedule; Usual, Customary and Reasonable.2
Daily Benefit AmountIn a long-term care policy the specific amount of insurance the policy pays for each covered day of long term care as defined in the policy. The enrollee may choose from a wide range of daily benefit amounts and, under some policies, different amounts for different types of care, such as a higher daily benefit for nursing home care and a somewhat lower benefit for home care.40
Data BookSee Actuary.
Data ConversionThe conversion of data from one software to another.77
Data Encryption StandardDESA widely-used method of data encryption using a private (secret) key.77
Data IntegrityRefers to the validity of data. A condition in which data has not been altered or destroyed in an unauthorized manner.77
Data MiningThe process of analyzing or extracting data from a database to identify patterns or relationships.77
Data SetA group of data elements relevant for a particular use.77
Data StructureA way to store and organize data in order to facilitate access and modifications.77
Data WarehouseA specific database (or set of databases) containing data from many sources that are linked by a common subject (e.g., a plan member).739
DatabaseA collection of information organized in such a way that a computer program can quickly select desired pieces of data.77
Database Management SystemDBMSA set of computer programs for organizing the information in a database. A DBMS supports the structuring of the database in a standard format and provides tools for data input, verification, storage, retrieval, query, and manipulation.77
Database MarketingA method of marketing that involves creating a database of customer information - including demographic, consumer preference, and sales history information - which is used to narrow the focus of an organization\'s direct marketing efforts.39
Date Of BirthDOBLocal date upon which a person was born as shown in a birth certificate.13
Date Of ServiceDOSDate on which a service was performed.
Day OutlierIn Medicare, this refers to a patient with an atypically long length of stay compared with other patients in a particular diagnosis related group. See also Cost Outlier.40
Death BenefitIn some long-term care policies, a benefit payable to the enrollee\'s survivors or estate if the enrollee dies before a specified age, often 65 or 70. The benefit amount is a refund of premiums the enrollee paid minus the amount of any benefits the enrollee received while living.40
Decision Making Capacity And IncapacityDecision making capacity is typically defined under state law as the ability of a patient to understand and appreciate the nature and consequences of health care decisions and to make an informed choice. If a person loses this ability, he or she is said to be incapacitated; and if a court determines that a person has become incapacitated, he/she is referred to as being legally incompetent.40
Decision Support SystemDSSA form of information technology that uses databases and decision models to enhance the decision-making process for Managed Care Organization executives, managers, clinical staff, and providers.39
Decision TreeThe fundamental analytic tool for decision analysis, is a way of displaying the temporal and logical sequence of a clinical decision problem. Its form highlights tree structural components: The alternative actions that are available to the decision maker; the probabilistic events that follow from and affect these actions, such as clinical information obtained or the clinical consequences revealed; and the outcomes for the patient that are associated with each possible scenario of actions and consequences.40
DecretionTermination of membership in a Medicare Health Maintenance Organization; always the last day of the month.40
Deductible1) The amount paid by the patient for medical care prior to insurance covering the balance.; 2) A type of cost sharing where the insured party pays a specified amount of approved charges for covered medical services before the insurer will assume liability for all or part of the remaining covered services; 3) Cumulative amount a member of a health plan has to pay for services before that person\'s plan begins to cover the costs of care. See also Coinsurance, Copayment, Cost Sharing.2
Deductible, Leveraging EffectA component of the insurance premium of \'fixed\' deductibles upon the price increase for a group medical plan. While premiums generally increase from one policy year to the next, employee-paid deductible usually remain constant or \'fixed\'. If insurance claims increase while the deductible remains the same between one policy year and the next, an economic adjustment is made in the premium structure to reflect the increase in the cost of the amount of benefits paid in comparison to increases in the total cost of services. Fixed deductibles result in greater inflation in group premiums that the underlying trend in medical care costs. The larger the deductible, the greater the impact on premium inflation the following policy year.40
Defensive MedicinePhysician practices just to reduce risk of a liability claim, e.g., performing diagnostic tests of marginal value. Defensive medicine totals an estimated $20.7 billion.2
Deficit Reduction Act Of 1984DEFRAFederal law with a number of implications, including the provision that requires companies to give employee spouses over 65 the opportunity to enroll under employer group health plans.40
Defined Contribution CoverageA funding mechanism for health benefits whereby employers make a specific dollar contribution toward the cost of insurance coverage for employees, but make no promises about specific benefits to be covered.2
De-Identified DataHealth information is considered de-identified when it does not identify an individual and there is no reasonable basis to believe that the information can be used to identify an individual. Information is considered de-identified if 18 identifiers are removed from the health information and if the remaining health information could not be used alone, or in combination, to identify a subject of the information.97
DeinstitutionalizationPolicy which calls for the provision of supportive care and treatment for medically and socially dependent individuals in the community rather than in an institutional setting.40
Demand ManagementA variety of strategies to reduce utilization of health care services such as telephone health help lines, intended to prevent unnecessary use of medical services. Also used to describe educational programs designed to teach patients about their medical conditions which results in better patient self management and the utilization of fewer health care resources in the long term.40
Dental Health Maintenance OrganizationDHMOAn organization that provides dental services through a network of providers to its members in exchange for some form of prepayment.39
Dental Point Of Service OptionA dental service plan that allows a member to use either a Dental Health Maintenance Organization network dentist or to seek care from a dentist not in the network. Members choose in-network care or out-of-network care at the time they make their dental appointment and usually incur higher out-of-pocket costs for out-of-network care.39
Dental POS OptionSee Dental Point Of Service Option.
Dental PPOSee Dental Preferred Provider Organization.
Dental Preferred Provider OrganizationAn organization that provides dental care to its members through a network of dentists who offer discounted fees to the plan members.39
Department Of HealthDOHA part of government which focuses on issues related to the general health of the citizenry. Subnational entities, such as states, counties and cities, often also operate a health department of their own. Health departments perform food licensing and food inspection (the person who performs this job is often called a Health Inspector), vaccination programs, free Sexually-Transmitted Disease (STD) and Acquired Immune Deficiency (AIDS) tests, and other medical assistance. Health departments also compile statistics about health issues of their area. 13
Department Of Health And Human ServicesHHSA Cabinet department of the United States government with the goal of protecting the health of all Americans and providing essential human services. Its motto is \"Improving the health, safety, and well-being of America\". Before 1979, the department was formerly known as the Department of Health Education and Welfare (HEW).13
Department Of JusticeDOJA Cabinet department in the United States government designed to enforce the law and defend the interests of the United States according to the law and to ensure fair and impartial administration of justice for all Americans (see 28 U.S.C. § 501). The DOJ is administered by the United States Attorney General (see 28 U.S.C. § 503), one of the original members of the cabinet.13
Department Of LaborDOLA Cabinet department of the United States government responsible for occupational safety, wage and hour standards, unemployment insurance benefits, re-employment services, and some economic statistics. Many U.S. states also have such departments. The department is headed by the United States Secretary of Labor. 13
Department Of TransportationDOTA Cabinet department of the United States government concerned with transportation. It was established by an act of Congress on October 15, 1966 and began operation on April 1, 1967. It is administered by the United States Secretary of Transportation.13
DependentAn individual who receives health insurance through a spouse, parent, or other family member.40
Depth Of Benefits Or CoverageRefers to the level of patient cost sharing required under a health insurance plan.40
Developmental DisabilityDDA severe, chronic disability which is attributable to a mental or physical impairment or combination of mental and physical impairments; is manifested before the person attains age 22; is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity of independent living, economic self-sufficiency; and reflects the person\'s needs for a combination and sequence of special, interdisciplinary, or generic care treatments of services which are lifelong or extended duration and are individually planned and coordinated.40
DiagnosisDxThe determination of the nature of a cause of a disease. A concise technical description of the cause, nature, or manifestations of a condition, situation, or problem.18
Diagnosis-Related GroupDRG1) A system of classifying patients on the basis of diagnoses for purposes of payment to hospitals.; 2) A system for determining case mix, used for payment under Medicare\'s PPS and by some other payers. The DRG system classifies patients into groups based on the principal diagnosis, type of surgical procedure, presence or absence of significant comorbidities or complications, and other relevant criteria. DRGs are intended to categorize patients into groups that are clinically meaningful and homogeneous with respect to resource use. Medicare\'s PPS currently uses almost 500 mutually exclusive DRGs, each of which is assigned a relative weight that compares its costliness to the average for all DRGs. See also Case Mix.2
Diagnostic And Treatment CodesSpecial codes that consist of a brief, specific description of each diagnosis or treatment and a number used to identify each diagnosis and treatment.39
Diagnostic GuidelinesA practice guideline targeted at evaluating patients with particular symptoms for the presence of diseases that would benefit from intervention. They are also used to guide the screening of asymptomatic patient populations for early stages of disease.40
Diagnostic Related GroupDRGA hospital classification system that groups patients by common characteristics requiring treatment.40
Diagnostic Related Group CreepThe illegal practice of manipulating and relabeling case mix into a higher reimbursement group.40
DictationThe process by which a physician records his/her notes about a patient. This recording is intended for reproduction in written word (Transcription).77
DifferentialThe out-of-pocket (or payroll deduction) difference that an eligible individual may be required to pay.40
Digital Imaging And Communications For MedicineDICOMLatest version of an original spec developed by American College of Radiology & National Electrical Manufacturer\'s Association. It provides standards for hardware interface, a minimum set of software commands, and a consistent set of data formats for machine-independent images and data.13
Digital SignatureSometimes referred to as Advanced Electronic Signature. Digital signature takes the traditional hand-written signature and creates a digital image of the signature to eliminate the need to print and sign documents.77
Direct AccessSee Self Referral.
Direct Contract HMOAn Health Maintenance Organization that contracts with each participating physician directly.40
Direct ContractingProviding health services to members of a health plan by a group of providers contracting directly with an employer, thereby cutting out the middleman or third party insurance carrier. The provider is usually at full risk in this situation.40
Direct CostCosts that are wholly attributable to the service in question, for example, the services of professional and paraprofessional personnel, equipment, and materials.40
Direct MailAn advertising medium, usually in print form, that uses a mail service to distribute an organization\'s sales offers or advertising messages.39
Direct MarketingA method of marketing that uses one or more media to elicit an immediate and measurable action - such as an inquiry or a purchase - from a customer or prospect. Also called direct response marketing.39
Direct Response MarketingSee Direct Marketing.
Direct Spending On HealthThe amount directly paid for health insurance premiums by a household, as well as other out-of-pocket expenses for health care services.40
Direct Utilization (Evaluation)Explicit utilization of specific ideas and findings of an evaluation by decision makers and other stakeholders.2
Directly Financed ServicesPublic health care and related social services (often funded by Federal, State and local governments) that are targeted towards the underserved and uninsured populations. They include public hospitals/clinics, Community and Migrant Health Centers, Health Care for the Homeless, and a variety of other grant and appropriations programs.40
Director Of OperationsThe manager who oversees the programs and services that support the organization as a whole, such as enrollment, claims, member services, office management, human resources, and other \'back room\' functions. Also called Chief Operations Officer.39
Directors And OfficersD&OSee Directors and Officers Liability Insurance.
Directors and Officers Liability InsuranceD&OLiability insurance payable to the directors and officers of a company, or to the corporation itself, to cover damages or defense costs in the event they are sued for wrongful acts while they were with that company. It has become closely-associated with broader management liability insurance, which covers liabilities of the corporation as well as the personal liabilities for the directors and officers of the corporation.13
DisabilityAs defined by the World Health Organization, a disability (resulting from an impairment) is a restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being.40
Discharge PlanningA process the Managed Care Organization uses to help determine what activities must occur before the patient is ready for discharge and the most efficient way to conduct those activities. [39] Services offered by health care facilities prior to discharge to help patients and their families develop an appropriate plan for post-discharge care. [40]39, 40
DisclaimerA qualifying statement. For example, a notice that while a statement may be generally true, there are exceptions.40
Discounted Fee-For-ServiceAn agreed upon rate for service that is usually less than the provider\'s full fee. This may be a fixed amount per service, or a percentage discount. Providers generally accept such contracts because they represent a means to increase their volume or reduce their chances of losing volume. See also Preferred Provider Organization, Exclusive Provider Prganization.40
Discounting (Evaluation)The treatment of time in valuing costs and benefits, that is, the adjustment of costs and benefits to their present values, requiring a choice of discount rate and time frame.2
Discrete DataA set of data is said to be discrete if the values belonging to it are distinct and separate, (i.e. they can be counted). Discrete data is more easily reportable as opposed to non-discrete or unstructured data.77
Disease ManagementA coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition. Also called Disease State Management.39
Disease ManagementAn effort to improve patient outcomes and lower costs by organizing managed care initiative around patients with a particular disease or condition.40
Disease State ManagementSee Disease Management.
DisenrollmentTerminating coverage with a health plan or insurance. See also Enrollment.40
Dispense As WrittenDAWMany brand name drugs have less expensive generic drug substitutes that are Therapeutically Equivalent. Prescriptions will also contain instructions on whether the prescriber will allow the pharmacist to substitute a generic version of the drug. DAW indicates that no substitution is allowed.13
Disproportionate ShareRefers to providers who serve a disproportionately high percentage of low-income, uninsured, or otherwise underserved patients.40
Disproportionate Share AdjustmentDSHA payment adjustment under Medicare\'s PPS or under Medicaid for hospitals that serve a relatively large volume of low-income patients.2
Disproportionate Share HospitalDSHA hospital that provides care to a high number of patients who cannot afford to pay and/or do not have insurance.40
DistributionThe activities and systems designed to make products or services available so that consumers can buy them.39
Distributional Effects (Evaluation)Effects of programs that result in a redistribution of resources in the general population.2
Do Not ResuscitateDNRAn advance directive that patients may make to forego cardiopulmonary resuscitation or other resuscitative efforts. See Living Will.40
Doc FixUS Congress provided relief to physicians agains the annual limitation on reimbursement set by the Sustainable Growth Rate calculations.
Doctors Office Quality Information TechnologyDOQ-ITA two-year special study that is designed to improve quality of care, patient safety, and efficiency for services provided to Medicare beneficiaries by promoting the adoption of EHR’s and Information Technology (IT) in primary care physician offices.77
Document ImagingConverting paper documents into an electronic format usually through a scanning process.77
Document ManagementIs a system involving scanning, categorizing and storing vital patient documents.77
DocumentationThe process of recording information.77
Domestic Insurance CompanyAn insurance company that operates under the laws of a specific state.40
Domicillary CareResidential program of the Veterans Administration providing health and social services to ambulatory disabled veterans. Generally involves less intensive care than a skilled nursing facility, but more than independent living.40
Double IndemnityPayment of twice the policy\'s normal benefit in case of loss resulting from specified causes or under specified conditions.40
Drive TimeThe length of time that members must drive to reach a primary care provider, which is typically set at a maximum of 15 minutes for urban areas and up to 30 minutes for rural areas.39
Drug CardsSee Pharmaceutical Cards.
Drug FormularyA listing of prescribed drugs covered by an insurance plan or used within a hospital. A positive formulary lists eligible products while a negative one lists exclusions. Some insurers will not reimburse for prescribed drugs not listed on the formulary; others may have limited reimbursement for non-formulary drugs.40
Drug Maintenance ListA catalog of a limited number of prescription medications, as designated by a managed health care organization, commonly prescribed by health care providers for their long-term patient use. This list is usually modified on a regular basis. Also called Additional Drug Benefit List.40
Drug Price ReviewDPRA monthly update of drug prices, at average wholesale price, from the American Druggist Blue Book.40
Drug Regimen ReviewDRRA comprehensive review of medications to determine if they are causing problems, having benefit or need changes to prevent a future problem or improve outcomes.92
Drug Use EvaluationDUEAn evaluation of prescribing patterns of physicians to specifically determine the appropriateness of drug therapy. There are three forms of DUE: Prospective (before or at the time of prescription dispensing), concurrent (during the course of drug therapy), and retrospective (after the therapy has been completed).40
Drug Use/Utilization ReviewDURAn evaluation of prescribing patterns or targeted drug use to specifically determine whether drugs are being used safely, effectively, and appropriately.39, 40
Dual Choice ProvisionsProvisions in the HMO Act of 1973 that required employers that offered healthcare coverage to more than 25 employees to offer a choice of traditional indemnity coverage or managed healthcare coverage under either a Closed-Panel HMO or an Open-Panel HMO.39
Dual EligiblesElderly and disabled Medicaid recipients who also qualify for Medicare coverage. Also called Dually Eligible.39
Due Process ClauseA provider contract provision which gives providers that are terminated with cause the right to appeal the termination.39
Duplicate Coverage InquiryA request to an insurance company or group plan by another insurance company or plan to determine whether other coverage exists for purposes of coordination of benefits.40
Duplication Of BenefitsOverlapping or identical coverage of an insured person under two or more health plans, usually the result of contracts with different insurers.40
Durable Medical EquipmentDMEDevices which are very resistant to wear and may be used over a long period of time. DME includes items such as wheelchairs, hospital beds, artificial limbs, etc.1
Durable Power Of AttorneyA document in which competent individuals can select other individuals to make decisions, including health care decisions, for them in the event they become incapacitated.40
Early And Periodic Screening, Diagnostic, And Treatment ServicesEPSDTA Medicaid program for recipients younger than 21 that provides screening, vision, hearing, and dental services at intervals that meet recognized standards of medical and dental practices and at other intervals as necessary to determine, ameliorate or correct any physical or mental illnesses or conditions.39, 40
E-CommerceSee Electronic Commerce.
Economic CredentialingHospital practice of determining whether to front physicians admitting privileges based on their ability to generate revenues and/or their cost-effectiveness.40
EditsCriteria that, if unmet, will cause an automated claims processing system to \'kick out\' a claim for further investigation.39
EffectivenessThe net health benefits provided by a medical service or technology for typical patients in community practice settings.2
EfficacyThe net health benefits achievable under ideal conditions for carefully selected patients.2
eHealth InitiativeeHIBased in Washington, D.C., the eHealth Initiative and its Foundation (eHI) are independent, non-profit, affiliated organizations whose missions are the same: to drive improvements in the quality, safety and efficiency of healthcare through information and information technology. We bring multiple stakeholders together to find common ground on a set of principles and policies for mobilizing information electronically that is responsible, sustainable, trustworthy, and meets the needs of every stakeholder in healthcare most importantly, patient61
Electronic CommerceSee E-Commerce.
Electronic Data InterchangeEDIThe computer-to-computer transfer of data between organizations using a data format agreed upon by the sending and receiving parties. [39] In health care, some common uses of this technology include claims submission and payment, eligibility, and referral authorization. [40]39, 40
Electronic EligibilityAn EMR feature which gives a payer access to deliver up-to-date insurance benefits eligibility information on patients.78
Electronic Health RecordEHRA longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician\'s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting. [3] It conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff, across more than one health care organization. (Doctor + patient side of record) [13]3, 13
Electronic Medical RecordEMRAn electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization. (Doctor\'s side of EHR). [13] A computerized record of a patient\'s clinical, demographic, and administrative data. Also called a Computer-Based Patient Record. [39] Computerized system providing real-time data access and evaluation in medical care. Together with clinical workstations and clinical data repository technologies, the EMR provides the mechanism for longitudinal data storage and access. A motivation for healthcare providers to implement this technology derives from the need for medical outcome studies, more efficient care, speedier communication among providers and management of health plans. [40]13, 39, 40
Electronic Medication Administration RecordeMARA point-of-care process utilizing bar code reading technology to monitor the bedside administration of medications. Generally accepted inventory management processes include: pharmacy to track medication inventory; inventory management concepts to include item identification; patient wristbands and medical records; verification process and decision-making tool at \'point-of-care\' at bedside. At the patient bedside, if any of the scanned information does not match the doctor\'s orders, a warning message is provided to the clinician.101
Electronic Order EntryEOEThe function of this program is to move from hand-written and verbal orders to computer-based entry.77
Electronic Patient Health InformationEPHISee Electronic Health Record.
Electronic Patient RecordEPRSee Computerized Patient Record.
Electronic PrescriptioneRxThe computer-based electronic generation, transmission and filling of a prescription, taking the place of paper and faxed prescriptions. e-Prescribing allows a physician, nurse practitioner, or physician assistant to electronically transmit a new prescription or renewal authorization to a community or mail-order pharmacy. Also called e-Prescribing.54
Electronic SuperbillAn electronic encounter form used for coding and billing.77
Eligibility DateThe defined date a covered person becomes eligible for benefits under an existing contract.40
Eligibility GuaranteeAn assurance of reimbursement to the health care provider for services/goods provided to a member who subsequently is found to be ineligible for benefits. Also called presumptive eligibility.40
Eligibility PeriodTime following the eligibility date (usually 31 days) during which a member of an insured group may apply for insurance without evidence of insurability. Also, in insurance policies, a period after the onset of an illness or injury during which no benefits are paid, effectively providing for a deductible. Common in long-term care policies, although some insurers offer policies with no elimination period. Sometimes incorrectly called a waiting period.40
Emergency DepartmentEDProvides immediate, unschled outpatient care.8
Emergency Medical ServicesEMSA system of health care professionals, facilities and equipment providing emergency care.40
Emergency Medical Treatment And Active Labor ActEMTALAA United States Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act. It requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a result of the act, patients needing emergency treatment can be discharged only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment.13
Emergi-CenterA health care facility whose primary purpose is the provision of immediate, short-term medical care for minor but urgent medical conditions.40
Employee Assistance ProgramsEAPWorkplace programs designed to help identify, educate, rehabilitate, and return the physically or emotionally impaired individual to the job. These programs may include helping employees gain access to health, legal and social services and to control specific conditions (e.g., chemical dependency, gambling, hypertension, stress, etc.).40
Employee Benefit SurveySurvey of employers administered by the U.S. Bureau of Labor Statistics to measure the number of employees receiving particular benefits such as health insurance, paid sick leave, and paid vacations.2
Employee Benefits ConsultantA specialist in employee benefits and insurance who is hired by a group buyer to provide advice on a health plan purchase.39
Employee Retirement Income Security ActERISAA broad-reaching federal law that establishes the rights of pension plan participants, standards for the investment of pension plan assets, and requirements for the disclosure of plan provisions and funding. [39] It also exempts self-insured health plans from state laws governing health insurance, including contribution to risk pools, prohibitions against disease discrimination, and other state health reforms.39, 40
Employer ContributionThe amount an employer contributes toward the premium costs of the contract. Employer contributions can be based on dollar amounts, percentages, employment status, length of service, single or family status, or other variables or combinations of the above.40
Employer MandateThe requirement that all employers above a minimum size provide a standard level of health insurance benefits to their employees.40
Employer Purchasing CoalitionsSee Purchasing Alliances.
Employment-Based Health Insurance PlanA group health plan that is sponsored by an employer for its employees and their dependents.40
Employment-Model IDsAn integrated delivery system that generally owns or is affiliated with a hospital and establishes or purchases physician practices and retains the physicians as employees.39
EMR Adoption ModelIdentifies and scores hospitals using a 8 step scale that charts the path to a fully paperless environment. It was created by the Health Information and Management Systems Society Analytics Group.83
EncounterA healthcare visit of any type by an enrollee to a provider of care or services.39
Encounter DataDescription of the diagnosis made and services provided when a patient visits a health care provider under a managed-care plan. Encounter data provide much of the same information abailable on the bills submitted by fee-for-service providers.2
Encounter ReportA report that supplies management information about services provided each time a patient visits a provider.39
Encounters Per Member Per YearThe number of Encounters related to each member on a yearly basis.40
EncryptionProcess of converting messages or data into a form that cannot be read without decrypting or deciphering it.77
EndorsementsSee Rider.
EnrolleeA person who is covered by health insurance. See also Beneficiary.2
EnrollmentPurchasing health care coverage from a health plan or insurance. Individuals who purchase coverage are known as enrollees. Also refers to the total number of enrolled covered persons in a health plan. See also Open Enrollment, Disenrollment.40
Enrollment BrokerIndependent organization that assists individuals in choosing and enrolling in a health plan. See also Benefits Manager.
Enrollment ProtectionSee Stop-Loss, Reinsurance.
Enterprise LiabilityLegislation that would make hospitals and other health care facilities legally and financially liable for all negligent injuries caused by their medical staffs.40
Enterprise Scheduling SystemAn information system that permits physician groups, hospitals, and other facilities within an enterprise to function as a single organization in arranging access to facilities and resources.39
Environmental HealthAn organized community effort to minimize the public\'s exposure to environmental hazards by identifying the disease or injury agent, preventing the agent\'s transmission through the environment, and protecting people from the exposure to contaminated and hazardous environments.2
Environmental Protection AgencyEPAA Federal and State agency responsible for programs to control air, water and noise pollution, solid waste disposal and other environmental concerns.40
E-PrescribingSee Electronic Prescription.
Equal Employment Opportunity CommissionEEOCThe EEOC was created by the Civil Rights Act of 1964. The purpose of the EEOC is to eliminate discrimination on the basis of race, color, religion, sex, national origin, disability or age in hiring, promoting, firing, wages, testing, training, apprenticeship, and all other terms and conditions of employment.40
Error RateA measure of the accuracy of information given and transactions processed.39
Essential Community ProvidersThose organizations in a community that specialize in serving low income persons or provide unique services that cannot be provided by others. Managed Care Organizations are sometimes required by public payers to contract with these providers to ensure a comprehensive continuum of care.40
Essential Lifestyle PlanningELPSee Person Centered Planning.
EthicsThe principles and values that guide the actions of an individual or population when faced with questions of right and wrong.39
Ethics In Patient Referrals ActA federal act which, along with its amendments, prohibits a physician from referring patients to laboratories, radiology services, diagnostic services, physical therapy services, home health services, pharmacies, occupational therapy services, and suppliers of durable medical equipment in which the physician has a financial interest. Also called the Stark Laws.39
EvaluationSee Formative Evaluation, Process Evaluation, Outcome Evaluation, Impact Evaluation.
Evaluation and Management CodingE&M CodingDocumentation guidelines for Evaluation and Management CPT codes from the Center for Medicare and Medicaid Services (formerly HCFA).77
Evaluation And Management ServiceEM1) A nonprocedural service, such as a visit or consultation, provided by physicians to diagnose and treat diseases and counsel patients.; 2)A nontechnical service, such as a visit or consultation, provided by most physicians to diagnose and treat diseases and counsel patients.2
EvercareMedicare managed care demonstration for nursing home residents. A geriatric Nurse Practitioner acts as a case manager.40
Evidence Of InsurabilityAny statement of proof of a person\'s physical condition affecting their acceptability for insurance or a health care contract.40
Evidence-Based MedicineEBMAims to apply evidence gained from the scientific method to certain parts of medical practice. It seeks to assess the quality of evidence relevant to the risks and benefits of treatments (including lack of treatment). According to the Centre for Evidence-Based Medicine, \'Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.\'13
Evidence-Based Order SetAn Order Set that is formulated based on rigorous evaluation of clinical outcomes of alternate treatment plans.6
Evidence-Based Practice CentersEPC13 centers were designated in 2002 by the Agency for Healthcare Research and Quality (AHRQ). Their primary mission is to generate, assemble, and synthesize knowledge and evidence necessary for the effective and efficient application of medical and public health practices. To accomplish this, the EPC integrates clinical expertise with comprehensive expertise in evidence-based methods including formal literature review, meta-analysis, decision analysis, and cost-effectiveness analysis. 10
Ex Ante Efficiency Analysis (Evaluation)An efficiency analysis undertaken prior to program implementation, usually as part of program planning, to estimate net outcome in relation to costs.2
Ex Post Efficiency Analysis (Evaluation)An efficiency analysis undertaken subsequent to knowing a program\'s net outcome effects.2
Excess ChargeSee Balance Billing.
ExchangeThe insurance marketplace that would be created under all current proposals, in which the uninsured and small businesses would go to buy coverage. To offer plans on the exchange, insurers would have to complay with regulation forbidding practices such as denying coverage because of preexisting conditiona. The hope is that pooling risk in one markrplace would lower rates for the uninsured and for small businesses [29]. The act of one party giving something of value to another party and receiving something of value in return.[39]29, 39
Excluded Hospitals And Distinct-Part UnitsSpecialty hospitals, rehabilitation, psychiatric, long-term care, children\'s, and cancer) that are excluded from Medicare\'s hospital inpatient PPS. Hospitals located in U.S. territories, Federal hospitals, and Christian Science Sanatoria are also excluded from PPS. Excluded facilities are paid under cost-reimbursement, subject to rate of increas limits. Rehabilitation facilities are slated to move into a prospective payment system in October 2000. Congress has also directed HCFA to develop a legislative proposal for a prospective payment system for long-term care facilities.2
Exclusion CoverageMethod of integrating payment for health benefits provided by Medicare and an employer. Medicare payments are subtracted from actual claims and the employer-sponsored plan\'s benefits are applied to the balance. Such coverage generally leaves the beneficiary responsible for the employer\'s plan\'s cost sharing and deductibles.2
ExclusionsPopulations or services can be excluded from a mainstream managed care plan, and reimbursed on a fee-for-service basis. An exclusion may be generally employed if mainstream plans are unwilling to enroll high cost individuals or if a system of care does not exist to serve this population, because either their disease is rare or their rural or remote location prohibits the formation of a managed care network.2
Exclusive Provider OrganizationEPOA form of Preferred Provider Organization in which patients must visit a caregiver who is on its panel of providers. If a visit to an outside provider is made, the EPO will offer limited or no coverage for the office or hospital visit.40
Exclusive Remedy DoctrineA rule which states that employees who are injured on the job are entitled to workers\' compensation benefits, but they cannot sue their employers for additional amounts.39
Exclusivity ClauseA part of a contract which prohibits a health care provider from contracting with more than one managed care organization.40
Executive CommitteeThe Managed Care Organization committee responsible for handling issues related to overall organizational policy, including lines of business and employment policies.39
Executive Quality Improvement CommitteeThe Managed Care Organization committee that oversees the organization\'s quality management committee, accreditation efforts, and other quality functions.39
Expansion PopulationsMedicaid recipients who do not meet categorically needy or medically needy criteria and therefore fall outside the traditional Medicaid population.39
ExpenditureIn the context of health care, monies spent on the acquisition of health care coverage and/or services.40
Expenditure LimitsIncludes various mechanisms which limit the amounts that may be spent to acquire health care coverage and services (e.g., negotiated fee schedules, hospital global operating budgets).40
Expenditure TargetsVoluntary or involuntary limits on health care spending. This may refer to spending for specific types of service (e.g., physician care), multiple types of service (e.g., hospital, physician, drugs), or all health care services. See also Global Budgets.40
ExpensesThe amounts spent or committed by an Managed Care Organization to pay for covered benefits and their administration.39
ExperienceThe actual cost of providing healthcare to a group during a given period of coverage.39
Experience RatingA rating method under which a Managed Care Organization analyzes a group\'s recorded healthcare costs by type and calculates the group\'s premium partly or completely according to the group\'s experience. See also Community Rating.39
Experience-Based CriteriaA utilization review resource that recognizes generally accepted community standards of practice and the overall experience and expert opinion of medical directors and other healthcare providers.39
Expert SystemA knowledge-based computer system whose purpose is to provide expert consultation to information users for solving specialized and complex problems.39
Explanation of BenefitsEOBA statement from the patient\'s insurance company that breaks down services rendered at time of doctor or hospital visit and amounts covered by insurance provider.78
Explanation Of Medicare BenefitsEOMBThe statement of payment from Medicare; it shows the amount charged by the provider, the amount approved by Medicareand the amount actually paid by Medicare. It is the statement that is submitted to the insurance company for payment under the Medigap policy. Other insurers sometimes use the term Explanation Of Benefits to refer to their own payment statements.40
Extended Care FacilityA skilled nursing facility that provides post-hospital services to be reimbursable by Medicare.2
Extensible Markup LanguageXMLA computer language used to define data elements on a Web page and communication between two business systems. Example: Standard messaging system for and EMR to integrate with other software such as a practice management or drug formulary database.78
Extension Of BenefitsA provision of many policies which allows medical coverage to be continued past the termination date of the policy for employees not actively at work and for dependents hospitalized on that date. Such extended coverage usually applies only to the specific medical condition that has caused the disability and continues only until the employee returns to work or the dependent leave the hospital.40
External Data RepresentationXDRAn IETF standard from 1995, that allows data to be wrapped in an architecture independent manner so data can be transferred between heterogeneous computer systems. It is implemented as a software library of functions that is portable between different operating systems and is also independent of the transport layer.13
External Quality Review OrganizationEQROSee Quality Improvement Organization.
External StandardsPerformance standards that are based on outside information such as published industry-wide averages or best practices.39
Externalities (Evaluation)Effects of a program that impose costs on persons or groups who are not targets.2
ExtranetA private computer network that incorporates Web-based technologies and links selected resources of a Managed Care Organization to external entities or individuals.39
Face SheetAlso called a Summary Screen or Patient Dashboard. This screen includes a summary of patient relevant information on one screen.77
Factored RatingCommunity rating impacted by group-specific demographics (Also called adjusted community rating).40
Failsafe Budget MechanismAn overall limit on Medicare spending proposed in a conference agreement [H.R. 2491] passed by the Congress in November 1995. The mechanism would obtain scored savings of $270 billion by the year 2002 based on economic assumptions of the Congressional Budget Office, and would provide a safeguard against unrestrained growth in Medicare spending. See Scored Savings.2
False Claims ActA Federal law that imposes liability for treble damages and fines of $5,000 to $10,000 for knowingly submitting a false or fraudulent claim for payment to the Federal government.40
Family Medical Leave ActFMLA1993 Federal law requiring that employers of 50 or more (and public employers of any size) allow employees to take leave to care for ill family members and to return to substantially similar employment conditions following the leave.40
Family Rest Residential CareResidential option in Delaware providing less care than assisted living, usually at the \'board and care\' level (i.e., no direct health or personal care services) but differs from rest residential in that it is provided in the home of a caregiver. Also called adult foster care.40
Farmers Home AdministrationFHAA division of the U.S. Department of Agriculture that guarantees hospital mortgages.40
Fat ClientA fat client is a network computer with a hard disc drive, as opposed to a thin client which has no disc drive.77
Favorable SelectionStrategy that encourages the enrollment of the healthier persons while discouraging the enrollment of sicker persons. See also Cherry Picking, Adverse Selection, Risk Selection.40
Fax-On-DemandA communication system that enables a member to request specified documents or forms by entering information on the telephone keypad and to receive the requested information by fax.39
Federal DeficitFederal government spending in excess of revenues.2
Federal Employee Health Benefits ProgramFEHBPA voluntary health insurance program for federal employees, retirees, and their dependents and survivors.39
Federal Financial ParticipationFFPThat portion paid by the Federal government to states for their share of expenditures for providing Medicaidservices, administering the Medicaid program, and certain other human service programs.40
Federal HMO ActFederal law regulating HMOs. Under the Federal HMO act, an entity must have three characteristics to call itself an HMO: (1) an organized system for providing health care or otherwise assuring health care delivery in a geographic area, (2) an agreed upon set of basic and supplemental health maintenance and treatment services, and (3) a voluntarily enrolled group of people.40
Federal Medical Assistance PercentageFMAPThe percentage of Federal matching dollars available to a state to provide Medicaid services. FMAP is calculated annually based on a formula designed to provide a higher Federal matching rate to States with lower per capital income. Currently at 50% (minimum FMAP) for Delaware. See also Medicaid.40
Federal Poverty LevelFPLIncome guidelines established annually by the Federal government. Public assistance programs usually define income limits in relation to FPL or the Supplemental Security Income (SSI) level for the provision of a bare minimun for food, clothing, transportation, shelter, and other necessities. See also Supplemental Security Income.2, 40
Federal Qualified Health CenterFQHCA reimbursement designation in the United States, referring to several health programs funded under the Health Center Consolidation Act (Section 330 of the Public Health Service Act). Health programs funded include: 1) Community Health Centers which serve a variety of Federally designated Medically Underserved Area/Populations; 2) Migrant Health Centers; 3) Health Care for the Homeless Programs; and 4) Public Housing Primary Care Programs that serve residents of public housing and are located in or adjacent to the communities they serve. FQHCs are community-based organizations that provide comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services to persons of all ages, regardless of their ability to pay.13
Federal RegisterAn official publication of the Federal government that provides final and proposed regulations of Federal legislation.40
Federal Trade CommissionFTCAn independent agency of the United States government, established in 1914 by the Federal Trade Commission Act. Its principal mission is the promotion of \"consumer protection\" and the elimination and prevention of what regulators perceive to be harmfully \"anti-competitive\" business practices, such as coercive monopoly.13
Federal Trade Commission ActA federal act which established the Federal Trade Commission (FTC) and gave the FTC power to work with the Department of Justice to enforce the Clayton Act. The primary function of the FTC is to regulate unfair competition and deceptive business practices, which are presented broadly in the Act. As a result, the FTC also pursues violators of the Sherman Antitrust Act. See also Antitrust Laws.39
Federally Qualified Health CenterFQHCA health center in a medically underserved area that is eligible to receive cost-based Medicare and Medicaid reimbursement.2
Federally Qualified HMOAn Health Maintenance Organization that has satisfied certain federal qualifications pertaining to organizational structure, provider contracts, health service delivery information, utilization review/quality assurance, grievance procedures, financial status, and marketing information as specified in Title XIII of the Public Health Service Act. See also Health Maintenance Organization.2
Federation Of American Health SystemsFAHSA trade association comprised of proprietary or investor-owned hospitals.40
Fee AllowanceSee Fee Schedule.
Fee DisclosurePhysicians and caregivers discuss, or post, their charges with patients prior to treatment.39, 40
Fee For ServiceFFSA method in which physicians and other health care providers receive a fee for services performed.40
Fee Hr Service EquivalencyQuantitative measures of the difference between the amount a provider receives from an alternative reimbursement system (e.g., capitation) compared to fee-for-service reimbursement.40
Fee MaximumSee Fee Schedule.
Fee ScheduleThe fee determined by a Managed Care Organization to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. Also called a Fee Allowance, Fee Maximum or Capped Fee.39
Fee Schedule Payment AreaA geographic area within which payment for a given service under the Medicare Fee Schedule does not vary. See Geographic Adjustment Factor.2
Fee-For-ServiceFFS1) Is the most prevalent payment mechanism for physicians. It is reimbursing the provider whatever fee he or she charges on completion of a specific service; 2) A method of paying health care providers for individual medical services rendered, as opposed to paying them salaries or capitated payments; 3) Type of payment used by some health insurers that pays providers for each service after it has been delivered. See also Capitation.2
Fee-For-Service Payment SystemA benefit payment system in which an insurer reimburses the group member or pays the provider directly for each covered medical expense after the expense has been incurred.39
FiduciaryRelating to, or found upon, a trust or confidence. A fiduciary relationship exists where an individual or organization has an explicit or implicit obligation to act in behalf of another person\'s or organization\'s interests in matters which affect the other person or organization. This fiduciary is also obligated to act in the other person\'s best interest with total disregard for any interests of the fiduciary.40
File Transfer ProtocolFTPA standard network protocol used to exchange and manipulate files over an Internet Protocol computer network, such as the Internet. FTP is built on a client-server architecture and utilizes separate control and data connections between the client and server applications.13
FinanceThe sources, timing, and channels of public health funds, and the authority to raise and distribute those funds.2
Finance CommitteeThe Managed Care Organization committee that sets the organization\'s broad investment policies and is responsible for reviewing and approving financial and accounting activities.39
Finance DirectorThe manager who is responsible for accounting activities such as budget planning, accounting, and internal audits, and financial operations such as membership billing and underwriting. Also called a chief financial officer.39
Financial Accounting Standards BoardFASBSince 1973, this has been the designated organization in the private sector for establishing standards of financial accounting. Those standards govern the preparation of financial statements. They are officially recognized as authoritative by the Securities and Exchange Commission (SEC) (Financial Reporting Release No. 1, Section 101, and reaffirmed in its April 2003 Policy Statement) and the American Institute of Certified Public Accountants (Rule 203, Rules of Professional Conduct, as amended May 1973 and May 1979). Such standards are important to the efficient functioning of the economy because investors, creditors, auditors, and others rely on credible, transparent, and comparable financial information.71
Financial ManagementThe process of managing a Managed Care Organization\'s financial resources, including management decisions concerning accounting and financial reporting, forecasting, and budgeting.39
Financial Services Modernization ActLegislation that allows convergence among the traditionally separate components of the financial services industry: banks, securities firms, and insurance companies. Also called the Gramm-Leach-Bliley (GLB) Act.39
FinancingRefers to mechanisms through which money to pay health care providers for the delivery of health care services is delivered.40
FirewallA system designed to prevent unauthorized access to or from a private computer network.77
First Contact Resolution RateThe percentage of questions that are answered, requests that are fulfilled, and transactions that are processed and completed at the initial point of contact.39
First Data BankThe leading provider of drug information. Provides context and integration information for heathcare of every type at every level.78
First Dollar CoverageA feature of an insurance plan in which there is no deductible, and therefore the plan\'s sponsor pays a proportion or all of the covered services provided to a patient as soon as he or she enrolls.40
Fiscal IntermediaryAn entity, usually an insurance company, that has a contract with HCFA to determine and make Medicare payments for Part A and certain Part B benefits to hospitals and other providers of services and to perform related functions in a certain geographic region. See also Medicare.2, 40
Fiscal NoteAn analysis by the Legislative Budget Office of the financial impact of proposed state legislation.40
Fiscal YearFYA 12-month period for which an organization plans the use of its funds, such as the Federal government\'s fiscal year (October 1 to September 30). Fiscal years are referred to by the calendar year in which they end; for example, the Federal fiscal year 1998 began October 1, 1997. Hospitals can designate their own fiscal years, and this is reflected in differences in time periods covered by the Medicare Cost Reports. See also PPS Year.2
Five-Year ReviewA review of the accuracy of Medicare\'s relative value scale that the Health Care Financing Administration is required to conduct every five years.2
Flexible Benefit PlanA benefit program that offers employees a number of benefit options, allowing them to tailor benefits to their needs.40
Flexible Spending AccountFSAOne of a number of tax-advantaged financial accounts that can be set up through a cafeteria plan of an employer in the United States. An FSA allows an employee to set aside a portion of his or her earnings to pay for qualified expenses as established in the cafeteria plan, most commonly for medical expenses but often for dependent care or other expenses. Money deducted from an employee\'s pay into an FSA is not subject to payroll taxes, resulting in a substantial payroll tax savings. The most common FSA, the medical expense FSA (also medical FSA or health FSA), is similar to a health savings account (HSA) or a health reimbursement account (HRA). However, while HSAs and HRAs are almost exclusively used as components of a consumer driven health care plan, medical FSAs are commonly offered with more traditional health plans as well. An FSA may be utilized by paper claims or an FSA debit card also known as a Flexcard.13
Focus Group InterviewAn unstructured, informal session in which six to ten people are led by a moderator who asks questions to guide the group into an in-depth discussion of a given topic.39
Food And Drug AdministrationFDAAn agency within the Federal government that is responsible for regulations pertaining to food and drugs sold in the United States.40
Foodborne IllnessIllness caused by the transfer of disease organisms or toxins from food to humans.2
ForecastingA process that involves predicting incoming and outgoing cash flows-primarily revenues and expenses-and predicting the values of its assets, liabilities, and capital or capital and surplus.39
Foreign Insurance CompanyAn insurance company that operates under the laws of another state.40
Formative EvaluationFormative evaluation, including pretesting, is designed to assess the strengths and weakensses of materials or campaigning strategies before implementation. It permits necessary revisions before the full effort goes forward. Its basic purpose is to maximize the chance for program success before the communication activity starts.2
Formula GrantFederal assistance to local governments in accordance with a distribution formula established by law or regulation. The actual payment is usually based on such factors as: population characteristics, per capita income, substandard housing, or rate of unemployment. Formulas indicate the total of which recipients are entitled if the requirements, regulations or other criteria of law are met. See also Categorical Grant, Block Grant.40
FormularyA list of approved drugs for treating various diseases and conditions. [1] A listing of drugs, classified by therapeutic category or disease class, that are considered preferred therapy for a given managed population and that are to be used by a Managed Care Organization\'s providers in prescribing medications. [39] Drugs outside of the formulary are not used, unless in rare, specific circumstances. [40]1, 39, 40
Foster CareSee Adult Foster Care, Family Rest Residential, Board and Care.
Foundation For AccountabilityFACCTIndependent national organization that has developed a quality system similar to Health Plan Employer Data And Information Set that places more emphasis on outcomes, but does not take into account case mix.40
Frail ElderlySenior population with any combination of chronic conditions, dementia or ADL dependencies.40
Free and Open Source SoftwareFOSSSoftware which is liberally licensed to grant the right of users to study, change, and improve its design through the availability of its source code. This approach has gained both momentum and acceptance as the potential benefits have been increasingly recognized by both individuals and corporate players.13
Free Look ProvisionAn insurance policy provision required by most states, allowing the policy owner to inspect the policy for a specified period of time. If desired the owner may return the policy to the insurer for a refund of the entire premium.40
Free Standing Emergency Medical Service CenterA health care facility that is physically separate from a hospital and whose primary purpose is the provision of immediate, short-term medical care for minor but urgent medical conditions. Also called Urgent Care Center.40
Free Standing FacilityUsually a specialty facility that is not part of a comprehensive care system. For example, a free-standing surgery facility or a free-standing assisted living facility.40
Free Standing Outpatient Surgical CenterA health care facility that is physically separate from a hospital, that provides pre-scheduled, outpatient surgical services. Also called Surgicenter or Ambulatory Surgical Facility.40
Freedom Of ChoiceFOCIn general, laws that permit enrollees to choose any provider and receive substantial reimbursement from their health plan. Also refers to a Federal Medicaid rule requiring states to ensure that Medicaidbeneficiaries are free to obtain services from any qualified provider. Exceptions are possible through waivers of Medicaid and special contract options. See also Any Willing Provider, Point-Of-Service.40
FrequencyThe number of times a service was provided.40
Fringe BenefitsNon-cash benefit, often including health insurance, provided to a worker by an employer.40
Full-Time EquivalentFTEA standardized accounting of the number of full-time and part-time employees.40
Fully Funded PlanA health plan under which an insurer or Managed Care Organization bears the financial responsibility of guaranteeing claim payments and paying for all incurred covered benefits and administration costs.39
Functional Independence Measure - Function Related GroupA Patient classification system developed for medical rehabilitation patients.2
Functional StatusA patient\'s ability to perform the activities of daily living.39
Functionally DisabledAn inability to live independently or to perform ADLs or IADLs independently.40
Functionally ImpairedSee Functionally Disabled.
Funding LevelThe amount of revenue required to finance a medical care program. Under an insured program, this is usually premium rate. Under a self-funded program, this amount is usually assessed per expected claim cost, plus stop-loss premium, plus all related fees.40
Funding MethodThe means by which an employer pays for the employee health benefit plan. The most common methods are 1) prospective and/or retrospective, 2) refunding products, 3) self-funding, and 4) shared risk management.40
Funding VehicleIn a self-funded plan, the account into which the money that an employer and employees would have paid in premiums to an insurer or Managed Care Organization is deposited until the money is paid out.39
Gag-ClauseA section of a physician\'s contract with a Managed Care Organizations or other such health plans, prohibiting the physician from frankly discussing all treatment options, covered or uncovered, expensive or inexpensive, that could be of benefit to the patient.84
Gag-RuleA provision in a provider contract with a managed care organization or insurer that prevents providers from discussing all available treatment options or financial incentives provided by the insurer with patients.40
GainsharingIs an incentive program focused on improving operating results, typically implemented at the group or organizational level.2
GamingGaining advantage by using improper means to evade the letter or intent of a rule or system.2
GastrointestinalGIPertaining to the stomach and intestine.18
GatekeeperThe person in a managed care organization who decides whether or not a patient will be referred to a specialist for further care. Physicians, nurses and physician assistants all function as gatekeepers.2
General Accounting OfficeGAOThe audit, evaluation, and investigative arm of the United States Congress. It is located in the legislative branch of the United States government.13
General Intensive CareProvides more intensive care than ordinary across a range of services.8
General Medical And Surgical CareProvides broad range of diagnostic and therapeutic services, including surgery.8
General PractitionerGPA physician whose practice is based on a broad understanding of all illnesses and who does not restrict his/her practice to any particular field of medicine.40
GeneralistsPhysicians who are distinguished by their training as not limiting their practice by health condition or organ system, who provide comprehensive and continuous services, and who make decisions about treatment for patients presenting with undifferentiated symptoms. Typically include family practitioners, general internists, and general pediatricians.2
Generic Drug Or SubstitutionIn cases in which the patent on a specific pharmaceutical product expires and drug manufacturers produce generic versions of the original branded product, the generic version of the drug (which is theorized to be exactly the same product manufactured by a different firm) is dispensed even though the original product is prescribed. Some managed care organizations and Medicaid programs mandate generic substitution because of the generally lower cost of generic products.40
Generic SubstitutionThe dispensing of a drug that is the generic equivalent of a drug listed on a pharmacy benefit management plan\'s formulary. In most cases, generic substitution can be performed without physician approval.1239
Genetic Testing/CounselingA service equipped with a laboratory and directed by a qualified physician to advise parents and prospective parents concerning the potential and implications of genetic defects. The laboratory is capable is analyzing human DNA, RNA, chromosomes, proteins, and certain other genetic material in order to detect possible genetic defects.8
Geographic Adjustment FactorGAFThe GAF for each service in a particular payment area is the average of the area\'s three geographic practice cost indexes weighted by the share of the service\'s total RVUs accounted for by the work, practice expense, and malpractice expense components of the Medicare Fee Schedule. See Geographic Practice Cost Index, Relative Value Units.2
Geographic AvailabilityThe number of primary care providers within a given radius of a particular target.39
Geographic FactorSee Geographic Multiplier.
Geographic MultiplierA factor used to make geographic adjustments to the Medicare Fee Schedule or any other fee schedule. Also called Geographic Factor.40
Geographic Practice Cost IndexGPCIAn index summarizing the prices of resources required to provide physicians\' services in each payment area relative to national average prices. There is a GPCI for each component of the Medicare Fee Schedule: physician work, practice expense, and malpractice expense. The indexes are used to adjust relative value units to determine the correct payment in each fee schedule payment area. See Fee Schedule Payment Area, Medicare Fee Schedule.2
Geriatric ServicesMedicine dealing with the process and diseases of aging. Could include adult day care, Alzheimer\'s services, and other specific treatment of older people.8
GeriatricsMedical field specializing in care for the elderly.40
GerontologySocial Science field studying the biological, psychological and social aspects of aging.40
GLB ActSee Financial Services Modernization Act.
Global BudgetsGlobal budgets or expenditure limits are prospectively defined caps on spending for some portion of the health care industry. Several industrialized countries have applied global budgeting in various forms. Many of these systems (e.g., France, Australia, Sweden, and Switzerland) concentrate their global budgets solely on hospital operating budgets treating capital expenditure outside the annual budget process. Others, including Canada and the United Kingdom, have global budgets that cover both hospital and physician expenditures. Global budgeting in the U.S. as envisioned by most proponents would establish binding targets for permissible growth in the U.S. health care system. Many issues remain unclear, however. In particular, the scope of services to be included (e.g., public vs. private sector programs), and the method for enforcing budget caps (e.g., price controls, premium controls, etc.).40
Global ServiceA package of clinically related services treated as a unit for purposes of billing, coding, or payment.40
Glycated HemoglobinA1cGlycated hemoglobin or HbA1c- the test for this gives a picture of a person\'s average blood glucose control for the past 2 to 3 months. This is an indication of the diabetes treatment plan is working.9
GovernanceThe legal authority and responsibility for the public health system.2
Grace PeriodA set number of days past the due date of a premium payment during which medical coverage may not be canceled and through which the premium payment may be made.40
Graduate Medical EducationGMEMedical education as an intern, resident or fellow after graduating from a medical school.40
Gramm-Leach-Bliley ActSee Financial Services Modernization Act.
GrandfatheringWhen rules change, current participants remain unaffected and the new rules only apply to new participants.40
Graphical User InterfaceGUI(Pronounced “gooey”). A program interface that takes advantage of the computer\'s graphics capabilities to make the program easier to use. Well-designed graphical user interfaces can help expedite the software learning process.77
Greatest Economic NeedThe need resulting from an income level at or below the poverty threshold established by the Bureau of the Census. See also Targeting.40
Greatest Social NeedThe need caused by non-economic factors which include physical and mental disabilities, language barriers, and cultural or social isolation including that caused by racial or ethnic status which restricts an individual\'s ability to perform normal daily tasks or which threatens his or her capacity to live independently. See also Targeting.40
Grid ComputingThe combination of compute resources from multiple administrative domains applied to a common task, usually to a scientific, technical or business problem that requires a great number of computer processing cycles or the need to process large amounts of data. One of the main strategies of grid computing is using software to divide and apportion pieces of a program among several computers, sometimes up to many thousands. Grid computing is distributed[citation needed], large-scale cluster computing, as well as a form of network-distributed parallel processing. The size of grid computing may vary from being small — confined to a network of computer workstations within a corporation, for example — to being large, public collaboration across many companies and networks. \"The notion of a confined grid may also be known as an intra-nodes cooperation whilst the notion of a larger, wider grid may thus refer to an inter-nodes cooperation\". This inter-/intra-nodes cooperation \"across cyber-based collaborative organizations are also known as Virtual Organizations\". It is a form of distributed computing whereby a “super and virtual computer” is composed of a cluster of networked loosely coupled computers acting in concert to perform very large tasks. This technology has been applied to computationally intensive scientific, mathematical, and academic problems through volunteer computing, and it is used in commercial enterprises for such diverse applications as drug discovery, economic forecasting, seismic analysis, and back-office data processing in support of e-commerce and Web services. What distinguishes grid computing from conventional cluster computing systems is that grids tend to be more loosely coupled, heterogeneous, and geographically dispersed. Also, while a computing grid may be dedicated to a specialized application, it is often constructed with the aid of general-purpose grid software libraries and middleware.13
Grievance ProcedureThe process by which a health plan member or participating provider can air complaints and seek remedies.40
Gross Domestic ProductGDPThe total current market value of all goods and services produced domestically during a given period; differs from the gross national product by excluding net income that residents earn abroad.2
Gross National ProductGNPValue of all goods and services produced in a country in one year, plus income earned by its citizens abroad, minus income earned by foreigners in the country. Different from Gross Domestic Product.13
Group Health InsuranceHealth insurance purchased through a group that exists for some purpose other than buying insurance, such as a workplace, labor union, or professional association.40
Group InsuranceAny insurance policy or health services contract by which groups of employees (and often their dependents) are covered under a single policy or contract, issued by their employer or other group entity.40
Group MarketA market segment that includes groups of two or more people who enter into a group contract with an Managed Care Organization under which it provides healthcare coverage to the members of the group.39
Group Model HMOA Health Maintenance Organization contracts with a multi-specialty group of physicians who are employees of the group practice. Also called Group Practice Model HMO.39
Group Practice AssociationA formal arrangement of three or more physicians or other health professionals providing health services. Income is pooled and redistributed to the members of the group according to a prearranged plan.40
Group Practice HMO ModelSee Group Model HMO.
Group Practice Model HMOSee Group Model HMO.
Group Practice Without WallsGPWWA legal entity that combines multiple independent physician practices under one umbrella organization and performs certain business operations for the member practices or arranges for these operations to be performed. The GPWW may maintain its own facility for business operations or it may hire another company to provide this function. Also called a clinic without walls.39
Group Purchasing OrganizationGPOA shared service which combines the purchasing power of individual organizations or facilities in order to obtain lower prices for equipment and supplies.1
Growth ChartA feature designed for Primary Care or an EMR that can be used for pediatric patients. Age, height, weight, and head measurements can be entered over the patient\'s lifetime and charted on a line graph.78
Guaranteed IssueThe requirement that an insurer or health plan accept everyone, regardless of health, income or age, that applies for coverage and guarantees the renewal of that coverage as long as the premium is paid.40
Guaranteed RenewableThe requirement that each insurer and health plan continue to renew health policies purchased by individuals as long as the person continues to pay the premium for the policy.2
HabilitationPrograms and activities designed to help individuals maximize their independence.40
Haphazard ChangeChange that is unplanned and uncontrolled and produces unpredictable results. Also called Random Change.39
Hardware TokenA physical device, such as a USB flash drive, that an authorized user of computer services is given to ease authentication. Also called Security Token.13
HCFA Common Procedural Coding SystemHCPCSFederal coding system for medical procedures. HCPCS includes Current Procedural Terminology (CPT) codes, national alpha-numeric codes and local alpha-numeric codes. The national codes are developed by HCFA to supplement CPT codes. They include physical services not included in CPT as well as non-physician services such as ambulance, physical therapy and durable medical equipment. The local codes are developed by local Medicare carriers to supplement the national codes. HCPCS codes are 5-digit codes, the first digit a letter followed by four numbers. HCPCS codes beginning with A through V are national; those beginning with W through Z are local. See also Coding, Current Procedural Terminology.40
Healtcare Information Technology Standards PanelHITSPA cooperative partnership between the public and private sectors. The Panel was formed for the purpose of harmonizing and integrating standards that will meet clinical and business needs for sharing information among organizations and systems.20
Health AlliancesNonprofit agencies that act as the health insurance purchasing agent for consumers under a system of managed competition, organized at either the state or regional level, or by employer groups. These alliances negotiated with provider networks to get the best plan at the lowest cost and would serve defined regions or classes of customers.40
Health And Human ServicesHHSSee U.S. Department of Health and Human Services.
Health And Welfare FundHealth care benefit funds established under provisions of the Taft-Hartley Act, financed through employer and employee contributions, and administered by a board composed equally of representatives from labor and management.40
Health Benefits ManagerIndependent organization that provides functions to assist enrollees. This may include information, acting as an enrollment broker, handling complaints and grievances etc.40
Health Care AuthorithyHCAWashington state agency that manage variuos state-sponsored health plans, including the Basic Health Plan and programs for public employees and retirees. HCA also provides funding for community clinics in various areas of the state.2
Health Care CoalitionVoluntary alliance of discrete interests sharing the principal objective of improving access to high quality health care services provided in a cost effective manner.40
Health Care CommissionA 17-member commission appointed by Governor Booth Gardner in May 1990 to study and develop comprehensive recommendations on fundamental reform of the health system in Washington State. Its goals were to recommend changes to Washington\'s health care system that would control costs, ensure universal access, implement incentives for the use of appropriate and effective health services, improve the health care liability system, and improve the state\'s purchasing of health services. The Commission\'s final report was submitted to the Governor and Legislature on November 30, 1992. The Commission sunset in December 1992.2
Health Care Data BaseCollection of information on health care episodes, such as utilization, costs, or charges.40
Health Care Decision CounselingServices, sometimes provided by insurance companies or employers, that help individuals weigh the benefits, risks and costs of health care tests and treatments. Unlike case management, health care decision counseling is non-judgmental. The goal of health care decision counseling is to help individuals make more informed choices about their health and medical care needs, and to help them make decisions that are right for the individual\'s unique set of circumstances. See also Demand Management.40
Health Care Delivery SystemThat combination of insurance companies, employer groups, providers of care and government agencies that work together to provide health care to a population.40
Health Care Expense, DirectAll direct expenditures associated with promoting, maintaining, and restoring the health of a defined population. For employers, this frequently includes but is not limited to the design and communication of the benefit plan(s); plan administration; financing the plan(s), which may include medical, dental, vision, and pharmaceutical programs; short and long term disability programs; sick pay; payroll taxes attributable to state and general health programs (e.g., worker\'s compensation, Medicare, Medicaid; and philanthropy). This may also include expenses for health promotion and wellness activities and on-site medical facilities.40
Health Care Financing AdministrationHCFAAn agency within the U.S. Department of Health and Human Services that is responsible for the administration of the Medicareand Medicaid programs.40
Health Care PrepaymentA health plan with a Medicare cost contract to provide only Medicare Part B premiums. Some administrative requirements for these plans are less stringent than those of risk contracts or other cost contracts.40
Health Care Prepayment PlanHCPPPlans that receive payment for their reasonable costs of providing Medicare Part B services to Medicare enrollees. [1] Some administrative requirements for these plans are less stringent than those of risk contracts or other cost contracts. [2] See also Cost Contract, Medicare Cost Contract, Medicare Risk Contract, Risk Contract.1, 2
Health Care Prepayment SystemSee Health Care Prepayment Plan.
Health Care ProviderAn individual or institution that provides medical services [e.g., a physician, hospital, laboratory]. This is distinct from an insurance company which \'provides\' insurance.2
Health Care ProxyA health care proxy is recognized in some states as an alternate method for naming a person to act on one\'s behalf in health care decision making. In a few states, a health care proxy may be included as part of a living will.40
Health Care Quality Improvement ActHCQIAA federal act which exempts hospitals, group practices, and HMOs from certain antitrust provisions as they apply to credentialing and peer review so long as these entities adhere to due process standards that are outlined in the Act.39
Health Care Quality Improvement ProgramHCQIPA program initiated by the Health Care Financing Administration to improve the quality of care delivered to Medicare enrollees in managed care plans.39
Health Care ReformChanges in the organization, delivery and financing of health care to improve access, quality and to reduce the cost of care.40
Health Data NetworkSee Health Information Network.
Health Impact AssessmentHealth impact assessment is any combination of procedures or methods by which a proposed policy or program may be judged as to the effect[s] it may have on the health of a population.2
Health InformaticsIs the intersection of information science, computer science, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health and (bio)medical research. Also called Health Care Informatics or Medical Informatics.13
Health Information ExchangeHIEThe mobilization of healthcare information electronically across organizations within a region or community. It provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care13
Health Information ManagementHIMThe discipline that focuses on health care data and the management of health care information, regardless of the medium and format.13
Health Information NetworkHINA computer network that provides access to a database of medical information. Also called a health data network.39
Health Information Technology Expert Panel IHITEP IIn 2007, the Agency for Healthcare Research and Quality (AHRQ) commissioned the National Quality Forum (NQF) to convene HITEP to address the ability of EHRs to create and aggregate data for quality measurement.42
Health Information Technology Expert Panel IIHITEP IIThe second HITEP will identify the clinical dataflow improvements and recommend the QDS to quality stakeholders including HITSP. NQF will also incorporate HITEP recommendations into the NQF measure endorsement process.42
Health Information Technology For Economic And Clinical HealthHITECHPart of the American Recovery and Reinvestment Act (ARRA). The majority of ARRA’s provisions focused on economic stimulus measures. ARRA also included, however, the Health Information Technology for Economic and Clinical Health Act (the “HITECH Act”), which (i) established new information security breach notification requirements that apply to a wide range of businesses and (ii) set forth substantially revised regulations promulgated pursuant to the HIPAA Act of 1996. See also ARRA 8.34
Health Information Technology Policy CommitteeHITPCA U.S. federal government advisory committee that will make recommendations to the National Coordinator for Health Information Technology (HIT) on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information. The American Recovery and Reinvestment Act of 2009 provides that the HITPC shall at least make recommendations on standards, implementation specifications, and certifications criteria in eight specific areas.19
Health Information Technology Standards CommitteeHITSCA U.S. federal government advisory committee within HHS charged with making recommendations to the National Coordinator for Health Information Technology (HIT) on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information. Initially, it will focus on the policies developed by the Health Information Technology Policy Committee’s (HITPC) initial eight areas. Within 90 days of the signing of ARRA, the HITSC must develop a schedule for the assessment of policy recommendations developed by the HITPC, to be updated annually. In developing, harmonizing, or recognizing standards and implementation specifications, the HITSC will also provide for the testing of same by the National Institute of Standards and Technology.64
Health InsuranceA mechanism to spread the risk of unforeseen expenditures across a broad base to protect the individual from personal expenditures for health care services. Health insurance may be purchased individually or on a group basis. It may be custom designed to cover specific services and procedures and include requirements to control the level of use and payment for these services. An employee health insurance benefit is a nontaxable form of compensation to the employee in lieu of taxable salary or wages, provided through employment. Various types of insurance, such as accident, disability income, medical expense, dental, vision, hearing, and accidental death and dismemberment may be made available through employment. Benefits may be available to dependents of active employees, retirees, spouses, survivors, and dependents through employment. Benefits for classes of active and retired employees and their dependents need not be uniform. The employer may purchase benefits or the costs may be shared between the employer and employee.40
Health Insurance Claim NumberThe number listed on the beneficiary\'s Medicare card consisting of nine digits followed by one or more letters. The nine digits represent the Social Security number of either the beneficiary or their spouse depending upon whose income it is based upon.40
Health Insurance PlanHIPAny combination of organized, public and privately offered plans that cover the health needs of individuals.
Health Insurance Portability And Accountability ActHIPAALaw enacted by the U.S. Congress in 1996. According to the Centers for Medicare and Medicaid Services website, Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. It helps people keep their information private. The AS provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation\'s health care system by encouraging the widespread use of Electronic Data Interchange in the U.S. health care system.13
Health Insurance Purchasing CooperativeHIPCA local board created under managed competition to enroll individuals, collect and distribute premiums, and enforce the rules that manage the competition.2
Health Insurance Trust FundThe Federal hospital insurance trust fund is a fund of the Treasury of the United States in which the monies collected from taxes on the annual earnings of employees, employers, and self-employed people covered by Social Security are deposited. Disbursements from the fund are made to help pay for benefit payments and administrative expenses incurred by the hospital insurance program (Medicare Part A).40
Health Insuring OrganizationHIOA hybrid of a state-funded health plan and a Health Maintenance Organization. It is usually a public corporation that pays for medical services provided to recipients in exchange for payment of a premium or subscription charges paid for by the corporation that assumes the underwriting risk.40
Health IRAsProposed tax-preferred plans to encourage saving for future medical expenses. Funds in health IRAs could be later cashed out for medical expenses.2
Health Level SevenHL7A health communications protocol for exchange of information between applications. HL7 is an ANSI accredited international standard developed by the Standard Development Organisation of the same name, based in Ann Arbor, MI. HL7 version 2 is the currently most commonly implemented version of this HL7 standard. HL7 version 2.5 covers messaging of patient demographics, inpatient and emergency episode details, outpatient scheduling, referrals, pathology/radiology orders and results, prescribing/dispensing/administration and more. This standard has largely been used for transmission of data among departments within institutions for orders, clinical observations, test results, etc. Specific parts of HL7 have applicable Community Health Information Network use where such data needs to be transmitted between institutions and systems.21, 40, 49
Health MaintenanceHMAlso called Preventive Health Maintenance is a system of guidelines (recommended schedules) of tests or procedures that have proven value in disease prevention.77
Health Maintenance OrganizationHMOA healthcare system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, usually in return for a fixed, prepaid fee.39
Health Maintenance OrganizationHMOA managed care plan that integrates financing and delivery of a comprehensive set of health care services to an enrolled population. HMOs may contract with, directly employ, or own participating health care providers. Enrollees are usually required to choose from among these providers and in return have limited copayments. Providers may be paid through capitation, salary, per diem, or prenegotiated fee-for-service rates. See also Capitation, Fee for Service, Managed Care, Managed Care Plan, Per Diem, Preferred Provider Organization.2
Health Manpower Shortage AreaHMSAAn area or group which the U.S. Department of Health and Human Services designates as having an inadequate supply of health care providers. HMSAs can include: (1) an urban or rural geographic area, (2) a population group for which access barriers can be demonstrated that prevent members of the group from using local providers, or (3) public or non-profit private residential facilities. See also Health Professional Shortage Area.40
Health Of Seniors SurveyA Health Care Financing Administration survey that measures Medicare patients\' functional status.39
Health PlanAn organization that acts as insurer for an enrolled population. See Fee-for-Service, Managed Care, Medical Savings Account.2
Health Plan Employer Data And Information SetHEDISA set of standardized measures of health plan performance. It allows comparisons between plans on quality, access and patient satisfaction, membership and utilization, financial information, and health plan management. It was developed by employers, Health Maintenance Organizations, and the National Committee for Quality Assurance.2
Health Plan Management SystemHPMSA database of information on Medicare Part A and Part B recipients who are enrolled in coordinated care plans.39
Health Plan Purchasing CooperativeHPPCA health insurance purchasing entity advanced by some health system reform proposals to enroll individuals, collect premiums, purchase enrollees\' insurance from participating health plans, and enforce the rules that manage health plan competition. See also Insurance Pool.2
Health Professional Shortage AreaHPSAA geographic area, population group, or medical facility that DHHSdetermines to be served by too few health professionals of particular specialties. Physicians who provide services in HPSAs qualify for the Medicare bonus payments, re-payment of medical school loans or other incentives. See also Health Manpower Shortage Area.40
Health PromotionProcess of fostering awareness, influencing attitudes, and identifying alternatives so that individuals can make informed choices and modify their behavior in order to achieve an optimum level of physical and mental health.40
Health Promotion ProgramAlso called Wellness Program. See Health Promotion.
Health Reimbursement ArrangementHRAU.S. Internal Revenue Service-sanctioned programs that allow an employer to reimburse medical expenses paid by participating employees, thus yielding \'tax advantages to offset health care costs\'.13
Health Risk AppraisalSee Health Risk Assessment.
Health Risk AssessmentHRAA process by which an Managed Care Organization uses information about a plan member\'s health status, personal and family health history, and health-related behaviors to predict the member\'s likelihood of experiencing specific illnesses or injuries. Also called Health Risk Appraisal.39
Health Risk BehaviorsBehaviors, such as smoking, lack of exercise, and overeating, that increase the potential for an individual to experience disease, or injury.2
Health Risk FactorsIn addition to Health Risks Behaviors defined above,risk factors include genetic factor such as a family history of heart disease, or environmental factors such as living in a polluted area.2
Health Savings AccountHASA tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a Flexible Spending Account, funds roll over and accumulate year over year if not spent. HSAs are owned by the individual, which differentiates them from the company-owned Health Reimbursement Arrangement that is an alternate tax-deductible source of funds. Funds may be used to pay for qualified medical expenses at any time without federal tax liability. Withdrawals for non-medical expenses are treated very similarly to those in an IRA in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier. These accounts are a component of consumer driven health care.13
Health Service PlanHSP
Health ServicesThe health care services or supplies covered under the plan contract.40
Health Services Act Of 1993A Washington State law enacted in May 1993 that sets forth early implementation measures and a process for overall reform of the health services system. The intent is to stabilize health services costs, assure access to essential services for all residents, actively address the health care needs of persons of color, improve the public\'s health, and reduce unwarranted health services costs.2
Health Services CommissionA Governor-appointed state regulatory commission created by the Health Services Act of 1993. The Commission has five voting members, and the Insurance Commissioner is a non-voting member. Responsibilities include defining the Uniform Benefits Package (UBP) and supplemental benefits package, setting a maximum premium for the UBP, and establishing a system of accountability for systems reform and cost control.2
Health Services CorporationHSCGeneral term to refer to a provider of an array of health services. Sometimes used in the insurance field to designate organizations that are required to meet special licensure requirements.40
Health Services Information SystemA state-wide health care data system which will track health care costs, quality, utilization, and outcomes of care. The development, implementation, and custody of the system is the responsibility of the Department of Health, with policy direction and oversight provided by the Health Services Commission.2
Health Services OrganizationHSO
Health Services ResearchHealth services research is the study of the scientific basis and management of health services and their effect on access, quality, and cost of health care. (NLM)2
Health SystemAll the services, functions and resources for which the primary purpose is to affect the health of the population.40
Healthcare Information Technology Research CenterHITRCThe health information technology extension program consists of a National Health Information Technology Research Center (HITRC) and Regional Extension Centers (or ‘‘regional centers’’). The major focus for the Centers’ work with most of the providers that they serve will be to help to select and successfully implement certified electronic health records (EHRs). While those providers that have already implemented a basic EHR may not require implementation assistance, they may require other technical assistance to achieve ‘‘meaningful user’’ status. All regional centers will assist adopters to effectively meet or exceed the requirements to be determined a ‘‘meaningful user’’ for purposes of earning the incentives.55
Healthcare QualityAccording to the Institute of Medicine, \'the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.\'39
Healthy StartA Medicaid program that provides health care for pregnant women and children who are at or below a specified level of income and age.40
Heath Information and Management Systems SocietyHIMSSHealthcare industry’s membership organization exclusively focused on providing global leadership for the optimal use of healthcare information technology and management systems for the betterment of healthcare.65
Help DeskContact point within an organization that provides end-user, technical assistance, typically for network and computer applications.
Herfindahl-Hirschman IndexHHIA commonly accepted measure of market concentration. It is calculated by squaring the market share of each firm competing in the market and then summing the resulting numbers. It takes into account the relative size and distribution of the firms in a market. It increases both as the number of firms in the market decreases and as the disparity in size between those firms increases.1
Hierarchical Coexisting Conditions ModelHCCA risk-adjustment model that groups beneficiaries based on their diagnoses.2
High-Cost CaseA patient whose condition requires large financial expenditures or significant human and technological resources.39
High-Risk CaseA patient who has a complex or catastrophic illness or injury or who requires extensive medical interventions or treatment plans.39
Hill-Burton ProgramFederal program created in 1946 to provide funding for the construction and modernization of health care facilities. Hospitals which receive Hill-Burton funds must provide specific levels of charity care.40
HIPAA ASC X12 version 5010X12 5010This defines the format of the Electronic Data Interchange data that must be used for data transmitted to/from the Centers for Medicare & Medicaid Services. Using this format is required to insure compliance with HIPAA requirements and in order to receive reimbursement.32
Histo-TechCuts and stains vary thin sections of body tissue for microscopic examination by a pathologist. 40
HMO LookalikeThis is a product where the benefit design looks much like that of an Health Maintenance Organization with coverage for preventative care services and dollar co-payments rather than percentage co-insurance. However, services are not restricted to network providers and there is no primary care physician requirement.40
HMO, Closed PanelPhysicians employed or contractually obligated exclusively or primarily to see the patients of an Alternative Delivery and Financing System health plan.40
Hold Harmless ProvisionA clause frequently found in managed care contracts, whereby the Health Maintenance Organization and the physician agree not to hold each other liable for malpractice or corporate malfeasance if either of the parties is found to be liable. It may also refer to language that prohibits the provider from billing patients in the event a managed care company becomes insolvent.40
Holding CompanyA company whose sole business is the ownership of other companies, which are its subsidiaries.39
Home And Community Based WaiverMedicaid waiver that provides a menu of community long term care services as an alternative to nursing home care. Limited to a specified number of slots in each state. The waiver generally provides a more liberal eligibility level than state plan Medicaid services. See also Medicaid Waiver.40
Home And Community-Based ServicesHCBSPrograms which provide services in the home or at a convenient location in the community. Commonly these programs provide assistance with meals, transportation or homemaking.40
Home CareIn contrast with inpatient and ambulatory care, home care is medical care ordinarily administered in the house setting when a patient is not sufficiently ambulatory to make frequent office or hospital visits. With these patients, intravenous therapy for example is administered at the patient\'s residence, usually by a health care professional. Home care reduces the need for hospitalization and it\'s associated costs.40
Home Delivered MealsA program authorized under Title III-C-2 of the Older Americans Act which provides, five or more days a week, at least one home delivered hot or other appropriate meal per day to older persons who are home bound, lack the capacity to prepare meals independently, or for whom congregate meal facilities are not available.40
Home HealthServices performed at an individual\'s home including a wide range of skilled and non-skilled services, including part-time nursing care, various types of therapy, assistance with activities of daily living and homemaker services such as cleaning and meal preparation. For Medicare purpose, this term refers specifically to intermittent, physician-ordered medical services or treatment.40
Home Health AgencyAn organization that provides medical, therapeutic or other health services in patients\' homes.40
Home Health Care AgencySee Home Health Agency.
Home Health ServicesNursing, therapy, and health-related homemaker or social services provided at home.8
Home Medical EquipmentDurable medical equipment prescribed by a physician for use by a patient at home. It is a means of continuing access to health care without remaining in the hospital. Such equipment may help the patient function more independently, it may assist recuperation, or it may be palliative. The equipment may be leased or purchased. These costs may be covered by a health plan.40
HomemakerGeneral term referring to a variety of non-skilled at-home services which may include some minor hands on care such as assistance with dressing and personal care, but also includes shopping, meal preparation, laundry services, housekeeping and similar activities. It is usually provided by employees of home health agencies.40
Horizontal Division Of MarketsAn illegal business practice that occurs when two or more organizations agree not to compete by dividing geographic marketing areas, product offerings, or customers.39
Horizontal Group BoycottAn illegal business practice that occurs when two competitors agree not to do business with another competitor or purchaser.39
Horizontal IntegrationConsolidation or merger of organizations that provide similar types of care. See also Vertical Integration.40
HospiceA facility or program that is licensed, certified or otherwise authorized by law, which provides Hospice Care.40
Hospice CareCare that address the physical, spiritual, emotional, psychological, financial, and legal needs of the dying patient and the family; provided by an interdisciplinary team of professionals and perhaps volunteers in a variety of settings, including hospitals, freestanding facilities, and at home.40
HospitalAn institution whose primary function is to provide inpatient diagnostic and therapeutic services for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care. Hospitals may be classified by length of stay (short-term or long-term), as teaching or non-teaching, by major types of services (psychiatric, tuberculosis, general, and other specialties, such as maternity, pediatric, or ear, nose and throat), and by type of ownership or control (Federal, State, or local government; for-profit and non-profit).40
Hospital AffiliationA contractual relationship between a health insurance plan and one or more hospitals whereby the hospital provides the inpatient benefits offered by the plan.40
Hospital AllianceA group of hospitals that have joined together to improve competitive positions and reduce costs by sharing common services and developing group purchasing programs. 40
Hospital Inpatient Prospective Payment SystemPPSMedicare\'s method of paying acute care hospitals for inpatient care. Prospective per case payment rates are set at a level intended to cover operating costs for treating a typical inpatient in a given DRG. Payments for each hsopital are adjusted for differences in area wages, teaching activity, care to the poor, and other factors. Hospitals may also receive additional payments to cover extra costs associated with atypical patients [outliers] in each DRG. Capital costs, originally excluded from PPS, are being phased into the system. By 2001, capital payments will be made on a fully prospective, per case basis. Prospective payment systems are also being developed for Medicare payments for home health services, outpatient hospital services, skilled nursing facilities, and rehabilitation facilities. See Capital Costs, Diagnosis-Related Groups, Outliers, Prospective Payment.2
Hospital InsuranceHIThe part of the Medicare program that covers the cost of hospital and related post-hospital services. Eligibility is normally based on prior payment of payroll taxes. Beneficiaries are responsible for an initial deductible per spell of illness and copayments for some services. Also called Part A coverage or benefits.2
Hospital Insurance ProgramSee Hospital Insurance.
Hospital Market BasketComponents of the overall cost of hospital care.40
Hospital Market Basket IndexA statistic of inflation of the overall cost of hospital care.40
Hospital OutshoppingThe bypassing of local hospitals by patients in favor of other hospitals (usually because the patients believe the quality of care is better in the other hospital).2
HospitalistA hospital-based internist who can be used to assume management of adult admissions from the Primary Care Physician, freeing that physician to do more office-based work. Hospitalists act as the hospital gatekeeper, to provide a valuable service by assessing the clinical needs of patients presenting to the emergency room and supervising inpatient care for those patients who are more critically ill, thereby reducing hospital inpatient costs.40
Hot KeysTypically, simultaneously pressing multiple keys on a computer at the same time, which is eqivalent to the command which switches the user to a different program or function within a software program. 77
HousekeeperNon-skilled environmental services provided in the home including help with housekeeping, laundry, cleaning, shopping and meal preparation. Does not include any hands-on care such as personal care or assistance with activities of daily living.40
Housing And Urban DevelopmentHUDSee U.S. Department of Housing and Urban Development.
Hybrid RecordDescribes a provider using a combination of paper and electronic medical records during the transition phase to EMR.78
Hybrid-Model HMOA combination of at least two managed care organizational models that are molded into a single health plan. Since its features do not uniformly fit only one type of model, it is called a hybrid.40
Hypertext Markup LanguageHTMLA text-based markup language used for web documents. The markup indicates page structure which can be used to create a useful rendering to a screen or other output device. 77
IdempotenceDescribes the property of operations in mathematics and computer science which means that multiple applications of the operation do not change the result. (timestamps to avoid duplicate data errors on replay)13
Immunization ProgramsPreventive care programs designed to monitor and promote the administration of vaccines to guard against childhood illnesses, such as chicken pox, mumps, and measles, and adult illnesses, such as pneumonia and influenza.39
Impact EvaluationImpact evaluation is the most comprehensive of the four evaluation types. it is desirable because it focuses on the long-range results of the program and changes or improvements in health status as a result. Impact evaluations are rarely possible beca use they are frequently costly, involve extended commitment and may depend upon other strategies in addition to communication. Also, the results often cannot be directly related to the effects of an activity or program because of other [external] Influences on the target audience which will occur over time.2
ImpairmentAny loss or abnormality of psychological, physiological, or anatomical structure or function from injury or disease. It represents a deviation from the person\'s usual biomedical state.40
Incentive PlansElements of health benefit plans that emphasize particular types of coverage and therefore serve to promote enrollee use of those benefits.40
IncentivesEconomic benefits given to providers to motivate efficiency in-patient care management.40
IncidenceThe number of new cases of a particular problem or condition that are identified or arise in a specified area during a specified period of time.2
Income StatementThe financial statement that summarizes an organization revenue and expense activity during a specified period.39
Incorporation By ReferenceThe method of making a document a part of a contract by referring to it in the body of the contract.39
Incurred But Not Reported ClaimsClaims or benefits that occurred during a particular time period, but that have not yet been reported or submitted to an insurer or Managed Care Organization, so they remain unpaid.39
Incurred But Not Reported ExpensesIBNRThis term refers to a financial accounting of all services that have been performed, but have not yet been invoiced or recorded.40
Incurred ClaimsA term that refers to the actual carrier liability for a specified period and includes all claims with dates of services within a specified period, usually called the experience period. Due to the time lag between dates of services and the dates claims payments are actually processed, adjustment must be made to any paid claims data to determine incurred claims.40
Indemnity BenefitsBenefits for which the insurance company payment is a fixed dollar amount.40
Indemnity Health PlanSimilar to a fee-for-service plan in which the insurer pays for all or part of covered services that the patient chooses to purchase from health care providers.40
Indemnity InsuranceInsurance providing a stipulated level of reimbursement for hospital/medical expenses, without regard to the actual expenses incurred during hospitalization.40
Indemnity PlansAn insurance policy in which beneficiaries are allowed total freedom to choose their health care providers. Those providers are reimbursed a set fee each time they deliver a service. Reimbursement is usually limited to a percentage of customary and reasonable charges (which may be less than the billed amount). See also Fee-For-Service.40
Indemnity Wraparound PolicyAn out-of-plan product that a Health Maintenance Organization offers through an agreement with an insurance company.39
Independent AgentsAgents that represent several health plans or insurers.39
Independent Case ManagementComprehensive professional coordination of the health resources necessary to the support of the patient\'s diagnosis, treatment, and recovery, facilitating the ability of the patient to function with as much independence as possible through the convergence of physical, psychological, social, functional, and personal services. The case manager may organize services that are more cost-effective and appropriate to the needs of the patient that would not otherwise be covered under a beneficiary\'s health benefit.40
Independent External ReviewAn appeals review that is conducted by a third party that is not affiliated with the health plan or a providers\' association and has no conflict of interest or stake in the outcome of the review.39
Independent LivingResidential option where no assistance is needed with ADLs or most IADLs. A senior housing apartment complex is an example of independent living.40
Independent Medical EvaluationIMEAn examination carried out by an impartial health care provider, generally board certified, for the purpose of resolving a dispute related to the nature and extent of an illness or injury.40
Independent Practice AssociationIPANetworks of independent physicians that contract with Managed Care Organizations and employers. They may be organized as sole proprietorships, partnerships, or professional corporations. [1] Services are provided at a negotiated per capita or fee-for-service rate. Physicians maintain their own offices and can contract with other Health Maintenance Organizations (HMO) and see other fee-for-service patients. [2] See also Group-Model HMO, Health Maintenance Organization, Network-Model HMO, Staff-Model HMO.1, 2
Independent Verification & ValidationIV&VAn independent entity evaluates the work of the implementation project team again the project documents looking for deviations and suggesting improvements.26
IndicatorA measure of a specific compononet of a health improvement strategy. An indicator can reflect an activity implemented to address a particular health issue-such as the number of children age two who have received all appropriate immunizations, or it might reflect outcomes from activities already implemented-such as a decline in the number of cases of childhood German Measles in any given year.2
Indigent CareSee Indigent Medical Care and Charity Care.
Indigent Medical CareCare given by health care providers to patients who are unable to pay for it.40
Indirect CostsThe costs that are shared by many services concurrently, for example, maintenance, administration, equipment, electricity, water. Also called overhead costs.40
Indirect Medical Education AdjustmentIMEA payment adjustment applied to DRG and outlier payments under PPS for hospitals that operate an approved graduate medical education program. For operating costs, the adjustment is based on the hospitals\'s ratio of the number of interns and residents to the number of beds. For capital costs, it is based on the hospital\'s ratio of interns and residents to average daily occupancy. [HCFA]2
Individual Case ManagementSee Independent Case Management.
Individual Health Care AccountA method of financing health care by giving tax advantage to individuals who establish and maintain personal accounts for health care purposes; similar to an Individual Retirement Account for retirement purposes. Also called medical savings account.40
Individual Health InsuranceHealth services contract or insurance policy which is purchased by an individual and which covers the individual (and usually the person\'s dependents) in contrast to a group insurance. Also called Personal Insurance.40
Individual MandateA requirement that all individuals obtain helath insurance. A mandate could apply to the entire population or just to children, or could exempt specified individuals.29
Individual MarketA market segment composed of customers not eligible for Medicare or Medicaid who are covered under an individual contract for health coverage.39
Individual Practice AssociationIPAThe individual practice association contracts with independent physicians who work in their own private practices, and see fee-for-service patients as well as Health Maintenance (HMO) enrollees. They are paid by capitation for the HMO patients and by conventional means for their fee-for-service patients. Physicians belonging to the IPA guarantee that the care needed by each patient for whom they are responsible will fall under a certain amount of money. They guarantee this by allowing the HMO to withhold an amount of their payments (i.e., usually 20% per year). If, by the end of the year, the physician\'s cost for treatment falls under the set amount, then the physician receives his entire Withhold Fund. If the opposite is true, the HMO can then withhold any part of this amount, at its discretion, from the fund. Essentially, the physician is put at risk for keeping down the treatment cost. This is the key to the HMO\'s financial viability. See also Independent Practice Association.40
Individual Retirement AccountIRAA retirement plan account that provides some tax advantages for retirement savings in the United States.13
Individual Stop-Loss CoverageA type of stop-loss insurance that provides benefits for claims on an individual that exceed a stated amount in a given period. Also called specific stop-loss coverage.39
Individual Tax CreditsInstead of employer or government health insurance coverage, all individuals would be required to purchase coverage directly from the insurer of choice. Individuals could participate in a group such as an Health Insurance Purchasing Cooperative (HIPC), where they can pay for their own insurance and receive a refundable tax credit to cover some portion of their health insurance costs. Low-income individuals with no tax liability may receive a voucher to purchase health insurance.40
Individually Identifiable Health InformationIIHIThose items in an EHR which can either directly or indirectly lead to identification of the individual linked to the information.99
Infant Mortality RateDeaths in the first year of life per 1000 births. According to the U.S. General Accounting Office, 50% of these deaths are due to lifestyle factors, 20% due to environmental factors, 20% due to biological factors, and 10% due to inadequate health care.40
Infection Isolation RoomEnvironmentally controlled room to minimize the possibility that infection will be spread because of breathing, coughing, or sneezing.8
InfectiousCapable of causing infection or disease by entrance of organisms [e.g. bacteria, viruses, protozoans, fungi] into the body, when then grow and multiply. Often used synonymously with \'communicable\'.2
Inflation ProtectionAn option offered on some long-term care policies which can increase the maximum daily and lifetime benefits to combat inflation. The protection is generally 5% per year, but varies from policy to policy as to whether the increase is calculated at simple or compound interest.40
Inflation RiderSee Inflation Protection.
Informal CareCare received at home from friends, neighbors or relatives who are not health care professionals. The vast majority of LTC services in the home are provided by informal caregivers.40
Informal SupportSee Informal Care.
InformaticsThe application of computer technology to the management of information.77
Information ManagementIMThe combination of systems, processes, and technology usedto provide an organization\'s information users with the information they need to carry out their job responsibilities.39
Information SystemISAn interactive combination of people, computer hardware and software, communications devices, and procedures designed to provide a continuous flow of information to the people who need information to make decisions or perform activities.39
Information TechnologyITThe wide range of electronic devices and tools used to acquire, record, store, transfer, or transform data or information.39
Informed ConsentInformed consent is a legal term referring to the right of individuals to make informed medical treatment decisions. Under State law, informed consent typically includes the right to be told of one\'s medical condition and prognosis, the risks and benefits associated with a recommended procedure or course of treatment, and the risks and benefits of other available treatment options, including the option of refusing treatment. When a person becomes mentally incapacitated, his or her right to give or withhold informed consent typically passes to the person\'s legal representative, usually an agent or attorney-in-fact under a durable power of attorney, a court-appointed guardian, or a close family member.40
In-Kind ResourcesHuman, cash or other resources or capability located within an agency, organization or institution as opposed to originating in the outside environment. Often used as a match for other funds. See also Match Certain Grants.40
InlierA patient whose length of stay or service cost resembles those of most other patients. See also Outlier.40
InpatientIPA patient who has been admitted at least overnight to a hospital or other health facility and occupies a hospital bed, crib, or bassinet while under observation, care, and diagnosis.40
Inpatient Prospective Payment SystemIPPSMedicare\'s payment system for inpatient hospitals and facilities. The specific amount that is paid is based on the DRG for the hospital admission.1
Inpatient ServicesItems and services furnished to a patient staying overnight in a hospital including bed and board, nursing and related services, diagnostic and therapeutic services, and medical or surgical services.40
InputThe labor. capital, and other resources hospitals use to produce goods and services.2
Inside DirectorsMembers of a company\'s board of directors who hold positions with the company in addition to their positions on the board.39
Inside LimitsProvisions that restrict the liability of an insurance plan. Various kinds of maximums can be imposed for specific services within a plan\'s overall limits. One example would be the limits on services for chemical dependency and mental illness in specific settings.40
InsolvencyA legal determination occurring when an organization no longer has the financial reserves or other arrangements to meet its contractual obligations to patients and subcontractors.40
Inspector GeneralIGIn the United States, a type of investigator charged with examining the actions of a government agency, military organization, or military contractor as a general auditor of their operations to ensure they are operating in compliance with general established policies of the government, to audit the effectiveness of security procedures, or to discover the possibility of misconduct, waste, fraud, theft, or certain types of criminal activity by individuals or groups related to the agency\'s operation, usually involving some misuse of the organization\'s funds or credit. In the United States, there exist numerous Offices of Inspector General (OIGs) at the federal, state, and local levels.13
Institutional CareUsually refers to nursing home or hospital care.40
Instrumental Activities Of Daily LivingIADLAn index or scale that measures a patient\'s degree of independence in Normal day-to-day housekeeping activities such as cooking, cleaning, shopping, etc. with which functionally impaired individuals may need assistance. See also Activities Of Daily Living.2, 40
InsuranceSharing the costs of the risk of incurring losses, whether for health expenses or property and casualty losses, across a base large enough to protect any one entity against the actual costs of an incurred loss. The costs of spreading the risk are assumed to be less than the costs of an actual loss. The insured group or insurance company is at financial risk for assuming the guarantee against loss for the specific instance.40
Insurance Market ReformThe goal of most insurance market reform initiatives is to materially change the nature of competition in health insurance markets by prohibiting, or severely limiting, the marketing, rating, and underwriting practices that identify and select the most favorable risks while rejecting the least favorable. Requirements that often accompany insurance market reform proposals include prohibition of experience rating in favor of modified community rating, open enrollment, use of a standard benefit package and elimination of preexisting conditions exclusions. Imposition of such regulations would have the effect of reducing the rate differential among groups, and among competing insurers. However, while premium costs would fall for some groups, they would rise for others.40
Insurance PoolSee Health Insurance Purchasing Cooperative.
Insurance ReformSee Insurance Market Reform.
Insured Claims Loss RatioThe result of incurred claims divided by premiums. A defined time period is usually specified.40
InsurerAn insurance company, managed care plan, government program, or \'self-funded\' group responsible for providing coverage.40
Insurer HMOA Health Maintenance Organization whose primary purpose is to provide health insurance and who contracts with independent providers for the health care network.40
Integrated CareAn approach used to manage all aspects of health care including primary care, acute care and long term care.40
Integrated Delivery And Financing SystemIDFS
Integrated Delivery NetworkIDNA network of facilities and providers working together to offer a continuum of care to a specific market or geographic area. Developed in the early 1980s, IDNs emerged to address common concerns like capitation, excess capacity, decreased margins, and complaints from patients regarding access.22
Integrated Delivery SystemIDSA provider organization that is fully integrated operationally and clinically to provide a full range of healthcare services, including physician services, hospital services, and ancillary services. [39] Collaboration between physicians and hospitals for a variety of purposes. Some models of integration include physician-hospital organization, management-service organization, group practice without walls, integrated provider organization and medical foundation. [40]39, 40
Integrated Delivery SystemIDSAn entity that usually includes a hospital, a large medical group, and an insurance vehicle such as a Health Maintenance Organization or Preferred Provider Organization. Typically, all provider revenues flow through the organization.2
Integrated Provider NetworkIPNA group of hospitals, physicians and ancillary providers which have joined together to create a system which provides comprehensive health care services through a coordinated, client-centered continuum designed to improve health care services in specified geographic markets Also called an IDS or an integrated delivery and financing system, especially when the organization offers an insurance plan. See also Community Care Network.40
Integrated Service NetworksISNIntegrated Service Networks are organizations that are accountable for the costs and outcomes associated with delivering a full continuum of health care services to a defined population. Under an ISN arrangement, a network of hospitals, physicians, and other health care providers furnish all needed health services for a fixed payment.2
Integrated Services NetworkISNSee Integrated Provider Network.
Integrating the Healtcare EnterpriseIHEAn initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. IHE promotes the coordinated use of established standards such as DICOM and HL7 to address specific clinical need in support of optimal patient care. Systems developed in accordance with IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively.79
IntegrationFor provider organizations, the unification of two or more previously separate providers under common ownership or control, or the combination of the business operations of two or more providers that were previously carried out separately and independently. [39] For computer systems, this allows for dependable, secure communication between enterprise applications.39, 77
Intensity Of ServicesThe number and complexity of resources used in producing a patient care service, such as a hospital admission or home health visit. Intensity of services reflects, for example, the amount of nursing care, diagnostic procedures, and supplies. See also Volume and Intensity of Services2
Intensity-Modulated Radiation TherapyIMRTA type of 3-dimensional radiation therapy that offers increased precision at varying intensities, rcing the chances of damaging normal tissue.8
Intensive Care UnitsICUHighly specialized care requiring sophisticated technologies given to patients who are in danger of disability or death.40
Interactive Voice Response SystemIVRSAn automated system that answers calls with recorded or synthesized speech and prompts the caller to respond to a menu of options by entering information through a touchtone keypad or by speaking into the phone.39
IntermediaryThe term used for Medicare contractors who process Medicare Part A claims.40
Intermediate CareA degree of nursing care evaluation that is less than that provided for skilled nursing care, but greater than that provided for custodial care. This level of care provides a planned, continuous program of nursing care that is preventive or rehabilitative in nature.40
Intermediate Care FacilityICFProvides a level of care to individuals requiring care above the level of room and board, but who do not require the degree of care and treatment that a hospital or skilled nursing facility is designed to provide. Examples are homes for the aged or rest homes.40
Intermediate Care Facility For Mentally Retarded PersonsICF/MROptional Medicaid services which provide residential care and services for individuals with developmental disabilities.40
Intermediate Nursing CareSee Intermediate Care.
InternA physician in training in the first year after graduating from medical school. See also Resident.40
Internal Rate Of Return (Evaluation)The calculated value for the discount rate necessary for total discounted program benefits to equal total discounted program costs.2
Internal StandardsPerformance standards developed within an organization that are based on its historic performance levels.39
International Classification Of Diseases, 10th EditionICD-10Starting in 2013, Centers for Medicare & Medicaid Services will require the use of ICD-10 for coding of diagnoses in billing/administrative transactions. The code set allows more than 155,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion of the 17,000 codes available in ICD-9. See also International Classification Of Diseases, 9th Edition.90
International Classification Of Diseases, 9th EditionICD-9Widely used classification system employed to codify diseases and medical conditions.40
International Classification Of Diseases, 9th Edition, Clinical ModificationICD-9-CMA diagnosis and procedure classification system designed to facilitate collection of uniform and comparable health information. This system is used to group patients into DRGs.2
InternetA public, international collection of interconnected computer networks.39
Internet Service ProviderISPAn entity which provides access to the internet. It connects its customers using a data transmission technology appropriate for delivering Internet Protocol datagrams, such as dial-up, DSL, cable modem, wireless or dedicated high-speed interconnects13
Interoperability1) \'The ability of two or more systems or components to exchange information and to use the information that has been exchanged.\' (IEEE); 2) The capability to provide successful communication between end-users across a mixed environment of different domains, networks, facilities and equipment.13, 77
Interoperatbility SpecificationsISStandards are being developed by the Healthcare Information Technology Standards Panel.20
Intervention StrategyA generic term used in public health to describe a program or policy designed to have an impact on an illness or disease.40
IntranetAn internal (private) computer network, built on Web-based technologies and standards, that is only available to members of the computer network.39
IntravenousIVWithin a vein.18
IPA Model HMOA Health Maintenance Organization which contracts with one or more associations of physicians in independent practice who agree to provide medical services to its members.39
Job-LockThe inability of individuals to change jobs because they would lose crucial health benefits.2
Joint Commission On Accreditation Of Healthcare OrganizationsJCAHOFounded in 1951, this independent, non-profit organization evaluates and accredits health care organization in the U.S., including hospitals, health plans, and other care organizations that provide home care, mental health care, laboratory, ambulatory care and long-term services.40
Joint VentureJVA type of partial structural integration in which one or more separate organizations combine resources to achieve a stated objective. The partipating independent practice companies share ownership of the venture and responsibility for its operations, but usually maintain separate ownership and control over their operations outside of the joint venture.39
Justice/EquityAn ethical principle, which, when applied to managed care, states that managed care organizations and their providers allocate resources in a way that fairly distributes benefits and burdens among the members.39
Key IndicatorsMeasures which identify progress is achieving important results. See also Outcome Measures, Performance Measures, Quality Assurance.40
KioskSmall computer workstations which allow information to be input. Patient kiosks are used for patients to input information into the system at the medical practice, usually input through a workstation in the waiting room.77
Laboratory SupervisorProvides laboratory services to meet the need of patients as ordered by the medical staff and performed in accordance with accepted standards and practices; directs, supervises, and coordinates functions and activities in any or all divisions of the clinical laboratories; Bacteriology, Blood Bank, Chemistry, Cytology, Hematology, Serology.40
Large Case ManagementSee Independent Case Management.40
Large GroupA large pool of individuals for which health coverage is provided by the group sponsor. A large group may be defined as more than 250, 500, 1,000, or some other number of members, depending on the Managed Care Organization.39
Large Local GroupsAccounts that contract on a local basis for group employee health benefits. These accounts contrast with national accounts.39
Large Urban AreaA metropolitan statistical area with a population of one million or more, or a New England County Metropolitan Area with a population of 970,000 or more. See also Metropolitan Statistical Area, Other Urban Area.2
Least Restrictive EnvironmentSetting that provides the greatest opportunity for independence while ensuring the safety of the individual.40
Legacy SystemA system that is considered old and possibly out-dated.77
Legacy System IntegrationThe integration of data between a legacy system and some other software program most commonly using Health Level Seven standards.77
Legend DrugDrug that can only be obtained by prescription.40
Length Of StayLOSThe number of days, counted from the day of admission to the day of discharge, that a plan member is confined to a hospital or other facility for each admission.39
Length-Of-Stay GuidelinesA utilization review resource that establishes an average inpatient length of stay based on a patient\'s diagnosis, the severity of the patient\'s condition, and the type of services and procedures prescribed for the patient\'s care.39
Level Of CareLOCAn assessment of the type of care necessary to meet the individual needs of the client. The assessment takes into consideration the client\'s needs in all aspects of development, level of functioning, and potential to benefit from a particular program.40
LiabilitiesAll debts and obligations of a company.39
LicensureThe process by which an agency of government (usually state government) grants permission to an individual or organization to engage in a given occupation or business based upon finding that the applicant has attained the competency required to ensure that the public health, safety and welfare will be reasonably well protected.40
Life ExpectancyAverage expected length of life for a group of people, of a particular age, chosen at a particular time (for example, for White infants born in 1960).2
Life Safety CodeStandards of construction, protection and occupancy that are necessary to minimize danger to life from fire, smoke, fumes, and panic. The Joint Commission on Accreditation of Healthcare Organizations and the Medicaid and Medicareprograms require compliance with the code. The code is adopted and published by the National Fire Protection Association and is Also called the NFPA 101.40
Lifetime Reserve DaysHospitalization (Part A) under Medicarefrom the 91st day of confinement through the 150th day. This period of consecutive hospitalization is not renewable; once used, the benefit is gone.40
Limiting ChargeThe maximum amount that a nonparticipating physician is permitted to charge a Medicare beneficiary for a service; in effect, a limit on balance billing. Starting in 1993 the limiting charge has been set at 115 percent of the Medicare-allowed charge. See Allowed Charge, Balance Billing, Nonparticipating Physician.2
Limiting CoverageThe maximum amounts that a non-participating physician is permitted to charge a Medicarebeneficiary for a service. Since 1993 the limiting charge has been set at 115% of the Medicare-allowed charge.40
Living WillA legal document generated by an individual to guide providers on the desired medical care in cases when the individual is unable to articulate his or her own wishes.40
Local Area NetworkLANSupplies networking capability to a group of computers in close proximity to each other such as in an office building, a school, or a home.77
LocalitySee Fee Schedule Payment Area.
Lock-InA provision that requires that enrollees remain in a health care plan for a specified period of time. See Open Enrollment.40
Logical Observation Identifiers Names And CodesLOINCA database and universal standard for identifying medical laboratory observations. It was developed and is maintained by the Regenstrief Institute, Inc., in 1994. LOINC was created in response to the demand for an electronic database for clinical care and management and is publicly available at no cost. It is endorsed by the American Clinical Laboratory Association and the College of American Pathologist. Since its inception, the database has expanded to include not just medical and laboratory code names, but also: nursing diagnosis, nursing interventions, outcomes classification, and patient care data set.13
Long Term Acute Care HospitalLTACA medical service delivery facility focused on patients with serious medical problems that require intense, special treatment for a long time (usually about 20-30 days). These patients often transfer from Intensive Care units in traditional hospitals. 36
Long Term Care Ombudsman ProgramLTCOPProgram that protects the health, welfare, safety, and rights of residents of long term care facilities. Trained and certified volunteers and professional staff visit long term care facilities, receive and investigate complaints, advocate for residents and mediate disputes.40
Long Term Care RiderAn attachment that may be added to some life insurance and other types of insurance policies to allow some or all of the death benefit or other primary benefit to be used to help pay for long term care costs under situations defined in the policy.40
Longitudinal Patient RecordLEPRLongitudinal Patient Record is an EHR that includes all healthcare information from all sources.77
Long-Term CareLTCOngoing health and social services provided for individuals who need assistance on a continuing basis because of physical or mental disability. Services can be provided in an institution, the home, or the community, and include informal services provided by family or friends as well as formal services provided by professionals or agencies. [2] Care given to patients with chronic illnesses and who are required a length of stay longer than 30 days. [40]2, 40
Long-Term Care InsuranceA continuum of maintenance and health services provided to the chronically or mentally ill or the disabled on an ongoing basis.40
Loss RateThe number and timing of losses that will occur in a given group of insureds while the coverage is in force.39
Loss RatioThe ratio of benefits paid out to premiums collected for a particular type of insurance policy. Low loss ratios indicate that a small proportion of premium dollars were paid out in benefits, while high loss ratios indicate that a high percentage of the premium dollars were paid out as benefits.2
M/R CoderResponsible for assigning diagnostic and procedure codes to the records of discharged patients and forwarding reports to insurance and governmental review boards as required. The coder also records and determines other required data such as attending physician, use of intensive care unit, number of consultations and referral source and requests diagnoses from physicians when not recorded.40
MacroA symbol, name or key (macro key) that represents a list of commands, actions, keystrokes or blocks of text. When the macro key code is typed, the program carries out the instructions of the macro. Users create macros to save time by replacing often-used, series of strokes (blocks of text) with quick macro key codes.77
Mail Order PharmacyA source for brand name, generic prescription and over-the-counter medicines by mail, usually at lower unit prices than a retail pharmacy.40
Mail-Order Pharmacy ProgramsPrograms that offer drugs ordered and delivered from a Mail Order Pharmacy to plan members at a reduced cost.39
Maintenance Of BenefitsMOBVariation of coordination of benefits that allows benefits only up to a maximum allowed had the enrollee been covered only under one health plan. This approach subtracts charges paid by the primary plan from total eligible expenses, then applies the secondary plan benefits to the remaining costs. See also Coordination Of Benefits.40
Major Diagnostic CategoryMDCA clinically coherent grouping of ICD-9-CM diagnoses by major organ system or etiology that is used as the first step in assignment of most diagnosis related groups (DRGs). MDCs are commonly used for aggregated DRG reporting.40
Major Teaching HospitalsHospitals with an approved graduate medical education program and a ratio of interns and residents to beds of 0.25 or greater. See also Indirect Medical Education Adjustment, Other Teaching Hospitals.2
MalpracticeA dereliction from professional duty or a failure to exercise an accepted degree of professional skill or learning by one (as a physician) rendering professional services which results in injury, loss, or damage. Also an injurious, negligent, or improper practice.40
Malpractice ExpenseThe cost of professional liability insurance incurred by physicians. A component of the Medicare relative value scale. See Relative Value Scale.2
Malpractice InsuranceInsurance purchased by doctors and other providers to cover them against malpractice lawsuits.40
Managed Behavioral Health OrganizationMBHOAn organization that provides behavioral health services by implementing managed care techniques.39
Managed CareOrganized programs designed to control access to impatient and ambulatory health services, to ensure the medical necessity of the proposed service and the delivery of the service at the most efficient and cost effective level of care consistent with high quality. Managed care is essential to the structure of Alternative Delivery and Financing Systems, such as Health Maintenance Organizations and Preferred Provider Organizations. Requirements can also be a component of traditional indemnity or Fee-For-Service health coverage. Managed care may include pre-admission or pre-treatment certification, second surgical opinion programs, fee or price negotiation, pre-treatment protocol review, pre-admission testing, continued stay review, discharge planning, and individual/large case management. Failure to comply with managed care requirements or decisions usually reduces health benefit coverage for claims. The penalties may affect both the patient and the provider(s).40
Managed Care OrganizationMCOAn organization that provides Managed Care.
Managed Care PlanA health plan that uses managed care arrangements and has a defined system of selected providers that contract with the plan. Enrollees have a financial incentive to use participating providers that agree to furnish a broad range of services to them. Providers may be paid on a prenegotiated basis. See also Health Maintenance Organization, Point-Of-Service, Preferred Provider Organization.2
Managed CompetitionA series of financial structures and methods used to manage the process by which individuals select health insurance coverage in a competitive market. The goal of managed competition is to encourage cost-conscious consumer choice when individuals select a plan. This, in turn, is intended to strengthen financial incentives for plans to deliver services in the most cost-effective manner. The basic structures of managed competition include a national board which would make decisions affecting benefit design and market rules, \'sponsors\' which manage the process of individual health insurance choice, and integrated health care delivery networks which provide and manage care. These structures have been termed as a NHB, HIPC, and AHP in several reform proposals.40
Managed CompetitionAn approach to health system reform in which health plans compete to provide health insurance coverage for enrollees. Typically, enrollees would sign up with a health plan purchasing entity and would be offered a choice of health plans during an open season.2
Managed Dental CareAny dental plan offered by an organization that provides a benefit plan that differs from a traditional fee-for-service plan.39
Managed Fee-For-ServiceAn insurance plan that works very much like normal plans except they have specific enforced utilization rules which include, but are not limited to: pre-hospitalization case review, prospective length of stay approvals, second opinions for surgery, current and previous records review, discharge planning and claims audits.40
Managed Health CareSee Managed Care.
Managed Health Care PlanAn insurance Plan that provides Managed Care. See Managed Care.
Managed Indemnity PlansHealth insurance plans that are administered like traditional indemnity plans but which include managed care \'overlays\' such as precertification and other utilization review techniques.39
Management GuidelinesA practice guideline that covers the evaluation and management of patients who is known to have a particular condition.40
Management Information SystemMISThese are distinct from regular information systems in that they are used to analyze other information systems applied in operational activities in the organization. Academically, the term is commonly used to refer to the group of information management methods tied to the automation or support of human decision making, e.g. Decision Support Systems, Expert systems, and Executive information systems.13
Management Services OrganizationMSOAn organization, owned by a hospital or a group of investors, that provides management and administrative support services to individual physicians or small group practices in order to relieve physicians of non-medical business functions so that they can concentrate on the clinical aspects of their practice. See also Administrative Services Organization.39
Mandated BenefitsEach state is responsible for the conduct of the insurance business within its boundaries rather than the Federal Government. Each state establishes its requirements for insurance company licensure. A state may establish minimum health insurance policy coverage provisions, such as a specified scope of services and covered providers. A state may require that all insured benefit plans include specific benefits, or both approaches may be used, depending upon the specific coverage under consideration. ERISA exempts self-insured employers from state mandates.40
Mandated Benefits, Federal PreemptionA legislative proposal that would require all employers to provide a minimum health benefit for all permanent employees as a condition of doing business. It would exempt employers meeting the Federal requirements from state mandated benefits.40
Mandated Employer InsuranceEmployers are required to provide health benefit coverage for their employees.2
Mandated Insurance BenefitsMinimum health insurance coverage requirements specified by government statute.2
Mandated ProvidersSee Essential Community Providers.
Manual RatesRates developed based upon the health plan\'s average claims data and then adjusted for group specific demographics, industry factors, or benefit variations. [4] A Managed Care Organization often lists manual rates in an underwriting or rating manual. [39]39, 40
Market AreaThe targeted geographic area or areas of greatest market potential.40
Market Basket IndexAn index of the annual change in the prices of goods and services providers used to produce health services. There are separate market baskets for PPS hospital operating inputs and capital inputs; and SNF, home health agency and renal dialysis facility operating and capital inputs.2
Market PenetrationThe part of the total health care market that a managed care company has captured.40
Market SegmentationThe process of dividing the total market for a product or service into smaller, more manageable subsets or groups of customers.39
Market ShareSee Market Penetration.
Market-Based ReformReliance on competition in the health care market to assure services of acceptable cost and quality to consumers without government mandates or involvement in rate-setting, financing, or administration. Can also refer to the reduction of barriers in the operation of a health care market.40
MarketingThe process of planning and executing the conception, pricing, promotion, and distribution of ideas, goods, and services to create exchanges that satisfy individual and organizational objectives.39
Marketing DirectorThe manager who oversees an organization\'s marketing and sales activities, including advertising, client relations, and enrollment and sales forecasting. Also called Chief Marketing Officer.39
Marketing MixThe four major marketing elements-product, price, promotion, and distribution (place)-that foster the exchange process.39
Marketplace MedicineAn attempt by purchasers to introduce competition for patients among providers and professionals as a cost containment mechanism.40
Master Patient IndexMPIA database that maintains a unique index (or identifier) for every patient registered at a health care organization. It is used by each registration application (or process) within the HCO to ensure a patient is logically represented only once and with the same set of registration demographic / registration data in all systems and at an organizational level. It can be used as enterprise tool to assure that vital clinical and demographic information can be cross-referenced between different facilities in a health care system ( see fig. 1). A MPI correlates and cross-references patient identifiers and performs a matching function with high accuracy in an unattended mode. A MPI is considered an important resource in a healthcare facility because it is the link tracking patient, person, or member activity within an organization (or enterprise) and across patient care settings.91
Match Certain GrantsRequirement that the grantee contribute a percentage of the resources necessary for carrying out the grant program. The usual resource is cash (hard match), but some programs accept personal and/or facilities in lieu of cash (soft match). See also In-Kind Resources.40
Material Safety Data SheetMSDSThe purpose of OSHA Hazard Communication Standard is to ensure the hazards of all chemical substances and mixtures produced or imported are evaluated and this hazard information is communicated by means of a printed written document called the MSDS. The MSDS must be written in English and contain certain required information including the chemical identity or common name, health hazards, emergency & first aid procedures, and safety precautions.40
Maternity-Stay LegislationGoverns the length of hospital stay for a mother and newborn following the newborn\'s birth. Most maternity-stay legislation follows guidelines jointly established by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics which recommend that a woman and newborn receive a minimum of 48 hours of hospital care following an uncomplicated vaginal delivery and 96 hours of care following a C-section.40
Maximum Allowable ChargeMACThe largest dollar amount to which an insurance carrier will apply plan benefits.40
Maximum Allowable CostMACSee Maximum Allowable Charge.
Maximum Allowable Costs ListA list of prescription medications established by the health plan and distributed to pharmacies, which will be covered at a generic product level.40
Maximum ConcentrationCmaxA term used in pharmacology that refers to the maximum concentration a drug achieves in a tested area after the drug has been administrated and prior to the administration of a second dose. Cmax is the opposite of Cmin, which is the minimum concentration that a drug achieves after dosing.13
Maximum Out Of Pocket CostsA limit on the total amount of co-payments, deductibles and co-insurance that a beneficiary is responsible for paying.40
McCarran-Ferguson ActA federal act that placed the primary responsibility for regulating health insurance companies and Health Maintenance Organizations that service private sector (commercial) plan members at the state level.39
Meaningful UseMUThe type and amount of Healthcare Information Technology must be available and in use to accomplish the ends envisioned in the American Reinvestment and Recovery Act in order to achieve targeted care improvements and cost savings.48
MEDCIN®A medical terminology engine and a registered trademark of MediComp Systems. It includes more than 250,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. It contains medical relationships through multiple clinical hierarchies for each term.77
MedicaidTitle XIXA joint Federal-State program that pays for medical and other services on behalf of certain groups of low-income persons. See Social Security Act,categorically needy, medically needy, and Medicaid waivers. The following provisions of the Social Security Act relate to managed care and long term care: 1902( r)(2) - Section of the Social Security Act which allows states to use more liberal income and resource methodologies than those used in determining SSI eligibility as the basis for setting Medicaid eligibility. 1903(m) - Section of the Social Security Act which allows State Medicaid programs to develop risk contracts with Health Maintenance Organizations or comparable entities. 1929 - Section of the Social Security Act which allows states to provide a broad range of Home and Community Care to functionally disabled individuals as an optional State plan benefit (unpopular because of caps on Federal participation).40
Medicaid Management Information SystemMMISThe reporting system used by HCFA to gather data on Medicaid use around the country. Can also refer to state or local Medicaid information systems.40
Medicaid Management Information SystemMMISAn integrated group of procedures and computer processing operations (subsystems) developed at the general design level to meet principal objectives, such as Title XIX program control and administrative costs; service to recipients, providers and inquiries; operations of claims control and computer capabilities; and management reporting for planning and control.
Medicaid Prudent Pharmaceutical Purchasing ActMPPPAEnacted as part of the Omnibus Budget Reconciliation Act of 1990, MPPPA provides that Medicaid must receive the best discounted price of any institutional purchaser of pharmaceuticals. In doing so, drug companies provide rebates to Medicaid equal to the difference between the discounted price and the price at which the drug was sold. This bill has resulted in cost shifting throughout the health industry.40
Medicaid WaiversAn exception to the usual requirements of Medicaid granted to a state by HCFA. The following numbers refer to the applicable section of the Social Security Act: 1115 - Allows states to waive provisions of Medicaid law to test new concepts which are consistent with the goals of the Medicaid program. System-wide changes are possible under this provision. Frequently used to establish Medicaid managed care programs. 1915(b) - Allows state to waive freedom of choice. States may require that beneficiaries enroll in Health Maintenance Organizations or other managed care programs, or select a physician to serve as their primary care case manager. 1915( c) - Allows states to waive various Medicaid requirements to establish alternative, community-based services for (a) individuals who would otherwise require the level of care provided in a hospital or skilled nursing facility, and/or (b) persons already in such facilities who need assistance returning to the community. Target populations for 1915( c) waivers include older adults, persons with disabilities, persons with mental retardation, persons with chronic mental illness and persons with AIDS. Also called a 2176 waiver in reference to the relevant section of the Omnibus Budget Reconciliation Act of 1981. 1915(d) - Similar to 1915( c) waiver except that expenditures for nursing facility and home and community-based services for person 65 years and older cannot exceed a projected amount, determined by taking a base year expenditure (last year before the waiver), and adjusting for inflation. Also eliminates requirements that programs be statewide and be comparable for all target populations. Income rules for eligibility can also be waived.40
Medical Advisory CommitteeThe Managed Care Organization committee that evaluates proposed policies and action plans related to clinical practice management, including changes in provider contracts, compensation, and changes in authorization procedures, reviews data regarding new medical technology, and examines proposed medical policies.39
Medical Aid UnitA medical facility where ambulatory patients can be treated without an appointment, and receive immediate, non-emergency care. The medical aid units are not usually opened 24 hours a day; patients calling a Health Maintenance Organization after hours with urgent, but not emergent, clinical problems, are often referred to these facilities. A similar facility is an Urgent Care Center or Unit, which may be opened 24 hours a day.40
Medical Care Evaluation StudiesMCEThe name given to a generic form of health care review in which problems in the quality of the delivery and organization of health care services are addressed and monitored.40
Medical CenterSee Ambulatory Care Facility.
Medical ClinicSee Ambulatory Care Facility.
Medical Consumer Price IndexAn inflationary statistic that measures the cost of all purchased health care services.40
Medical DirectorThe health plan physician executive who is responsible for the quality and cost-effectiveness of the medical care delivered by the plan\'s providers. Also called a chief medical officer.39
Medical ErrorA mistake that occurs when a planned treatment or procedure is delivered incorrectly or when a wrong treatment or procedure is delivered.39
Medical FoundationsMFAn organization through which physicians, hospitals and other providers can integrate the delivery of medical service. Usually an MF is an affiliate of a hospital through a common parent organization or is a subsidiary of a hospital. In most cases MFs are non-profit entities that own and manages facilities, equipment and supplies of a medical practice. They usually contract directly with patients and third party payers and employ non-professional personnel as well as physicians.40
Medical Group PracticeSee Consolidated Medical Group.
Medical HomeAn approach to providing comprehensive primary care that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. The provision of medical homes may allow better access to health care, increase satisfaction with care, and improve health. Also called Patient-Centered Medical Home.13
Medical IndigenceInability to pay for needed medical care, whether through insurance, savings, current income, or borrowing against future income.40
Medical IRAA tax-exempt account into which each household would contribute a limited amount of money to cover medical costs or buy insurance.40
Medical Loss RatioThe cost ratio of health benefits used compared to revenue received. Calculated as total medical expenses/total revenue.40
Medical Problem ListA list of a person\'s clinically significant medical problems and the date of first diagnosis for each.
Medical ProtocolsGuidelines that physicians should follow in order to have an acceptable clinical outcome. They provide the caregiver with specific treatment options or steps when faced with a particular set of clinical symptoms or signs or laboratory data. These should be designed through an accumulated database of clinical outcomes. See also Evidence-Based Order Set, Order Set.40
Medical Savings AccountMSAA health insurance option consisting of a high-deductible insurance policy and a tax-advantaged savings account. Individuals would pay for their own health care up to the annual deductible by withdrawing from the savings account or paying out of pocket. The insurance policy would pay for most or all costs of covered services once the deductible is met. Also called Individual Health Care Account.2
Medical Services OrganizationMSOSee Provider Sponsored Organization.
Medical Social ServicesMSSMedical social services professionals help individuals, couples and families cope with the social, psychological, cultural and medical issues resulting from an illness. Professionals in medical social services also help patients fully utilize medical care and services. They may help patients with advance directives and other long-term care issues. They assure that patients’ medically related emotional and social needs are met and maintained throughout their medical treatment.102
Medical TechnologyIncludes drugs, devices, techniques, and procedures used in delivering medical care and the support systems for that care.2
Medical UnderwritingSee Underwriting.
Medically Appropriate ServicesDiagnostic or treatment measures for which the expected health benefits exceed the expected risks by a margin wide enough to justify the measures.1539
Medically IndigentA category within the state medical assistance program that defines an individual who is unable to pay for his/her health care.40
Medically Necessary ServicesA service or treatment which is appropriate and consistent with diagnosis, and which, in accordance with accepted standards of practice in the medical community of the area in which the health services are rendered, could not have been omitted without adversely affecting the member\'s condition or the quality of medical care rendered.40
Medically NeedyOptional component of the Medicaid program that allows states to offer Medicaid to persons who would otherwise be eligible, but whose incomes are too high. Such persons become eligible by spending a portion of their income each month on outstanding medical bills. See Spend Down, Categorically Needy.40
Medically Needy IndividualsIndividuals who meet the financial resource requirements of categorically needy individuals, but whose monthly income exceeds specified maximums.39
Medically Underserved AreaMUAA whole county or a group of contiguous counties, a group of county or civil divisions or a group of urban census tracts in which residents have a shortage of personal health services.45
Medically Unnecessary DaysMUDA term used to describe that part of a stay in a facility deemed to be excessive to diagnose and treat a medical condition because the stay was either too long, or more appropriate care is available in a less costly or more efficient setting.40
Medical-Necessity ReviewSee Prior Authorization.
MedicareTitle XVIIIFederal program established under Title XVIII of the Social Security Act of 1965, that provides basic health care and limited long term care people over 65, those eligible for Social Security disability payments, and those who need kidney dialysis or transplants without regard to income level. Beneficiaries must pay premiums, deductibles and coinsurance. Part A - Medicare hospital insurance that helps pay for medically necessary inpatient hospital care, and, after a hospital stay, and limited inpatient care in a skilled nursing facility, for limited home health care or hospice care. Part B - Medicare medical insurance that helps pay for medically necessary physician services, outpatient hospital services and supplies that are not covered by the hospital insurance. Part C - See Medicare Advantage See also Beneficiary, Cost Sharing, Medically Necessary, Medigap.2, 39, 40
Medicare AdvantageMAAlso called Medicare Part C and as of 2003, the new name for Medicare+Choice (M+C). The Balanced Budget Act of 1997 (BBA) established this program. An eligible individual may elect to receive Medicare benefits through enrollment in a plan which generally takes the form of a Managed Care Organization that places providers at risk for those benefits.1, 40
Medicare AssignmentAn agreement in advance by a physician to accept Medicare\'s Allowed charge as payment in full (guarantees not to balance bill). Medicare pays its share of the allowed charge directly to physicians who accept assignment and provides other incentives under the Participating Physician and Supplier Program.2
Medicare Bonus PaymentAn additional 10% payment to the physician above the allowed charge for services delivered to Medicare Beneficiaries in designated Health Professional Shortage Areas.40
Medicare Catastrophic Coverage ActMCCAFederal legislation passed in 1988 (repealed November 23, 1989) that significantly increased the benefit amounts provided under Medicare both Part A and Part B, in a variety of ways.49
Medicare Choices DemonstrationA demonstration project designed to offer flexibility in contracting requirements and payment methods for Medicare\'s managed-care program. Participating plans include PSOs and Preferred Provider Organizations. Plans are required to submit encounter data to HCFA, and most will test new risk-adjustment methods.2
Medicare Cost ContractA contract between Medicare and a health plan under which the plan is paid on the basis of reasonable costs to provide some or all of Medicare-covered services for enrollees. See also Health Care Prepayment Plan, Medicare Risk Contract.2
Medicare Cost HMO Or ContractProspective payment for acute and primary health care (monthly fee per patient with settlement annually based on actual costs). Primarily used in rural areas where full capitation is not feasible.40
Medicare Cost ReportMCRAn annual report required of all institutions participating in the Medicare program. It records each institution\'s total costs and charges associated with providing services to all patients, the portion of those costs and charges allocated to Medicare patients, and the Medicare payments received. See also PPS Year.2
Medicare Current Beneficiary SurveyMCBSA longitudinal survey administered by HCFA that provides information on specific aspects of beneficiary access, utilization of services, expenditures, health insurance coverage, satisfaction with care, health status and physical functioning, and demographic information. 2
Medicare Economic IndexMEIAn index that tracks changes over time in physician practice costs. From 1975 through 1991, increases in prevailing charge screens were limited to increases in the MEI. See also Prevailing Charge, Volume Performance Standard System.2
Medicare Fee ScheduleThe resource-based fee schedule Medicare uses to pay for physicians\' services. See also Resource-Based Relative Value Scale, Conversion Factor, Geographic Practice Cost Index.2
Medicare Insured GroupMIGEmployer (or union) groups receiving a capitated rate from Medicare in exchange for integrating Medicare covered services into the employers own traditional retiree health plan.40
Medicare Medical Savings Account (Msa) PlansThe Medicare+Choice delivery option that consists of a high-deductible catastrophic insurance policy and a tax-deferred medical savings account established for individual Medicare beneficiaries.39
Medicare Part ASee Medicare.
Medicare Part BSee Medicare.
Medicare Part CSee Medicare.
Medicare Payment Advisory CommissionMedPACA non-partisan congressional advisory body created by the Balanced Budget Act Of 1997. It is charged with providing policy advice and technical assistance concerning the Medicare program and other aspects of the health system. It conducts independent research, analyzes legislation, and makes recommendations to Congress. The Physician Payment Review Commission (PPRC) was merged with the Prospective Payment Assessment Commission (ProPAC) to create MedPAC.40
Medicare Prescription Drug, Improvement, And Modernization ActMMAA law of the United States which was enacted in 2003.] It produced the largest overhaul of Medicare in the public health program\'s 38-year history. Also called Medicare Modernization Act.13
Medicare Provider Analysis And Review FileMedPARA Health Care Finance Adminstration data file that contains charge data and clinical characteristics, such as diagnoses and procedures, for every hospital inpatient bill submitted to Medicare for payment.2
Medicare Risk ContractA contract between Medicare and a health plan under which the plan receives monthly capitated payments to provide Medicare-covered services for enrollees, and thereby assumes insurance risk for those enrollees. A plan is eligible for a risk contract if it is a Federally Qualified Health Maintenance Organization or a Competitive Medical Plan. See also Adjusted Average Per Capita Cost, Competitive Medical Plan, Medicare Cost Contract.2
Medicare Secondary PayerSee Cost Shifting, Medicare.
Medicare SelectA form of Medigap insurance that allows insurers to experiment with the provision of supplemental benefits through a network of providers. Coverage of supplemental benefits is often limited to those services furnished by participating network providers and emergency, out-of-area care.2
Medicare Self Referral OptionA Medicare+Choice Point-Of-Service option that allows enrollees in a Medicare Risk Health Maintenance Organization to go out of plan at a higher cost.40
Medicare SupplementA private medical expense insurance policy that provides reimbursement for out-of-pocket expenses, such as deductibles and coinsurance payments, or benefits for some medical expenses specifically excluded from Medicare coverage.39
Medicare Supplement PolicySee Medigap.
Medicare Waiver(222) Section of the Social Security Amendments of 1972 allowing the Federal Government to waive Medicare payment rules and allow alternative payment methods including capitation.40
Medicare+ChoiceM+CRenamed in 2003 to Medicare Advantage. See also Medicare.
MedicareplusProgram to offer private health plans to Medicare beneficiaries, as proposed under the conference agreement passed by the Congress in November 1995 [H.R. 2491 ].2
Medigap InsurancePrivately purchased individual or group health insurance policies designed to supplement Medicare coverage. Benefits may include payment of Medicare deductibles, coinsurance and balance bills, as well as payment for services not covered by Medicare. Medigap insurance must conform to one of ten federally standardized benefit packages. Also called Medicare Supplemental Policy.2
MedsuppNickname for Medicare Supplemental Policy. See also Medigap.40
MemberA participant in a health plan who makes up the plan\'s enrollment.40
Member MonthA unit of volume measurement. A member month is equal to one member enrolled in a Health Maintenance Organization for one month, whether or not the member actually receives any services during the period. Two member months are equal to one member enrolled for two months or two members enrolled for one month.40
Member ServicesThe broad range of activities that an organization and its employees undertake to support the delivery of the promised benefits to members and to keep members satisfied.39
Members Per YearThe number of members effective in the health plan on a yearly basis.40
Mental Health Parity ActMHPAA law which prohibits group health plans from applying more restrictive annual and lifetime limits on coverage for mental illness than for physical illness.39
Mental Health/Substance AbuseMH/SA
MergerA type of structural integration that occurs when two or more separate providers are legally joined.39
Messenger ModelA type of Independent Practice Association (IPA) that simply negotiates contract terms with Managed Care Organizations (MCOs) on behalf of member physicians, who then contract directly with MCOs using the terms negotiated by the IPA. This type of IPA is most often used with Fee-For-Service or Discounted Fee-For-Service compensation arrangements.39
Meta-AnalysisA systematic, typically quantitative method for combining information from multiple studies.2
Metropolitan Statistical AreaMSAA geographic area that includes as least one city with 50,000 or more inhabitants, or a Census Bureau-defined urbanized area of at least 50,000 inhabitants and a total MSA population of at least 100,000 (75,000) in New England).2
Military Health SystemMHSA worldwide healthcare system operated by the U.S. Department of Defense that focuses its efforts on population health improvement by integrating the delivery of healthcare services for active-duty personnel, retirees, and the families of active-duty personnel and retirees.39
Military Treatment FacilitiesMTFsHospitals, clinics, and treatment centers that the Army, Navy, Air Force, and Coast Guard operate to deliver care to Military Health System beneficiaries.39
Miller TrustsCommonly known as income sheltering devices, these trusts enable otherwise income-ineligible Medicaid applicants to qualify for Medicaid.40
Minimum BenefitsSee Standard Benefits Package.
Minimum Data SetsMDSFederal data collection system for assessing nursing home patients. The MDS for nursing facility residents is a comprehensive resident assessment instrument (RAI) that measures functional status, mental health status, and behavioral status to identify chronic care patient needs and formalize a care plan in response to 18 Resident Assessment Protocols (RAPs). Under Federal regulation, assessments are conducted at a time of admission into a nursing facility, upon return from a 72-hour hospital admission, whenever there is a significant change in status, quarterly, and annually, See also Resource Utilization Groups.40
Minimum PremiumFinancing mechanism for a medical benefit program in which an employer remits only a portion of the conventional premium to the insurer to cover the cost of administering the benefits program and to providing specific and aggregate stop-loss insurance. The employer funds a \'bank account\' which the insurer draws upon for payment of claims.40
Minnesota Multiphasic Personality InventoryMMPIOne of the most frequently used personality tests in mental health. The test is used by trained professionals to assist in identifying personality structure and psychopathology.13
Mixed Model HMOA health plan that includes more than one form of Health Maintenance Organization within a single plan.40
Mobile Intensive Care UnitMICUAn intensive care unit that is readily movable, for example, an ambulance.13
Modified Community RatingMCRA separate rating of medical service usage in a given geographic area using age-sex data. See also Adjusted Community Rating.39, 40
Modified Fee-For-ServiceA system in which providers are paid on a fee-for-service basis, with certain fee maximums for each procedure.40
Moral HazardTendency of an enrollee to use benefits unnecessarily unless given incentives (such as co-payments and deductibles) not to do so. See also Cost Sharing.40
MorbidityA measure of disease incidence or prevalence in a given population, location, or other grouping of interest.2
MortalityA measure of deaths in a given population, location, or other grouping of interest.2
Most-Favored-Nation ClauseMFNA \'Most Favored Nation\' (MFN) clause is a contractual agreement between a supplier and a customer that requires the supplier to sell to the customer on pricing terms at least as favorable as the pricing terms on which that supplier sells to other customers. These clauses are sometimes found in the contracts health insurers enter into with providers.1
Multiple Employer TrustMETLegal trust established by a plan sponsor that brings together a number of small, unrelated employers for the purpose of providing group medical coverage on an insured or self-funded basis.40
Multiple Employer Welfare ArrangementMEWAA group of employers joined together to offer employees health benefits comparable to traditional health insurance packages. Employers take part to reduce health insurance costs and spread the risk over a larger group of people.40
Multiple Option PlanA health plan design that offers employees the option of electing to enroll under one of several types of coverage, usually from among a Health Maintenance Organization, a Preferred Provider Organization and a Major Medical Indemnity Plan.40
Multipurpose Internet Mail Extensions MIMEEnables e-mail clients to send and receive graphics, audio, and video files via the Internet mail system. 77
Multipurpose Senior CenterA community or neighborhood facility established for the organization and provision of a broad spectrum of supportive services, including health, social, nutritional, and educational services, and the provision of facilities for recreational activities for older individuals.40
Multislice Spiral Computer TomographyMSCTAn imaging technology that is a special type of CT scan. It provides 3-dimensional images and shows more detail than conventional CT scans can provide.8
Multispecialty GroupA group of doctors who represent various medical specialties and who work together in a group practice.40
MultumA popular drug formulary and alerts database.78
Mutual CompanyA company that is owned by its members or policyowners.39
National AccountsLarge group accounts that have employees in more than one geographic area that are covered through a single national contract for health coverage.17 Contrast with large local groups.39
National Cancer RegistryA unit within the National Institutes of Health that provides updates on the latest cancer diseases, research and diagnosis.40
National Center For Health Services ResearchA division within the U.S. Department of Health and Human Services that supports analyses and evaluations of the health care system and its financing and underwrites the development and testing of new approaches to improve the distribution, use and cost-effectiveness of services.40
National Center For Health StatisticsA division within the U.S. Department of Health and Human Services that is responsible for gathering data on illness and disability, producing the vital statistics of the nation and tracking the use and availability of health services and resources.40
National Claims History SystemNCHA Health Care Financing Adminstration data reporting system that combines both Part A and Part B claims in a common file. The National Claims History system became fully operational in 1991.2
National Drug CodeNDCA national classification system for identification of drugs. Similar to the universal product code (UPC).40
National Health BoardNHBThe National Health Board has been described by most managed competition plans as an independent Federal agency charged with implementation and oversight of the national health care plan. It would likely be responsible for developing the uniform benefits package, setting standards and registration requirements for AHPs and HIPCs, and any other tasks as designated by Congress or the Administration. Board members would serve staggered terms and be insulated from the Executive and Legislative branches. Membership would reflect provider, consumer and public policy interests.40
National Health ExpendituresAll spending in a country for health services, including individual expenditures not reimbursed, the administrative costs of non-profit and government health programs, the net cost to enrollees of private health insurance, government expenditures designed to promote health in general, non-commercial health research, and construction of medical facilities.40
National Health InsuranceNHIThe government as the single payor of medical bills. Key features often include: federal financing from general tax revenues; beneficiary contributions and/or payroll taxes; government fee controls; and prospective budgets.2
National Health ServiceNHSThe name commonly used to refer to the four publicly funded healthcare systems of the United Kingdom, collectively or individually, although only the health service in England uses the name without further qualification.13
National Institute for Standards and TechnologyNISTFounded in 1901, NIST is a non-regulatory federal agency within the U.S. Department of Commerce. NIST\'s mission is to promote U.S. innovation and industrial competitiveness by advancing measurement science, standards, and technology in ways that enhance economic security and improve our quality of life. (Formerly the National Bureau of Standards, NBS). 63
National Institute Of Mental HealthNIMHA part of the federal government of the United States and the largest research organization in the world specializing in mental illness. It is one of the 27 component organizations of the National Institutes of Health, which is in turn part of the U.S. Department of Health and Human Services13
National Institute On AgingNIAFederal agency within the National Institutes of Health that conducts and supports biomedical and behavioral research to increase knowledge of the aging process and associated factors resulting from old age. NIA conducts laboratory and clinical research at it Gerontology Research Center in Baltimore, MD and its clinics. NIA funds research on aging at universities, hospitals, and other organizations.40
National Institutes Of HealthNIHA division within the U.S. Department of Health and Human Services that is responsible for most of the agency\'s medical research programs.40
National Practitioner Data BankNPDBA database maintained by the U.S. Department of Health and Human Services that contains information on physicians and other medical practitioners against whom medical malpractice claims have been settled or other disciplinary actions have been taken.39, 40
National Provider IdentifierNPIA unique number assigned to healthcare providers. Currently required for insurance billing.78
Nationwide Health Information NetworkNHINA secure, nationwide, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting health and healthcare. This critical part of the national health IT agenda will enable health information to follow the consumer, be available for clinical decision making, and support appropriate use of healthcare information beyond direct patient care so as to improve health.24
NCPDP SCRIPT StandardSCRIPTSCRIPT is a standard created to facilitate the transfer of prescription data between pharmacies, prescribers, intermediaries, and payers. The current standard supports messages regarding new prescriptions, prescription changes, refill requests, prescription fill status notification, prescription cancellation, medication history, and transactions for long term care environments. Enhancements have been added for Drug Use/Utilization Review (DUR) alerts, standardized sig (instructions), allergies, and diagnosis information.23
Needs Assessment (Evaluation)Systematic appraisal of the type, depth, and scope of a problem.2
Negotiated Fee ScheduleFees set through an organized bargaining process usually used to help determine a global budget. Also called negotiated payment schedule.40
Net BenefitsThe total discounted benefits minus the total discounted costs (also called net rate of return.2
Net IncomeThe excess of total revenues over total expenses. Also called profit.39
Net LossIf total expenses exceed total revenues, the excess of total expenses over total revenues.39
Net Loss RatioThe result of total claims liability and all expenses divided by premiums. This is the carrier\'s loss ratio after accounting for all expenses.40
NetworkThe group of physicians, hospitals, and other medical care professionals that a managed care plan has contracted with to deliver medical services to its members. [39] A system for communication among two or more communications- it may be a wired system (using Ethernet cabling), a wireless system (using routers) or a combination of both. [77]39, 77
Network Attached StorageNASIs file-level computer data storage connected to a computer network providing data access to heterogeneous network clients.13
Network Management DirectorA health plan manager who is responsible for developing and managing the Managed Care Organization\'s provider networks including such activities as recruiting, credentialing, contracting, service, and performance management for providers.39
Network-Model HMOA Health Maintenance Organization that contracts with several different medical groups, often at a capitated rate. Groups may use different methods to pay their physicians. See also Group-Model HMO, Health Maintenance Organization, Independent Practice Association, Staff-Model HMO.2
New Business UnderwritingThe risk evaluation a Managed Care Organization performs when it first issues coverage to a group.39
New Drug ApplicationNDA\"The vehicle in the United States through which drug sponsors formally propose that the FDA approve a new pharmaceutical for sale and marketing. The goals of the NDA are to provide enough information to permit FDA reviewers to establish the following: 1) Is the drug safe and effective in its proposed use(s) when used as directed, and do the benefits of the drug outweigh the risks?; 2) Is the drug’s proposed labeling (package insert) appropriate, and what should it contain?; 3) Are the methods used in manufacturing (Good Manufacturing Practice, GMP) the drug and the controls used to maintain the drug’s quality adequate to preserve the drug’s identity, strength, quality, and purity?
Newborns\' And Mothers\' Health Protection ActNMHPAA law which specifies that group health plans or group healthcare insurers cannot mandate that hospital stays following childbirth be shorter than 48 hours for normal deliveries or 96 hours for Cesarean births.39
NFPA Storage CodesNational Fire Protection Association storage codes. As fire departments inspect businesses, especially radiology departments, several questions arise including storage codes for x-ray films and chemicals. Contact your local fire department for further information for your area.40
No Balance Billing ProvisionA provider contract clause which states that the provider agrees to accept the amount the plan pays for medical services as payment in full and not to bill plan members for additional amounts (except for co-payments, coinsurance, and deductibles).39
Nominal ValueMeasurement of an economic amount in terms of current prices. See Real Value.2
Nominating CommitteeA committee that recommends nominations for an organization\'s officers as required in the organization\'s bylaws.39
NoncontributoryA situation in which the plan sponsor pays the entire cost or premiums for coverage. Employees do not contribute toward the cost of the coverage.40
Nondiscrimination RulesSection 89, Internal Revenue Code . Provisions contained in the Tax Reform Act of 1986 (P.L. 99-514), amending Section 89 of the Internal Revenue Code to help ensure more equity in the provision of employer-financed group term life, accident, health and welfare benefits among the highly compensated and other employees. The provision became effective January 1, 1989. The Internal Revenue Service will establish tests to determine continuous employer compliance with the requirements. Financial penalties for the employer that fails to meet Section 89 requirements will be imposed upon its highly compensated employees.40
Nonforfeiture FeatureA provision in some long-term care policies offering a guarantee that certain policy benefits will remain available even if the enrollee stops paying premiums. One type of non-forfeiture is a paid-up policy providing the same benefits for a shorter period of lower benefits for the same period as the original policy. Return of premium benefits are another form of non-forfeiture. Also called lapsed coverage protection.40
Non-Group MarketA market segment that consists of customers who are covered under an individual contract for health coverage or enrolled in a government program.39
Non-InfectiousNot spread by infectious agents. Used to describe diseases such a heart disease, most cancers, and cirrhosis. Often used synonymously with \'noncommunicable\'.2
Non-MaleficenceAn ethical principle which, when applied to managed care, states that managed care organizations and their providers are obligated not to harm their members.1839
Nonparticipating PhysicianSee Nonparticipating Provider.
Nonparticipating ProviderA health care provider who has not contracted with the carrier or health plan to be a participating provider of health care and who, therefore, is not obligated to accept assignment on all Medicare claims. See Assignment, Participating Physician, Participating Physician and Supplier Program.2, 40
Nonphysician PractitionerA health care professional who is not a physician. Examples include advanced practice nurses and physician assistants.2
North American Industry Classification SystemNAICSThe standard used by Federal statistical agencies in classifying business establishments for the purpose of collecting, analyzing, and publishing statistical data related to the U.S. business economy. It replaced the Standard Industry Classification (SIC) codes.85
Nuclear Regulatory CommissionNRCA Federal commission created in 1974 to protect the public health and safety by regulating civilian uses of nuclear materials.40
Nursing FacilityNFAn institution that provides skilled nursing care and rehabilitation services to injured, functionally disabled, or sick persons. Formerly, distinctions were made between Intermediate Care Facilities and Skilled Nursing Facilities. The Omnibus Budget Reconciliation Act of 1987 eliminated this distinction effective October 1, 1990, by requiring all nursing facilities to meet SNF certification requirements. See Skilled Nursing Facility. 2
Occupancy RateA measure of inpatient health facility use, determined by dividing available bed days by patient days. It measures the average percentage of facilities\' beds occupied.40
Occupational HealthActivities undertaken to protect and promote the health and safety of employees in the workplace, including minimizing exposure to hazardous substances, evaluating work practices and environments to reduce injury, and reducing or eliminating other health threats.2
Occupational Safety And Health AdministrationOSHAA Federal agency within the U.S. Department of Labor that is responsible for setting standards to promote and enforce employee safety in the workplace.40
Office Of Inspector GeneralOIGThe enforcement arm within the U.S. Department of Health and Human Services that oversees investigations of alleged violations of Medicare and Medicaid laws and rules.40
Office of Interoperability and StandardsOISWorks with and coordinates with other offices in ONC and HHS to provide leadership in the development and implementation of a nationwide interoperable health information technology infrastructure and advance the development, adoption, and implementation of interoperable health information technology standards. Designated as Section ARC within the ONC organizational structure.99
Office Of Management And BudgetOMBA Federal agency responsible for providing fiscal accounting and budgeting services for the Federal government.40
Office Of Personnel ManagementOPMAmong other things, the Federal agency that administers and directs all Federal Employee Health Benefits Programs.40
Office Of Professional Standard Review OrganizationsThe health standards and quality bureau of the Health Care Financing Administration.40
Office Of Technology AssessmentOTAAn office of the United States Congress from 1972 to 1995. Its purpose was to provide Congressional members and committees with objective and authoritative analysis of the complex scientific and technical issues of the late 20th century. It was a leader in practicing and encouraging delivery of public services in innovative and inexpensive ways, including distribution of government documents through electronic publishing.13
Office Of The Inspector GeneralOIGAn office that is part of Cabinet departments and independent agencies of the United States federal government as well as some state and local governments. Each office includes an Inspector General and employees charged with identifying, auditing, and investigating fraud, waste, abuse, and mismanagement within the parent agency. See also Inspector General.13
Office Of The National Coordinator For Health ITONCPart of the Office of the Secretary for the U.S. Department of Health and Human Services. ONC is the principal Federal entity charged with coordination of nationwide efforts related to the implementation and use of electronic health information exchange. The position was established on April 27, 2004, through Executive Order (EO) 13335 (George W. Bush), Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator, which directed the National Coordinator \'to provide leadership for the development and nationwide implementation of an interoperable health information technology infrastructure to improve the quality and efficiency of health care\'. ONC provides counsel to the Secretary of HHS and Departmental leadership for the development and nationwide implementation of an interoperable health information technology infrastructure. Use of this infrastructure will improve the quality, safety and efficiency of health care and the ability of consumers to manage their health information and health care.25
Off-Open Enrollment TerminationSee Attrition Rate.
Older Americans ActOAA1965 Federal legislation to create a network of state and area agencies on aging. These agencies help plan and fund programs and services for persons over the age of sixty.40
Omnibus Budget Reconciliation ActOBRAAn amendment to the Federal budget that outlines new Federally funded programs or revisions to existing programs. In 1985, the amendment was called the Consolidated Omnibus Budget Reconciliation Act, or COBRA.40
One And Done Customer ServiceSee First Contact Resolution Rate.
One Stop Primary CareAn approach in the UK that brings together a variety of primary care and community services into a single site to provide more convenient patient access.103
Open AccessAllows members to see participating providers, usually a specialist, without a referral from the health plan\'s gatekeeper. These types of arrangements are most often found in Independent Practice Association-model Health Maintenance Organizations.40
Open Ended HMOSee Point-Of-Service Plan.
Open EnrollmentIf an employer offers the covered population two or more options in selecting health benefits coverage, there is usually an annual period of time within which the employee can make changes in the coverage previously selected. Changes might include an increase in out-of-pocket expenditures to reduce personal premium participation or a change from indemnity insurance to Health Maintenance Organization or Propective Payment Organization coverage.40
Open Enrollment TerminationSee Attrition Rate.
Open FormularyThe provision that drugs on the preferred list and those not on the preferred list will both be covered by a Primary Benefit Management Plan or Managed Care Organization.39
Open PHOA type of physician-hospital organization that is available to all of a hospital\'s eligible medical staff.39
Open Systems InterconnectionOSIAn effort to standardize networking that was started in 1977[1] by the International Organization for Standardization (ISO), along with the ITU-T.13
Open-Panel HMOA Health Maintenance Organization in which any physician in an area who meets its standards of care may contract with it as a provider. The physicians typically operate out of their own offices and see other patients as well as HMO members.39, 40
Operational IntegrationThe consolidation into a single operation of operations that were previously carried out separately by different providers.39
Opportunity Costs (Evaluation)The value of opportunities foregone because of an intervention project.2
Optical Character RecognitionOCROCR is recognition of printed or written characters by a computer.77
Optimal HealthOptimal health...[is] a balance of physical, emotional, social, spiritual and intellectual health.2
Order SetA pre-defined list specifying what treatments, in which sequence, the care giver should order to manage a particular condition.6
Organ Procurement OrganizationOPOA non-profit Federally funded organization that has many responsibilities in the organ transplantation process.40
Organized Delivery SystemA comprehensive, integrated network of providers who manage and deliver many levels of care in comprehensive set of health services.40
OryxThe integration of performance measurement into the Joint Commission\'s accreditation process. Each accredited facility must select vendors that have been approved by the Joint Commission On Accreditation Of Healthcare Organizations for the performances measurement system.40
Other Teaching HospitalsHospitals with an approved graduate medical education program and a ratio of interns and residents to beds of less than 0.25. See Indirect Medical Education Adjustment, Major Teaching Hospitals.2
Other Urban AreaA metropolitan statistical area with a population of less than one million, or a New En-land County Metropolitan Area with fewer than 970,000 people. See also Large Urban Area, Metropolitan Statistical Area.2
Out Of NetworkServices received from a provider who does not participate with the enrollee\'s health plan. See Point-Of-Services, Freedom Of Choice.40
Out Of PlanSee Out Of Network.
OutcomeThe consequence of a medical intervention on a patient.2
Outcome And Effectiveness ResearchMedical or health services research that attempts to identify the clinical outcomes of the delivery of health care.40
Outcome AuditA type of patient/medical care evaluation study in which criteria are designed to focus upon desired patient outcome or results of treatment, as distinguished from a process audit in which criteria focus upon the components of appropriate clinical intervention.40
Outcome EvaluationOutcome evaluation is used to obtain descriptive data on a project and to document short-term results. Task-focused results are those that describe the output of the activity, e.g., the number of public inquiries received as a result of a public servi ce announcement. Short-term results describe the immediate effects of the project on the target audience, e.g., percent of the target audience showing increased awareness of the subject. Information that can result from an outcome evaluation includes: knowledge and attitude changes; expressed intentions of the target audience; short-term or intermediate behavior shifts; and policies initiated or other institutional changes made.2
Outcome ManagementCollecting and analyzing results of medical performance and using that information to optimize healthcare results.40
Outcome MeasuresAssessments to gauge the results of treatment for a particular disease or condition. Outcome measures include the patient\'s perception of restoration of function, quality of life and functional status, as well as objective measures of mortality, morbidity and health status.40
Outcome StandardsLong-term objectives that define optimal, measurable future levels of health status, maximum acceptable levels of disease, injury, or dysfunction, or prevalence of risk factors.2
Outcomes And Assessment Information SetOASISFederal monitoring system for Home Health Agencies.40
Outcomes And Effectiveness ResearchSee Outcome And Effeciveness Research.
Outcomes MeasuresHealthcare quality indicators that gauge the extent to which healthcare services succeed in improving or maintaining satisfaction and patient health.39
Outcomes ResearchResearch on the effects on health, function, or quality of life of the patient resulting from various health services or from ways of organizing and financing health services.40
OutlierA comparative term describing a patient whose stay in the hospital is unusually long or whose costs for hospital care are unusually high compared to other patients with the same diagnosis or condition. The Medicare program uses Diagnosis Related Groups as categories to identify outliers. Under Medicare, additional payments are made for outliers meeting certain conditions.40
Out-Of Pocket CostsTotal costs paid directly by consumers for insurance co-payment and deductibles, prescription or over-the-counter drugs, and other services.2
Out-Of-Area BenefitsThe coverage allowed to Health Maintenance Organization members for emergency and other situations outside of its prescribed geographic area .40
Out-Of-Pocket CapSee Out-Of-Pocket Maximum.
Out-Of-Pocket ExpensePayments made by an individual for medical services. These may include direct payments to providers as well as payments for deductibles and coinsurance for covered services, for services not covered by the plan, for provider charges in excess of the plan\'s limits, and for enrollee premium payments.2
Out-Of-Pocket MaximumAn annual limit on how much in deductibles and co-payments the patient is required to pay. Also called Stop-Loss Provision.40
OutpatientOPA person who receives health care services without being admitted to a hospital.40
Outpatient CareTreatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.39
Outpatient Prospective Payment SystemOPPSMedicare\'s system for payment to outpatient departments of hospitals and other outpatient facilities. The specific amount that is paid is determined by the relevant APC.1
Outpatient ServicesMedical and other services provided by a qualified facility where an overnight stay is not required, such as therapy and other clinics, labs and diagnostic centers. See Inpatient Services, Ambulatory Care.40
Outside DirectorsMembers of a company\'s board of directors who do not hold other positions with the company.39
Outside ReferralReferral to a consultant provider not on the managed care company\'s staff or within its network of providers.40
OutsourcingThe hiring of external vendors to perform specified functions, such as data and information management activities.39
Over The Counter DrugsA drug that does not require a prescription.40
Overvalued ProcedureA procedure for which the payment rate has been reduced because it was identified as \'overvalued\' under the customary, prevailing, and reasonable payment system.40
P&T CommitteeSee Pharmacy and Therapeutics Committee.
Paid AmountThe portion of a submitted charge that is actually paid by both third-party payers and the insured, including copayments and balance bills. For Medicare this amount may be less than the allowed charge if the submitted charge is less. or it may be more because of balance billing. See Allowed Charge. Balance Billing, Payment Rate, Submitted Charge.2
Paid ClaimsThe amount paid to providers to satisfy the contractual liability of the carrier or plan sponsor. These amounts do not include any member liability for ineligible charges, deductibles, or co-payments.40
Paid Claims Loss RationThe result of paid claims divided by premiums.40
Paid-Up PolicyIn long-term care insurance, it is generally the operation of a non-forfeiture feature under which the enrollee\'s coverage continues for some period based on the amount of premiums paid when the policy lapses. Methods for providing the paid-up policy may include full benefits for a shorter benefit period or partial benefits for the full original benefit period. Some policies also have a provision which pays up the policy under specified conditions upon the death of an insured spouse. Some companies offer limited or single payment premium modes that result in paid up policies when a specified number of annual premiums have been paid.40
Pain ManagementA formal program that teaches caregivers how to manage chronic and acute pain based on existing guidelines and protocols.8
Palliative CareCare which is provided to relieve pain rather than provide a cure. Also called Comfort Care.40
Parent CompanyA company that owns another company.39
Part A MedicareSee Medicare.
Part B MedicareSee Medicare.
Partial CapitationAn insurance arrangement where the payment made to a health plan is a combination of a capitated premium and payment based on actual use of services; the proportions specified for these components determine the insurance risk faced by the plan.2
Partial Hospitalization ServicesA mental health or substance abuse program operated by a hospital that provides clinical services as an alternative or follow-up to inpatient hospital care.40
Partial Psychiatric Hospitalization ProgramIntensive outpatient care for patients with mental illness, lasting three hours or more rather than the usual one-hour visits.8
Partial Risk ContractA contract between a purchaser and a health plan, in which only part of the financial risk is transferred from the purchaser to the plan. See also Self-Insured Health Plan.2
Participant Driven SupportsProgram in which an individual decides how limited funds, services, or other resources are used. Most commonly used in reference to attendants employed directly by a consumer who is responsible for, or has influence over, hiring, scheduling and firing. Also called consumer directed care.40
Participating DentistSee Participating Provider.
Participating HospitalSee Participating Provider.
Participating PhysicianSee Participating Provider.
Participating Physician And Supplier ProgramPARA program that provides financial and administrative incentives for physicians and suppliers to agree in advance to accept assignment on all Medicare claims for a one-year period. See Assignment.2
Participating ProviderA health care provider who has a contractual arrangement with a health care service contractor, Health Maintenance Organization, Preferred Provider Organization, Independent Practice Association or other Managed Care Organization.40
PatientPerson who is receiving medical care. There are two types of patients: Inpatient and Outpatient.40
Patient AdvocateServes as a liaison between patient and hospital staff. Assists patients in interpreting hospital policies, procedures, and services and to obtaining solutions to problems and concerns. Assists staff in gaining awareness of patients\' perceptions of the hospital experience.40
Patient Flow DataPatient flow data identifies the zip code of each patient discharged from a hospital.1
Patient Medical Record InformationPMRIThe information that is contained in a person\'s medical record, regardless whether that is paper-based or elecronic.13
Patient Origin StudyA study, generally undertaken by an individual health program or health planning agency, to determine the geographic distribution of the residences of the patients served by one or more health programs. Such studies help define catchment areas that are useful in locating and planning the development of new services.40
Patient PerceptionA type of outcomes measure related to whether the patient feels completely \'better\' after treatment or feels improved compared to how he or she felt prior to receiving treatment.39
Patient PortalAllow patients and providers to communicate over the Internet in a secure environment.77
Patient Protection ActsLegislation that requires health benefit plans to take a number of steps to protect patient interests under managed care. The provisions of the acts vary according to state, but some of the most common require plans to disclose coverage provisions, benefits, exclusions, utilization review protocols and policies regarding specialist referral. Many of the acts ban language in provider contracts that may prevent physicians from discussing all treatment options (known as \'gag\' clauses), and require plans to disclose financial incentive plans for providers that may limit care and referrals and provide appeals processes for denied claims. Provisions may also require that individuals be given a choice between Health Maintenance Organization, Preferred Provider Organization and POS options, and that enrollees be allowed direct access to certain types of physicians, such as OB/GYNs. Plans can also be required to disclose their criteria for selecting and deselecting physicians and to provide due process for providers.40
Patient Representative (Ombudsman)A person or office that assists patients who have complaints.8
Patient Self-Determination ActA Federal law that requires health care facilities to determine if new patients have a living will and/or durable power of attorney for health care and take patients\' wishes into consideration in developing their treatment plans.40
Patient-Centered Medical HomePCMHSee Medical Home.
Pay For SkillsIs compensation that rewards individuals for developing the various skills necessary for certain roles or jobs.2
PayerGenerally regarded as the guarantor of payment. Could be an employer, health and welfare fund, insurer, or a broker for the employer or labor organization acting in a purchasing agent capacity, or an individual.40
Pay-For-PerformanceSee Payment for Performance.
Payment For PerformanceP4PPayment for Performance pays providers based on their success in meeting specific performance measures.1
Payment RateThe total amount paid for each unit of service rendered by a health care provider, including both the amount covered by the insurer and the consumer\'s cost sharing: sometimes referred to as payment level. Also used to refer to capitation payments to health plans. For Medicare payments to physicians, this is the same as the allowed charge. See Allowed Charge.2
Payment WithholdSee Risk Contract.
Peer ReviewA system in which the appropriateness of healthcare services delivered by a provider to health plan members is evaluated by a panel of medical professionals.39
Peer Review CommitteeA committee that reviews cases of healthcare services delivery in which the quality of care is questionable or problematic.39
Peer Review OrganizationPROAn entity established by the Tax Equity and Fiscal Responsibility Act of 1982. [40] It is 1) An organization contracting with Health Care Financing Administration to review the medical necessity and the quality of care provided to Medicare beneficiaries; formerly called Utilization and Quality Control Peer Review Organization.; 2) An organization that contracts with HCFA to investigate the quality of health care furnished to Medicare beneficiaries and to educate beneficiaries and providers. PROs also conduct limited review of medical records and claims to evaluate the appropriateness of care provided. [2] 2, 40
Pended AuthorizationAn authorization decision that is delayed.39
Per Capita Health Care SpendingAnnual spending on health care per person.2
Per Case PaymentA set rate of payment for a hospital admission, including all ancillary services excluding separately billed physician services.40
Per Diem PaymentFixed daily payments that do not vary with the level of services used by the patient. This method generally is used to pay institutional providers, such as hospitals and nursing facilities. See also Capitation.2
Per Diem RateSee Per Diem Payment.
Per Member Per MonthPMPMThe amount of money paid or received on a monthly basis for each individual enrolled in a managed care plan. A form of Capitation.40
Per Member Per YearPMPYThe amount of money paid or received on a yearly basis for each individual enrolled in a managed care plan. A form of Capitation.40
Percent Of PremiumA predetermined percentage of premium is shared between the payer and provider to pay for the costs of medical services provided to the covered population.40
Performance MeasureA specific measure of how well a health plan does in providing health services to its enrolled population. Can be used as a measure of quality. Examples include percentage of diabetics receiving annual referrals for eye care, mammography rate, or percentage of enrollees indicating satisfaction with care. See also Outcome Measures, Key Indicators, Quality Assurance.2, 40
Performance StandardThe target rate of expenditure growth set by the Volume Performance Standard system.2
Periodic Interim PaymentsPIPAn automatic, biweekly payment by Medicare to a hospital or skilled nursing facility to cover expected charges. Actual charges are balanced against these in the provider\'s accounting system.88
Person Centered PlanningProcess to identify and respond to the expressed needs and desires of an individual. Also called personal futures planning or essential lifestyle planning.40
Personal Attendant ServicesPASSee Attendants.
Personal CareOptional Medicaid benefit which allows a state to provide services to assist functionally impaired individuals in performing the activities of daily living (e.g., bathing, dressing, feeding, grooming, etc.). See Activities Of Daily Living, Attendant Service.40
Personal Care AdvisorSee Care Coordination Benefit.
Personal Care AdvocateSee Care Coordination Benefit.
Personal Care PhysicianSee Primary Care Provider.
Personal Desktop AssistantSee Personal Digital Assistant.
Personal Digital AssistantPDAPDA is a handheld device with a multitude of uses such as scheduling appointments on a calendar, creating to-do lists, storing libraries of medical information, viewing patient specific data. PDA allow for mobility. They are Also called palmtops, hand-held computers and pocket computers.77
Personal Emergency Response SystemPERSA devise, carried or worn, that can be activated in an emergency to alert a central location through the phone system. Family, friends, or emergency services are then contacted to check on the nature of the emergency.40
Personal Futures PlanningSee Person Centered Planning.
Personal Health Care Expenditures[1] These are outlays for good and services relating directly to patient care.; [2] The part of total national or state health expenditures spent on direct health care delivery, including hospital care, physician services, dental services, home health,nursing home care, and prescription drugs.2
Personal Health InformationPHIA person\'s aggregate health information that is protected under HIPAA.89
Personal Health RecordPHRA record, typically electronic, of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual. See also Electronic Health Record.13
Personal InsuranceSee Individual Insurance.
Pharmaceutical CardsIdentification cards issued by a pharmacy benefit management plan to plan members. These cards assist Primary Benefit Managers s in processing and tracking pharmaceutical claims. Also called Drug Cards or Prescription Cards.39
Pharmaceutical CareA strategy that attempts to utilize drug therapy more efficiently to achieve definite outcomes that improve a patient\'s quality of life. A pharmaceutical care system requires a reorientation of physicians, pharmacists, and nurses toward effective drug therapy outcomes. It is a set of relationships and decisions through which pharmacists, physicians, nurses, and patients work together to design, implement, and monitor a therapeutic plan that will produce specific therapeutic outcomes.40
Pharmacy And Therapeutics CommitteeThe Managed Care Organization committee that develops, updates, and administers its formulary and regularly reviews reports on clinical trials, drug utilization reports, current and proposed therapeutic guidelines, and economic data on drugs. [39] A group of physicians, pharmacists, and other health care providers from different specialties, who advise a managed care plan regarding safe and effective use of medications. The P&T Committee manages the formulary and acts as the organizational line of communication between the medical and pharmacy components of the health plan. [40]39, 40
Pharmacy Benefit Management PlanA type of managed care specialty service organization that seeks to contain the costs of prescription drugs or pharmaceuticals while promoting more efficient and safer drug use. Also called a Prescription Benefit Management Plan.39
Pharmacy Benefit ManagerPBMA company under contract with managed care organizations, self-insured companies, and government programs to manage pharmacy network management, drug utilization review, outcomes management, and disease management.1
Pharmacy Services Administrative OrganizationPSAOAn organization that is dedicated to provide prescription benefits to enrollees of managed care plans that utilizes existing community pharmacies. The PSAO contracts as a provider group with the managed care organization, so that the individual pharmacies receive negotiating representation in numbers and the prepaid health plan does not have to provide the capital necessary to start, own, and operate their own pharmacy department.40
Physical/Occupational RehabilitationVariety of inpatient services for the disabled to help patients attain or retain the highest possible function.8
Physical/Occupational TherapyOutpatient services to help people who don\'t need to stay in the hospital attain or retain the highest possible function.8
Physician Contingency ReservePCRSee Withhold.
Physician DispensingA physician gives the patient his or her initial doses of a commonly prescribed drug during an office visit. The prescription is usually refilled at the pharmacy and not the physician\'s office. Doctors who dispense medications usually stock 20 to 30 drugs (antibiotics, anti-inflammatories, etc.). Pharmacists see this as a reduction in their marketshare, whereas physicians see this as both an extra service and convenience to their patients. 40
Physician IncomeNet income after expenses and before taxes. Median net income for physicians in 1991 was $139,000. Physician net income in 1991 was 13% of U.S. health expenditures.2
Physician Organization ArrangementPOASee Physician Hospital Organization.
Physician Payment Review CommissionPPRCA bipartisan congressional advisory group established in 1986 to advise Congress on setting Medicare and Medicaid reimbursement. In 1990, PPRCs responsibilities were expanded to include other payment policy issues. See Medicare Payment Advisory Commission.40
Physician Practice Management CompanyPPMCA company, owned by a group of investors, that purchases physicians\' practice assets, provides practice management services, and, in most cases, gives physicians a long-term contract to continue working in their practice and sometimes an equity (ownership) position in the company.39
Physician ServicesOne portion of national health care expenditures. Includes physicians\' overhead, administrative expenses, and income. Total expenditures for physician services in 1991 were $142 billion or 19% or total health spending.2
Physician WorkA measure of the physician\'s time, physical effort and skill, mental effort and judgment, and stress from iatrogenic risk associated with providing a medical service. A component of the Medicare relative value scale. See Relative Value Scale.2
Physician-Hospital OrganizationPHOA joint venture between a hospital and some or all of the physicians who have admitting privileges at the hospital. [1] The hospital and physicians - both in individual and group practices - negotiate as an entity directly with insurers. It may also undertake utilization review, credentialing, and quality assurance. Physicians retain ownership of their own practices, maintain significant business outside the PHO, and typically continue in their traditional style of practice. [2] Its primary purpose is contract negotiations with Managed Care Organizations and marketing [39]; to obtain payer contracts and to further mutual interests; one type of Integrated Delivery System. [40]1, 2, 39, 40
Physician\'s Current Procedural TerminologyCPTA list of medical services and procedures performed by physicians and other providers. Each service and/or procedure is identified by its own unique 5-digit code. CPT has become the health care industry\'s standard for reporting of physician procedures and services, thereby providing an effective method of nationwide communication. See HCFA Common Procedural Coding System.40
Physicians’ Desk ReferencePDRA reference book published yearly that contains drug monographs and an illustrated section for drug identification; it is also available on CD-ROM.18
Picture Archiving and Communication SystemPACSAn information system for the storage and distribution of digital radiology images over a networked environment that allows for instant access to images and reports.77
Plan For Achieving Self SupportPASSOption to exempt certain income used to improve independence from consideration in determining financial eligibility for disability payments under SSI.40
Plan FundingThe method that an employer or other payer or purchaser uses to pay medical benefit costs and administrative expenses.39
Planned ChangeChange that is deliberate, controlled, collaborative, and proactive.39
PlatformThe basic technology of a computer system\'s hardware and software that defines how a computer is operated and determines what other kinds of software can be used.77
Play Or PayEmployers are required to provide at least a minimum standard benefits package for their employees or pay a payroll tax. Employees in firms that choose to pay the tax will be \'pooled\' together for the purchase of health insurance either into a single public program like Medicare or a program in which enrollees choose from competing private health plans. Payroll tax revenues, individual premiums (with subsidies provided for low-income persons) and other general tax revenues would finance the health benefit costs.40
Point and ClickAllowing the activation of commands by moving the cursor over certain areas or icons and clicking a pointing device.77
Point-of-CarePOC refers to the time while with the patient, either bedside or during an encounter.77
Point-Of-Purchase PlanA benefit plan that expands enrollee options to choose providers. It usually consists of two or more delivery and financing options including an alternative delivery system, such as a Health Maintenance Organization or Preferred Provider Organization, and another plan such as traditional fee-for-service coverage. The participant is not locked-in but may change coverage options each time care is obtained. The scope of benefits and payment provisions are structured to provide incentives for greater use of the alternative delivery system option.40
Point-Of-ServicePOSA health insurance plan in which members do not have to choose how to receive services until they need them. The most common use of the term applies to a plan that enrolls each member in both a Health Maintenance Organization (or HMO-like) system and an indemnity plan. These plans provide different benefits, depending on whether the member chooses to use plan providers or go outside the plan for services. Also called an Open-Ended HMO.1, 40
Point-Of-Service PlanPOS1) A managed-care plan that combines features of both prepaid and fee-for-service insurance. Health plan enrollees decide whether to use network or non-network providers at the time care is needed and usually are charged sizable copayments for selecting the latter. See Health Plan, Health Maintenance Organization, Preferred Provider Organization; 2) A health plan in which enrollees select providers either within or outside of a preferred network, with co-payment or deductibles higher for out-of-network providers; 3) A health plan with a network of providers whose services are available to enrollees at a lower cost than the services of non-network providers. POS enrollees must receive authorization from a primary care physician in order to use network services. POS plans typically do not pay for out-of-network referrals for primary care services. See also Propsective Payment Organization.2
Point-Of-Service ProductA healthcare option that allows members to choose at the time medical services are needed whether they will go to a provider within the plan\'s network or seek medical care outside the network.39
Policy DevelopmentThe process whereby public health agencies evaluate and determine health needs and the best ways to address them.2
Policy Significance (Evaluation)The significance of an evaluation\'s findings for policy and program development (as opposed to their statistical significance).2
Policy Space (Evaluation)The set of policy alternatives that are within the bounds of acceptability to policymakers at a given point in time.2
PolicyholderUnder a group plan, the group is the policyholder; under an individual plan, the individual is the policyholder. The policyholder is the one who has the contract or agreement with the insurer.40
Political Action CommitteePACA group of people organized to collect and distribute contributions to political candidates.40
PoolingThe practice of underwriting a number of small groups as if they constituted one large group.39
Population At Need (Evaluation)Units of potential targets that currently manifest a particular condition.2
Population At RiskSegment of population with significant probability of having or developing a particular condition.2
Population Carve-OutsA population carve-out provides health care to a designated population, targeted or defined by a specific health condition.2
PortabilityThe requirement that insurers waive any Pre-existing Condition Exclusion for someone who was previously covered through other insurance as recently as 30 to 90 days earlier. For example, an individual changing job would be guaranteed coverage with the new employer, without a waiting period or having to meet additional deductible requirements. See also Pre-existing Condition Exclusion.2
PortalA website considered as an entry point to other websites. Examples are a Patient Portal.77
POS ProductSee Point-Of-Service Product.39
Post Retirement Health BenefitPRHBThe degree to which a person enjoys the important possibilities of his or her life.13
Potentially Avoidable HospitalizationsPAHAdmissions to a hospital that could have been avoided if adequate and timely health care had been available.2
PPS Inpatient MarginA measure that compares PPS operating and capital payments with Medicare-allowable inpatient operating and capital costs. It is calculated by subtracting total Medicare-allowable inpatient operating and capital costs from total PPS operating and capital payments and dividing by total PPS operating and capital payments. See also PPS Operating Margin.2
PPS Operating MarginA measure that compares PPS operating payments with Medicare-allowable inpatient operating costs. This measure excludes Medicare costs and payments for capital, direct medical education, organ acquisition, and other categories not included among Medicare-allowable inpatient operating costs. It is calculated by subtracting total Medicare-allowable inpatient operating costs from total PPS operating payments and dividing by total PPS operating payments.2
PPS YearA designation referring to hospital cost reporting periods that begin during a given Federal fiscal year, reflecting the number of years since the initial implementation of PPS. For example, PPS1 refers to hospital fiscal years beginning during Federal fiscal year 1984, which was the first year of PPS. For a hospital with a fiscal year beginning July 1, PPS 1 covers the period from July 1, 1984, through June 30, 1985. See also Fiscal Year.2
Practice ExpenseThe cost of nonphysician resources incurred by the physician to provide services. Examples are salaries and fringe benefits received by the physician\'s employees, and the expenses associated with the purchase and use of medical equipment and supplies in the physician\'s office. A component of the Medicare relative value scale. See Relative Value Scale.2
Practice Expense Relative ValueA value that reflects the average amount of practice expenses incurred in performing a particular service. All values are expressed relative to the practice expenses for a reference service whose value equals one practice expense unit. See Relative Value Scale.2
Practice GuidelinesA statement of what is known about the benefits, risks and costs of particular courses of medical treatment to achieve the best possible patient outcome. Also called Practice Parameters.40
Practice ManagementPMThe management of the physician business operations including scheduling, registration, and billing.28
Practice Management SoftwarePMSSoftware that deals with the day-to-day operations of a medical practice. It frequently allows users to capture patient demographics, schedule appointments, maintain lists of insurance payers, perform billing tasks, and generate reports.13
Practice ParametersSee Practice Guidelines.
Pre-Admission CertificationReview and approval process completed before hospital admission to ensure the medical necessity for the acute level of care and for the proposed services and procedures, to avoid a weekend admission, and to forecast the expected length of stay. The review process may include an assessment of the physician\'s proposed treatment protocol and fees. Compliance with changes in the treatment plan recommended by the reviewing entity may be a condition of receiving full coverage under the health benefit. The benefit level may be reduced or services not covered at all if the patient fails to comply with plan requirements. The pre-admission review process may also include an administrative confirmation of the patient\'s eligibility for benefits, covered services and restrictions, and the determination of applicable deductibles, co-payments, and maximums.40
Pre-Admission NotificationSimilar to pre-admission certification, a condition of receiving full benefits. Failure to notify the reviewing agency within the time limitations may result in a reduced level or denial of benefits. Differs from certification programs since the counseling offered by the notification agency is not binding upon the patient.40
Pre-Admission ReviewSee Pre-Admission Certification.
Pre-Admission ScreeningPASProcess to determine the appropriateness of an applicant for nursing home placement.40
Pre-Admission Screening And Annual Resident ReviewPASARRScreening process for mental disabilities which assures that patients get the proper placement and access to services.40
Pre-Admission TestingA utilization management technique that requires plan members who are scheduled for inpatient care to have preliminary tests, such as X-rays and laboratory tests, performed on an outpatient basis prior to admission.39
Pre-AuthorizationSimilar to pre-admission certificate, a condition of receiving health benefits. Review and approval process that must be completed before services are provided, when an inpatient or ambulatory site is proposed for care. The review process may include an assessment of the physician\'s proposed protocol and fees. Compliance with changes in the proposed treatment plan recommended by reviewing entity may be a condition of receiving full coverage under the health benefit.40
Pre-CertificationA utilization management technique that requires a plan member or the physician in charge of the member\'s care to notify the plan, in advance, of plans for a patient to undergo a course of care such as a hospital admission or complex diagnostic test. Also called prior authorization.39
PredeterminationA procedure where a provider submits a treatment plan to the health insurer before treatment begins. The insurer reviews the treatment plan and notifies the provider of one or more of the following: patient\'s eligibility, covered services, amounts payable, co-payment and deductibles and plan maximums.40
Pre-Estimate Of CostSee Pre-Authorization.40
Pre-Existing ConditionIn group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage.39
Pre-Existing Condition ExclusionA practice of some health insurers to deny coverage to individuals for a certain period, for example, six months, for health conditions that already exist when coverage is initiated. See Portability.2
Pre-Existing Condition LimitationsA provision in insurance policies that excludes health conditions existing prior to coverage sign up. These limitations exclude specified conditions entirely or for a specified period. When an individual changes jobs and enrolls in a new insurance plan, these limitations can cause a critical gap in health benefits.2
Pre-Existing ConditionsWhen a physical or mental condition of a newly insured individual is present prior to the insurance of the new insurance policy. Normally, these exclusions last from 6 to 12 months, however, more severe conditions may be considered as lifetime exclusions.40
Preferred Provider ArrangementPPAAs defined in state laws, a contract between a healthcare insurer and a healthcare provider or group of providers who agree to provide services to persons covered under the contract. Examples include Preferred Provider Organizations and Exclusive Provider Organizations.39
Preferred Provider OrganizationPPO1) Are somewhat similar to Independent Practice Associations and Health Maintenance Organizations in that the it is a corporation that receives health insurance premiums from enrolled members and contracts with independent doctors or group practices to provide care. However, it differs in that doctors are not prepaid, but they offer a discount from normal FFS charges; 2) A health plan with a network of providers whose services are available to enrollees at lower cost than the services of non-network providers. PPO enrollees may self-refer to any network provider at any time; 3) A health plan in which enrollees receive services from a defined network of providers who agree to providee specific services for a set of fee. See also Fee for Service, Health Maintenance Organization, Managed Care, Managed Care Plan, Point-of-Service Plan.2
Preferred ProvidersSee Preferred Provider Orgainzation.
PremiumProspectively determined rate for insurance coverage for specific health benefits. Generally, a health insurance plan will have different premium rates for single subscribers, married subscribers and for subscribers with dependants.40
Premium Cost SharingThe sharing of the cost of the health plan premium between the employer or other group sponsors and the enrollees.40
Premium SupportPublic subsidy to purchase private insurance.40
Premium TaxA state tax levied on commercial insurance premiums.40
Premium, Community-RatedPremiums based upon the claims experience of all those insured by the carrier and not dependent upon the claims experience of each policyholder. See Community Rating.40
Premium, Experience-RatedPremium based on the projected utilization and claims experience of a specific group. See Experience Rating.40
Prepaid CareHealthcare services provided to a Health Maintenance Organization member in exchange for a fixed, monthly premium paid in advance of the delivery of medical care.39
Prepaid Group PracticeA healthcare system that offers plan members a wide range of medical services through an exclusive group of providers in return for a monthly premium payment.39
Prepaid Group Practice PlanA plan which specified health services are rendered by participating physicians to an enrolled group of persons, with a fixed periodic payment made in advance by [or on behalf of] each person or family. If a health insurance carrier is involved, a contract to pay in advance for the full range of health services to which the insured is entitled under the terms of the health insurance contract. A Health Maintenance Organization is an example of a prepaid group practice plan.2
Prepaid Health PlanPHPNot the same as a Health Maintenance Organization even though the terms are often used interchangeably in commercial managed care business. PHPs can contract on a capitated basis for a non-comprehensive set of services (often called Partial Capitation) or on a cost basis. Federally Qualified Health Centers can also be designated as PHPs if they meet certain conditions. See also Sub-Capitation.40
Prescription Benefit Management PlanSee Pharmacy Benefit Management Plan.
Prescription CardsSee Pharmaceutical Cards.
Pre-Service ReviewPre-service review programs examine the medical necessity and appropriateness of proposed services to be provided in the ambulatory or inpatient setting that may require frequent treatment, extended courses of treatment, or require the use of expensive technologies. Dental and vision benefits may require predetermination for certain services or charges.40
Presumptive EligibilitySee Eligibility Guarantee.
Prevailing ChargeOne of the screens that determined a physician\'s payment for a service under the Medicare CPR payment system. In Medicare, it was the 75th percentile of customary charges, with annual updates limited by the MEI. See Customary Charge; Usual, Customary and Reasonable Charge; Medicare Fee Schedule; Medicare Economic Index.2
PrevalenceNumber of existing cases with a particular condition in a specified area at a specified time.2
PreventionActions taken to reduce susceptibility or exposure to health problems (primary prevention), detect and treat disease in early stages (secondary prevention), or alleviate the effects of disease and injury (tertiary prevention).2
Prevention MeasuresActions taken to reduce susceptibility or exposure to health problems, to detect and treat disease in early stages, or to alleviate the effects of disease and injury.2
Preventive CareComprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination and immunizations.40
Preventive Health MaintenancePHMSee Health Maintenance.
Preventive ServicesServices intended to prevent the occurrence of a disease or its consequences.2
Price FixingAn illegal business practice that occurs when two or more independent competitors agree on the prices or fees that they will charge for services.39
PricingThe process of deciding the premium to charge for a health plan or a given set of benefits.39
Primary CareA basic level of health care provided by the physician from whom an individual has an ongoing relationship and who knows the patient\'s medical history. Primary care services emphasize a patient\'s general health needs such as preventive services, treatment of minor illnesses and injuries, or identification of problems that require referral to specialists. Traditionally, primary care physicians are family physicians, internists, gynecologists and pediatricians.2
Primary Care Case ManagementPCCMMedicaid managed care option allowed under section 1915(b) of the Social Security Act in which each participant is assigned to a single primary care provider who must authorize most other services such as specialty physician care before they can be reimbursed by Medicaid. See Gatekeeper.40
Primary Care NetworkA plan similar to a Health Maintenance Organization which provides health services for a fixed price, relying on participating primary care physicians to serve as \'gatekeepers\' to control patient access to institutional services and specialty care. The primary care physician determines the patient\'s need for specialty care and any resulting referrals.40
Primary Care PhysicianSee Primary Care Provider.
Primary Care ProviderPCPA physician or other medical professional who serves as a group member\'s first contact with a plan\'s healthcare system. Also called a Primary Care Physician, Personal Care Physician, or Personal Care Provider.39
Primary CoverageThat coverage which pays first when an individual is covered under two or more insurance plans.40
Primary Dissemination (Evaluation)Dissemination of the detailed findings of an evaluation to sponsors and technical audiences.2
Primary Medical GroupPMG
Primary Source VerificationA process through which an organization validates credentialing information from the organization that originally conferred or issued the credentialing element to the practitioner.2239
Prior ApprovalAn authorization for the delivery of services that must be obtained prior to the delivery of those services. Commonly used in the Medicaid program and managed care plans. See Medicaid,managed care, and utilization review. Also called Prospective Review, Pre-Approval, Prior Authorization.40
Prior AuthorizationSee Prior Approval.
Private Duty NursingMedicaid term to refer to covered skilled nursing services provided in the home.40
Private ExpendituresThese are outlays for services provided or paid for by nongovernmental sources - consumers, insurance companies, private industry, and philanthropic and other nonpatient care sources.2
Private Fee-For-Service PlansPFFSThe Medicare+Choice delivery option under which coverage is provided by private insurance carriers rather than through the federal government.39
Probationary PeriodSee Waiting Period.
Problem ListSee Medical Problem List.
Process AuditA type of patient/medical care evaluation study in which the criteria are designed to focus on the components of appropriate clinical intervention.40
Process EvaluationProcess evaluation examines the procedures and tasks involved in implementing a program. This type of evaluation also can look at the administrative and organizational aspects of the program.2
Process MeasuresHealthcare quality indicators related to the methods and procedures that an Managed Care Organization and its providers use to furnish service and care.39
ProductivityThe ratio of outputs (goods and services produced) to inputs (resources used in production). Increased productivity implies that the hospital or health care organization is either producing more output with the same resources or the same output with fewer resources.2
Professional AssociationPAA non-profit organization seeking to further a particular profession, the interests of individuals engaged in that profession, and the public interest.13
Professional Liability InsuranceThe insurance physicians purchase to help protect them from the financial risks associated with medical liability claims. Also called Malpractice Insurance.40
Professional Review OrganizationPROAn organization that reviews the activities and records of a health care provider, institution, or group. The reviewer is generally a physician if a physician is the subject of the review; a group of administrators, physicians, and allied health care personnel if a hospital is the subject of the review; etc. The PRO can be state-sponsored or independent.40
Professional Standards Review OrganizationPSROOrganization responsible for determining whether care and services provided were medically necessary and meet professional standards regarding eligibility for reimbursement under the Medicare and Medicaid programs.2
ProfessionalismA set of characteristics or behaviors that are worthy of the high standards of an occupation that requires advanced training in a specialized field.39
Profile AnalysisSee Profiling.
ProfilingAn analytic tool that uses epidemiologic methods to compare practice patterns of providers on the dimensions of cost, service use, or quality of care. The provider\'s pattern of practice is expressed as a rate aggregated over time for defined population of patients.40
ProfilingExpressing a pattern of practice as a rate - some measure of utilization [costs or services] or outcome [functional status, morbidity, or mortality] aggregated over time for a defined population of patients - to compare with other practice patterns. May be done for physician practices, health plans, or geographic areas.2
ProfitSee Net Income.
Profit And LossP&LAlso called an \'Income statement\', a P&L is an organization\'s financial statement that indicates how the revenue (money received from the sale of products and services before expenses are taken out, also known as the \'top line\') is transformed into the net income (the result after all revenues and expenses have been accounted for, also known as the \'bottom line\'). Its purpose is to show whether the organization made or lost money during the period being reported.13
Program Of All-Inclusive Care For The ElderlyPACEA community-based program, involving both Medicare and Medicaid, that provides integrated healthcare and long-term care to elderly persons who require a nursing-facility level of care.39
Promise Keeping/TruthtellingAn ethical principle which, when applied to managed care, states that managed care organizations and their providers have a duty to present information honestly and are obligated to honor commitments.2439
PromotionThe element of the marketing mix that an organization uses to: 1) inform consumers about its products, the prices of its products, and how to obtain its products; 2) persuade consumers to purchase its products; 3) remind consumers about the benefits associated with transacting business with the organization.39
Promotion MixThe four tools of promotion-advertising, personal selling, sales promotion, and publicity.39
Proportion RulesThe 75/25 Rule and the 50/50 Rule refer to references in Federally statutory requirements for enrollment composition in a full-risk Medicaid or Medicare program. The 75/25 Rule states that an Health Maintenance Organization or Health Insuring Organization that has a Medicaid comprehensive risk contract cannot have more than 75 percent of its total enrollment be a combination of Medicaid and Medicare risk enrollees. Prepaid Health Plans sponsored by Federally Qualified Health Centers are exempt from the 75/25 Rule. The 50/50 Rule states that a Health Maintenance or Competitive Medical Plan that has a Medicare risk contract cannot have more than 50 percent of its total enrollment be a combination of Medicaid and Medicare enrollees.40
Proprietary HospitalAn investor-owned hospital operated for the purpose of making a profit for its owner.40
Prospective PaymentA method of paying health care providers in which rates are established in advance. Providers are paid these rates regardless of the costs they actually incur.2
Prospective Payment Assessment CommissionProPACSee Medicare Payment Advisory Commission.
Prospective Payment Review CommissionAn independent body established by Congress to advise it on Medicare policies for reimbursing physicians.40
Prospective Payment SystemPPS[1] The Medicare system used to pay hospitals for inpatient hospital services; based on the DRG classification system.; [2] Medicare\'s acute care hospital payment method for inpatient care. Prospective per-case payment rates are set at a level intended to cover operating costs in an efficient hospital for treating a typical inpatient in a given diagnosis-related group. Payments for each hospital are adjusted for differences in area wages, teaching activity, care to the poor, and other factors. Hospitals may also receive additional payments to cover extra costs associated with atypical patients [outliers] in each DRG. Capital costs, originally excluded from PPS, are being phased into the system. By 2001, capital payments will be made on a fully prospective, per-case basis. See also Capital Costs, Diagnosis-Related Groups, Outliers, Preferred Provider Organization.2
Prospective PricingMethod of third party payment by which prices for services are established in advance for a specified period of time. These prices are firm regardless of the actual costs incurred in a specific episode of care.40
Prospective ReviewThe review and possible authorization of proposed treatment plans for a patient before the treatment is implemented. See also Prior Authorization.39
ProtectionElimination or reduction of exposure to injuries and occupational or environmental hazards.2
ProtocolsSee Clinical Guidelines, Medical Protocols.
ProviderGenerically, a professional engaged in the delivery of health services, including physicians, dentists, nurses, podiatrists, optometrists, clinical psychologists, etc. Hospitals and long term care facilities are also providers. The Medicare program uses the term \'provider\' more narrowly, to mean participating institutions: hospitals, skilled nursing facilities, home health agencies, etc.40
Provider ManualA document that contains information concerning a provider\'s rights and responsibilities as part of a network.39
Provider ProfilingThe collection and analysis of information about the practice patterns of individual providers.39
Provider Reimbursement Review BoardA Federal board responsible for making decisions regarding provider appeals on Medicare reimbursement issues.40
Provider Services OrganizationPSOSee Provider-Sponsored Organization.
Provider Sponsored/Services NetworkPSN
Provider-Services NetworkSee Provider-Sponsored Organization.
Provider-Sponsored OrganizationPSOA provider-owned entity that is certified by HCFA to participate in the Medicare + Choice program and to assume risk for benefits provided to Medicare beneficiaries. Also called Provider Services Organizations.40
Pryor BillSee Medicaid Prudent Pharmaceutical Purchasing Act.40
Public Health[1] Activities that society does collectively to assure the conditions in which people can be healthy. This includes organized community efforts to prevent, identify, preempt, and counter threats to the public\'s health.; [2] the Department of Health and local health departments have primary responsibility for protecting the health of the public. The State Board of Health and local boards of health also provide forums for developing health policy and can make rules and regulations to protect and promote the health of the public.2
Public Health Department/DistrictLocal (county or multi- county) health agency, operated by local government, with oversight and direction from a local board of health, which provides public health services throughout a defined geographic area2
Public Health ServicePHSA Federal agency responsible for public health services and programs including biomedical research.40
Public OptionA government-run insurance plan that would be offered on the Exchange alongside private insurance plans. People would pay premiums, as with a private plan. It would probably pay providers at rates above Medicare\'s but below what private insurers pay.
Pull Down MenuAlso called a dropdown menu. These are a menu commands options that appears when you select an item with a mouse or hotkey combinatio.77
Purchasing AlliancesLocally based, privately operated organizations that offer affordable group health coverage to businesses with fewer than 100 employees. Also called purchasing pools, health insurance purchasing co-ops, employer purchasing coalitions, or purchasing coalitions.2539
Purchasing CoalitionsSee Purchasing Alliances.
Purchasing PoolsSee Purchasing Alliances.
Pure Community RatingSee Standard Community Rating.
Pure PremiumThe costs of claims for covered services for eligible individuals under a health insurance contract. This does not include administrative and other insurance costs included in the total costs incurred by an insurer under a contract.40
Qualified Medicare BeneficiaryQMBA person whose income falls below 100% of Federal poverty guidelines and whose resources do not exceed twice the resource limit of the SSI program, for whom the state must pay the Medicare Part B premiums, deductibles and co-payments. See also Specified Low Income Medicare Beneficiaries.40
QualityIn a managed care context, a Managed Care Organization\'s success in providing health-care and other services in such a way that plan members\' needs and expectations are met.39
Quality AssessmentQAAn ongoing process to monitor and evaluate aspects of patient/medical care against pre-established criteria and standards to determine the medical necessity, appropriateness, and effectiveness of the services provided.40
Quality AssuranceAn interactive management process designed to objectively ensure the appropriateness and effectiveness of patient care. It includes identifying deficiencies, implementing corrective action(s) to improve performance, and monitoring the corrective actions to ensure that quality of care has been enhanced. In the broadest sense, this ongoing process should involve the medical and professional staff, the administration, and the governing body of the health care facility.40
Quality Assurance Reform InitiativeQARISee Quality Improvement System For Managed Care.
Quality Data SetQDS15
Quality ImprovementQIA continuous process that identifies problems in health care delivery, examines solutions to those problems, and regularly monitors the solutions for improvement.40
Quality Improvement OrganizationQIOOrganizations that contract with Centers For Medicare And Medicaid Services to review care provided to Medicare beneficiaries. [1] Formerly known as a Peer Review Organization. Can also be used in a more general sense to refer to any independent quality review organization.[40] The Medicare QIO program consists of a national network of fifty-three QIO’s found in each state responsible to work with consumers, physicians, hospitals, and other caregivers to refine care delivery systems. They are associated with the DOQ-IT program. [77] See also Quality Assurance. 1, 40, 77
Quality Improvement System For Managed CareQISMCA Health Care Finance Administration program designed to strengthen Managed Care Organization\'s efforts to protect and improve the health and satisfaction of Medicare and Medicaid enrollees.39
Quality ManagementQMAn organization-wide process of measuring and improving the quality of the healthcare provided by a Managed Care Organization.39
Quality Management CommitteeA committee that oversees the organization\'s quality assessment and improvement activities in both clinical and non-clinical areas.39
Quality Of CareThe degree or grade of excellence with respect to medical services received by patients, administered by providers or programs, in terms of technical competence, need, appropriateness, acceptability, humanity and structure.40
Quality Of LifeQOL
Quality Of Life YearQALYA measure of disease burden, including both the quality and the quantity of life lived. It is used in assessing the value for money of a medical intervention. 13
Quality Reporting Document ArchitectureQRDAA standards development initiative formed to develop an electronic data standard for exchange of patient-level quality measurement data between health care information systems.20
Quality-Adjusted Life YearThis unit of measure is one way to quantify health outcomes resulting from some type of intervention. The number of quality-adjusted life-years is the number of years at full health that would be valued equivalently to the number of years of life experienced in a less-desirable health state. For example, if a year of life confined to bed is considered on half as desirable as a year spent in full health, then 10 years of survival confined to bed would be counted as five quality-adjusted life-years.40
Quality-Of-Life MeasuresAn assessment of patient\'s perceptions of how they deal with their disease or with their everyday life when suffering from a particular condition. It is subjective in the sense that the kinds of information cannot be measured objectively; however, it has been in health care literature for at least 20 years. It has been tapped in the area of pharmaceuticals most recently in the last five or six years. Through statistical means, the indices that have been developed to measure various aspects of quality of life have been validated over time, and we know that these measures are reliable and reproducible.40
QueryThe primary mechanism for retrieving information from a database and consists of questions presented to the database in a predefined format.77
Race To The BottomProcess in which health plans in a highly competitive market reduce the scope of their benefit packages in order to offer lower premiums. Competitors must follow suit or risk attracting sicker enrollees. See also Adverse Selection.40
Radio Frequency IdentificationRFIDThe use of an object (typically referred to as an RFID tag) applied to or incorporated into a product, animal, or person for the purpose of identification and tracking using radio waves. Some tags can be read from several meters away and beyond the line of sight of the reader.13
Random ChangeSee Haphazard Change.
RateOccurrence or existance of a particular condition expressed as a proportion of units in the population (e.g., deaths per 1,000 adults).2
Rate CellAmount paid for an individual\'s care in a Medicare HMO-based facility based on the relevant Adjusted Average Per Capita Cost.40
Rate SettingA method of paying health care providers in which the federal or state government establishes payment rates for all payers for various categories of health services.2
Rate SpreadThe difference between the highest and lowest rates that a health plan charges small groups. The National Association of Insurance Commissioners\' Small Group Model Act limits a plan\'s allowable rate spread to 2 to 1.39
RatingThe process of calculating the appropriate premium to charge purchasers, given the degree of risk represented by the individual or group, the expected costs to deliver medical services, and the expected marketability and competitiveness of the Managed Care Organization\'s plan.39
Rating BandsLimits on how much an insurer can vary health insurance premiums to different groups for the same insurance plan.40
Reactive ChangeChange that is controlled, but rarely planned, and that can lead to positive, negative, or even unintended results.39
Real ValueMeasurement of an economic amount corrected for change in price over time (inflation), thus expressing a value in terms of constant prices. See Nominal Value.2
Reasonable And CustomaryR&CSee Reasonable And Customary Fee.
Reasonable And Customary FeeR&CA charge that, in the context of the community, is fair. A customary charge is a charge or fee that falls within the customary range of charges or fees prevailing in a specific geographic area for the provision of a similar service, procedure, or supply.40
RebateA reduction in the price of a particular pharmaceutical obtained by a PBM from the pharmaceutical manufacturer.2739
ReceivershipA situation in which the state insurance commissioner, acting for a state court, takes control of and administers a Health Maintenance Organization\'s assets and liabilities.39
RecidivismThe frequency of the same patient returning to a provider with the same presenting problems. Usually refers to recurring inpatient hospital services.40
RecipientA person who receives a Medicaid service while eligible for the Medicaid program. Individuals may be Medicaid eligible without being Medicaid recipients. See also Medicaid.40
ReciprocityThe right of an enrollee in a health plan who is temporarily away from home to receive necessary medical care under the arrangements of a health plan in the area in which the enrollee receives medical care.40
ReconsiderationReview of an adverse coverage determination that may be requested by the patient or representative, the attending physician, or the hospital. Reconsideration is performed by the original reviewing body, not by an independent appeals panel.40
RecredentialingAn Managed Care Organization\'s periodic review of the qualifications of a current network provider to verify that the provider still meets the standards for participation in the network.39
RedliningAn insurance practice used to exclude entire occupations, businesses, geographic areas, and age groups from health insurance coverage to limit loss.40
Redundant Array of Independent DisksRAIDA way of storing the same data in different places on multiple hard disks. Often used on servers to provide redundancy in the event of a hard drive failure.78
Reference ArchitectureProvides a proven template solution for an architecture for a particular domain. It also provides a common vocabulary with which to discuss implementations, often with the aim to stress commonality. A reference architecture often consists of a list of functions and some indication of their interfaces (or APIs) and interactions with each other and with functions located outside of the scope of the reference architecture. Reference architectures can be defined at different levels of abstraction. A highly abstract one might show different pieces of equipment on a communications network, each providing different functions. A lower level one might demonstrate the interactions of procedures (or methods) within a computer program defined to perform a very specific task. A reference architecture provides a template, based on the generalization of a set of successful solutions. These solutions have been generalized and structured for the depiction of both a logical and physical architecture based on the harvesting of a set of patterns that describe observations in a number of successful implements. Further it shows how to compose these parts together into a solution. Reference Architectures will be instantiated for a particular domain or for specific projects13
Reference Information ModelRIMHealth Level Seven-promulgated standard30
ReferralThe recommendation by a physician and/or health plan for a member to receive care from a different physician or facility.40
Refined Diagnosis Related GroupRDRGAn expanded list of diagnosis related groups to take into account a patient\'s severity of illness.40
RefinementThe correction of relative values in Medicare\'s relative value scale that were initially set incorrectly.2
Reflexive Controls (Evaluation)Outcome measures taken on participating targets before interventions and used as control observations.2
Regional Health Information NetworkRHINA region-based Health Information Network.
Regional Health Information OrganizationRHIOThese are ordinarily geographically-defined entities which develop and manage a set of contractual conventions and terms, arrange for the means of electronic exchange of information, and develop and maintain HIE standards.13
RegulationAn authoritative rule having the force of law dealing with details or procedures for implementing governmental programs. Regulations are issued by executive authority of the Federal or state government. See also Statute.40
RehabilitationTo restore health following an accident, injury or illness. Acute Rehabilitation: Early rehabilitation phase as soon as medically stable. Primary emphasis is to provide intensive physical and cognitive restorative services in the early months following injury. Typical stay 3-4 months (short term). Based in medical facility. Sub-Acute Rehabilitation: Post-acute phase of rehabilitation. Capacity to treat for 6-24 months. Need not be hospital based. Stay based on demonstrated improvement. Transitional Rehabilitation: To prepare for community re-entry. Non-medically based. Emphasis on functional skills for maximum independence. May be in group home or part of a continuum of rehabilitation center. Typical stay 4-8 months. Greater focus on compensation vs. restoration. Long Term Rehabilitation Program: May be called Extended Rehabilitation. Have full range of rehabilitation services available. Frequently after initial year of rehabilitation when progress is slower. Generally not permanent placement. May be facility or community based. Rehabilitative (restorative) Care: Skilled care provided by a trained medical person (physical therapist, R.M., speech therapist).40
Reinstated BenefitsWhen a policy has lapsed due to nonpayment of premiums, benefits may be reinstated at the company\'s option. It is common for the company to determine proof of insurability before it will do so.40
ReinsuranceA mechanism to protect against part or all of the financial losses that may be incurred through insuring for risk. Reinsurance may be used for property and casualty losses as well as for life and health claims. It is a common Stop-Loss mechanism used by self-insured and insured entities throughout the economy, including business and industry, labor organizations, hospitals, Health Maintenance Organizations, individual professionals, and even insurance companies. It is commercially available from insurance underwriters. The coverage may be uniquely written for an individual claimant or groups of claimants. Also called Risk Control Insurance.40
Relative ValueSee Relative Value Scale.
Relative Value Of ServicesSee Relative Value Scale.
Relative Value ScaleRVSAn index that assigns weights to each medical service: the weights represent the relative amount to be paid for each service. It is used in the development of the Medicare Fee Schedule consists of three cost components: physician work, practice expense, and malpractice expense. See also Malpractice Expense, Medicare Fee Schedule. Physician Work, Practice Expense, Resource-Based Relative Value Scale.2
Relative Value UnitRVUThe unit of measure for a Relative Value Scale. It must be multiplied by a dollar conversion factor to become payment amounts. See also Conversion Factor, Relative Value, Relative Value Scale.2
Reliability The ability of a system or component to perform its required functions under stated conditions for a specified period of time. 77
Remote AccessThe ability to access a network or computer via a protected passage from a remote location, e.g. from home or another practice location which allows an EMR vendor to perform off-site system maintenance.78
RenewabilityGuarantee that coverage cannot be discontinued as long as the insurer continues to do business in that particular market. However, the premium that can be charged is not necessarily protected.40
Renewable At The Option Of The Insurance CompanyThis refers to policy contract renewability. The insurance company can choose to cancel the policy on an individual basis.40
RenewalContinuance of coverage under a policy beyond its original term by the acceptance of a premium for a new policy term.40
Renewal UnderwritingThe process by which an underwriter reviews each year all the selection factors that were considered when the contract was issued, then compares the group\'s actual utilization rates to those the Managed Care Organization predicted to determine the group\'s renewal rate.39
Replacement InsuranceInsurance that substitutes coverage under one policy for coverage under another policy.2
Report CardsInformation on health plan performance presented in a consumer friendly manner to facilitate cross-plan comparisons.40
Representational State TransferRESTA style of software architecture for distributed hypermedia systems such as the World Wide Web. The term Representational State Transfer (REST) was introduced and defined in 2000 by the doctoral dissertation of Roy Fielding, one of the principal authors of the Hypertext Transfer Protocol (HTTP) specification versions 1.0 and 1.1.13
Reproductive Health/Fertility CenterFacility for providing information and counseling about fertility problems, including laboratory and surgical tests and procres. May provide in vitro or other fertilization.8
Request For ProposalRFPAn invitation for suppliers, often through a bidding process, to submit a proposal on a specific commodity or service.13
Required RequestA system enacted by state lawmakers in 1987 requiring hospitals to request organs from a deceased\'s family when the deceased is determined to be medically suitable.40
Research And DevelopmentR&DCreative work undertaken on a systematic basis in order to increase the stock of knowledge, including knowledge of man, culture and society, and the use of this stock of knowledge to devise new applications.13
ReservesMonies earmarked to cover anticipated claims and operating expenses for a set period of time. Reserves are an obligated amount and have three principal components: reserves for known liabilities not yet paid; reserves for losses incurred but unreported; and other reserves for various special purposes, including contingency reserves for unforeseen circumstances.40
Resident1) A physician in training after medical school graduation. In the modern era, specialties require at least three years of residency training. Many specialties require four years or more, and it is not uncommon for physicians to undertake fellowships for further specialty training after a residency; 2) An individual in a nursing home, assisted living or other residential facility. See also Intern.40
Resident Assessment InstrumentRAISee Minimum Data Set, Resource Utilization Groups.40
Resident Assessment ProtocolsRAPsProcess used to assess nursing home residents who have problems (such as incontinence, or dementia) that have an especially significant impact on their care. See also Minimum Data Set, Resource Utilization Groups.40
Resource Conservation And Recovery ActRCRAEnacted in 1976, is the principal Federal law in the United States governing the disposal of solid waste and hazardous waste.13
Resource Utilization GroupsRUGS IIIPatient classification system for nursing home patients used by the Federal government and some states to determine reimbursement levels for nursing home care. See also Minimum Data Set.40
Resource-Based Relative Value ScaleRBRVSA method used by Managed Care Organizations to determine provider reimbursement that attempts to take into account, when assigning a weighted value to medical procedures or services, all resources that physicians use in providing care to patients, including physical or procedural, educational, mental (cognitive), and financial resources.39
Respite CareShort term care which is needed in order to maintain health or safety and provides temporary relief from care-giving duties to a member of the immediate family (or any other unpaid, primary caregiver). Respite care can include such services as home care, home health care, adult day care and institutional care.40
Rest Residential CareResidential option providing less care than assisted living, usually at the \'board and care\' level (i.e. no direct health or personal care services) provided in a congregate facility. See also Family Rest Residential Care, Foster Care, Board and Care.40
Restoration Of BenefitsProvision of some LTC policies stating that once an individual is benefit-free for a specified length of time, usually six months, those benefits already paid out are restored.40
RetentionInsurance carrier\'s provision in experience rating for taxes, cost for the assumption of risk, benefit plan administration, maintaining reserves, other expenses and contributions to the return on equity of the insurance company.40
Retroactive ReviewSee Retrospective Review.
Retrospective ReviewA type of utilization review that occurs after treatment is completed in order to authorize payment and medical necessity and appropriateness of care.39
Return Of Premium BenefitA type of non-forfeiture benefit included in some long-term care policies that provides a cash value accumulation and return of premiums in the future to enrollees who receive no policy benefits or minimal benefits while the policy is in force. Exact provisions vary from policy to policy, but generally provide a greater return the longer the policy is in force and usually deduct the amount of any claims paid before returning premiums to the enrollee.40
Return on InvestmentROIReturn on investment typically means measuring an increase in revenue, a decrease in expense or an avoidance of expense.77
Revenue CycleThe provider\'s workflow involved in the complete cycle of billing, tracking and collecting from 3rd party payers- both private and government- for services provided. This may be facilitated by software and processes called the Revenue Cycle Management System.6
Revenue Cycle ManagementRCMSee Revenue Cycle.
Revenue ShareThe proportion of a practice\'s total revenue devoted to a particular type of expense. For example, the practice expense revenue share is that proportion of revenue used to pay for practice expense.2
RevenuesThe amounts earned from a company\'s sales of products and services to its customers.39
Review, ConcurrentAssessment of a patient\'s need for inpatient hospital services at admission and at specified intervals throughout the inpatient stay, using objective criteria to determine the medical necessity of acute inpatient care. Includes admission review, continued stay review, and utilization review.40
Review, PeerAn examination by practicing physicians or other health professionals of the medical necessity, appropriateness, and quality of the health care services ordered or provided by other physicians or other health professionals. The efficiency and effectiveness of the patient care services are also reviewed. It may be conducted while the patient is in the hospital (concurrent review) or after discharge (retrospective review).40
Review, PrivateReview of patient care episodes to ensure the medical necessity and appropriateness of services and charges, usually for services financed through institutional purchaser health benefit programs. Private review services are offered by many entities, including insurance companies and their subsidiary companies specializing in managed care services, hospitals, and foundations for medical care. Peer review organizations (PRO), Federally authorized agencies, sell review services to private sector purchasers of health care. There are currently no licensure or certification standards for private review programs. Private review is usually implemented through a contractual relationship between the purchaser and the reviewing entity; it may also be financed on a fee per review, an annual fee based upon the number of covered individuals, or percentage of the annual premium or expenditure, or some combination, and may include a performance incentive bonus relating the costs of conducting the review services, the projected health plan expenditures, and actual savings.40
Review, UtilizationSee Utilization Review.
RiderA legal document that modifies a health care services contract or insurance policy, either expanding, decreasing or otherwise revising the coverage to be provided. Also called Amendment or Endorsement.40
RiskThe chance or possibility of loss, often employed as a utilization control mechanism within a Health Maintenance Organization setting. Risk is also defined in insurance terms as the possibility of loss associated with a given population. 40
Risk AdjusterA measure used to adjust payments made to a health plan on behalf of a group of enrollees in order to compensate for spending that is expected to be lower or higher than average, based on the health status or demographics of the enrollees.40
Risk Adjustment1) Risk Adjustment uses the results of risk assessment in order to fairly compensate plans that, by design or accident, end up with a larger-than-average share of high-cost enrollees.; 2) Increases or reductions in the amount of payment made to a health plan on behalf of a group of enrollees to compensate for health care expenditures that are expected to be higher or lower than average. See also Risk Selection.2
Risk AgreementTerm used in the disability community to refer to a signed document by both an individual and a services provider that details the tasks that will be the responsibility of each party. In particular it refers to those services that the consumer does not choose to accept even though the service provider believes they are necessary.40
Risk AnalysisThe process of evaluating the expected medical costs for a prospective group and determining what product, benefit level and price to offer in order to best meet the needs of the group and the carrier.40
Risk Assessment1) Is the means by which plans and policymakers estimate the anticipated claims costs of enrollees.; 2) Identifying and measuring the presence of direct causes and risk factors which, based on scientific evidence or theory, are thought to directly influence the level of a specific health problem.2
Risk CommunicationThe production and dissemination of information regarding health risks and methods of avoiding them.2
Risk ContractA legal agreement between a payer and provider to share in either the net revenues after expenses or financial losses incurred as a result of providing health care services within a defined delivery system, such as a Health Maintenance Organization or Preferred Provider Organization. A percentage of provider or professional payments that are withheld by the payer to satisfy the risk provisions at the end of the fiscal period.40
Risk Control InsuranceThe acceptance by one or more insurers of a portion of the risk underwritten by another insurer who has contracted for the entire coverage. It is also called reinsurance or stop-loss insurance.40
Risk CorridorForm of risk sharing where loss or profit is limited to a small percentage of the break even point to prevent excessive profiteering or catastrophic losses to a risk bearer such as a managed care organization. Often used by public payers such as state governments in Medicaid managed care plans.40
Risk FactorBehavior or condition which, based on scientific evidence or theory, is thought to directly influence susceptibility to a specific health problem.2
Risk FactorsConditions that influence a person\'s health status and are capable of causing illness or injury, including genetic or biological risk factors, life style, or environmental conditions.40
Risk LoadA factor that is multiplied into the rate to offset some adverse characteristic of the group.40
Risk MeasureMeasure of the expected per capita costs of efficiently provided health care services to a defined group for a specified future period.2
Risk PoolsLegislatively created programs that group together individuals who cannot get insurance in the private market. Funding for the pool is subsidized through assessments on insurers or through government revenues. Maximum rates are tied to the rest of the market.2
Risk Pools, Medically UninsurableTo facilitate access to health care services for individuals with health risks that are considered medically uninsurable, some states are creating risk pools though legislation. These are funded though a variety of mechanisms, including a premium tax on commercial insurance policies, payroll taxes, general revenues, or a combination of these approaches. Premiums for policies are usually 150% or more of the generally available insurance premium to avoid disrupting the insurance market.40
Risk Pools, Residual RiskSmall groups that include individuals with known health conditions requiring medical services are considered to be high risk and have premiums that are higher than average for groups of comparable size. Creating a larger pool by merging these groups to spread the risk across a larger base or to seek relief through government-sponsored and funded risk pools are two approaches under consideration to contain the premium costs for residual risk groups.40
Risk ProductInsurance plan involving partial or full risk.40
Risk SegmentationDisproportionate numbers of persons with higher than average risk of health problems being concentrated in particular risk pools. See also Adverse Selection.40
Risk Selection1) The process by which health plans seek to enroll healthy, low-cost subscribers.; 2) Enrollment choices made by health plans or enrollees on the basis of perceived risk relative to the premium to be paid; 3) Any situation in which health plans differ in the health risk associated with their enrollees because of enrollment choices made by the plans or enrollees, that is, where one health plan\'s expected costs differ from another\'s due to underlying differences in their enrolled populations. See also Risk Adjustment.2
Risk SharingSharing the opportunity for reward or loss.40
Risk WithholdSee Withhold.
Risk-Adjusted CapitationA method of payment to either an organization or individual provider which takes the form of a fixed amount per person per period and which is varied to reflect the health characteristics of individuals or groups of individuals.2
Risk-AdjustmentThe statistical adjustment of outcomes measures to account for risk factors that are independent of the quality of care provided and beyond the control of the plan or provider, such as the patient\'s gender and age, the seriousness of the patient\'s condition, and any other illnesses the patient might have. Also called case-mix adjustment.39
Risk-Bearing EntityAn organization that assumes financial responsibility for the provision of a defined set of benefits by accepting prepayment for some or all of the cost of care. A risk-bearing entity could be an insurer, a health plan, a self-funded employer or a provider sponsored network, for example.40
Room And BoardSee Board And Care.
Routine NotificationA system being proposed at the state and national levels requiring hospitals to call a regional telephone number when death is imminent to determine if organs are suitable for transplant.40
RxNormA standardized nomenclature for clinical drugs and drug delivery devices, is produced by the National Library of Medicine. In this context, a clinical drug is a pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent. A drug delivery device is a pack that contains multiple clinical drugs or clinical drugs designed to be administered in a specified sequence. In RxNorm, the name of a clinical drug combines its ingredients, strengths, and/or form.7
ScalableRefers to how well a hardware or software system can adapt to increased demands.77
Scope Of BenefitsRefers to the range of services, providers, and settings covered by a health benefit plan.40
Scope Of CoverageSee Scope Of Benefits.
Scored SavingsAmount of savings expected to be obtained from enacting new legislation. The Congressional Budget Office makes official estimates by calculating the difference in spending projected under current law and under the proposed legislation.40
ScreeningThe method by which managed care organizations limit access to health care for unnecessary reasons. In most Health Maintenance Organization\'s, a phone call to the physician or his or her medical office staff is required before an office visit can be arranged. \'Gatekeepers\' and concurrent review are other methods of screening patients.40
Screening ProgramsPreventive care programs designed to determine if a health condition is present even if a member has not experienced symptoms of the problem.39
Second Opinion ProgramVoluntary or mandatory medical or surgical review program established by a health benefit program to ensure the medical necessity of proposed services or procedures. The second opinion is paid for by the plan and provided by a physician other than the professional recommending the treatment. Payment for care is usually assured under the benefit program regardless of the second opinion recommendation if the patient obtains the second opinion in accordance with the health benefit requirements. Coverage limitations may be imposed upon beneficiaries not complying with mandatory programs. Second opinion programs may be required for inpatient and for ambulatory services and procedures. These programs may be considered a cost containment mechanism as well as a means to help ensure the medical necessity of proposed services.40
Secondary CareServices provided by medical specialists, such as cardiologists, urologists and dermatologists, who generally do not have first contact with patients.40
Secondary CoverageThe plan that has the responsibility for payment of any eligible charges not covered by the primary coverage.40
Secondary Dissemination (Evaluation)Dissemination of summarized, often simplified findings to audiences composed of stakeholders.2
Secondary InsuranceAny insurance that supplements Medicare coverage. The three main sources for secondary insurance are employers, privately purchased Medigap plans, and Medicaid.2
Section 1115 WaiversWaivers that gave states the authority to offer more comprehensive services to specified categories of Medicaid recipients through demonstration projects.39
Section 1915(B) WaiversWaivers that allowed states to manage Medicaid recipients\' access to providers by assigning recipients to a primary care case manager or by enrolling recipients in a Health Maintenance Organization.39
Secure Hash AlgorithmSHAA set of cryptographic hash functions designed by the National Security Agency (NSA) and published by the NIST as a U.S. Federal Information Processing Standard.13
SecurityIs the effort to create a secure computing platform, designed so that agents (users or programs) can only perform actions that have been allowed.77
SegmentsSubsets or manageable groups of customers in a total market.39
Selective ContractingThe practice of a Managed Care Organization by which it enters into participation agreements only with certain providers (and not with all providers who qualify) to provide health care services to health plan participants as members of its provider panel.40
Self ReferralArrangements for care beyond primary care made by the patient rather than the provider. Health Maintenance Organizations generally specify to which in-house departments or services a patient may self refer. Physicians self-referral is when providers refer patients to a facility in which they have a vested interest.40
Self-Administered PlanHealth benefit plan administered by the employer or health and welfare fund rather than through an insurance carrier or third party administrator.40
Self-Funded PlanA health plan under which an employer or other group sponsor, rather than an Managed Care Organization or insurance company, is financially responsible for paying plan expenses, including claims made by group plan members. Also called a self-insured plan.39
Self-FundingOften confused with self-insurance, a self-funded health care plan is funded entirely by the employer. A self-funded plan may be self-administered, or the employer may contract with an outside administrator for an administrative services only arrangement. Self-funded plans obtain stop-loss insurance to cover catastrophic illnesses.40
Self-InsuranceThe practices of an employer or organization assuming complete responsibility for health care losses of its employees. This usually includes setting up a fund against which claim payments are drawn and claims processing is often handled through an administrative service contract with an independent organization.40
Self-InsuredEmployers who assume direct responsibility or risk for paying for employees\' health care without purchasing health insurance. They usually contract with an outside firm to handle claims payment and/or utilization review.40
Self-Insured Health PlanEmployer-provided health insurance in which the employer, rather than an insurer, is at risk for its employees\' medical expenses.2
Self-Insured PlanSee Self-Funded Plan.
Senior MarketA market segment that is comprised largely of persons over age 65 who are eligible for Medicare benefits.39
Sensitive Health InformationSHI\"Individually identifiable health information that is deemed by the individual (or their
designee) as requiring protections and particular care in its handling or dissemination that is greater than the protections afforded other personally identifiable health information. What information an individual considers to be “sensitive” is not necessarily the same set of information that another individual considers sensitive, nor is it necessarily the same as the information designated under HIPAA to be Protected Health Information (PHI). \"99
SensitivityExtent to which the criteria used to identify the target population results in the inclusion of persons, groups, or objects at risk.2
Sentinel EventAn adverse health event that may have been avoided through appropriate care or alternative interventions. Providers are required to alert the Joint Commission On Accreditation Of Healthcare Organizations and often state licensing authorities of all sentinel events, including a review of risk factors, preventative measures and case analysis.40
Server FarmA group of networked servers that are housed in one location.77
Service AreaThe geographic area serviced by the health plan as approved by the state regulatory agencies and/or detailed in the certification of authority.40
Service Carve-OutsA service carve-out provides a set of specific services outside a mainstream plan; these services might be administered separately and reimbursed on either a capitated or a fee-for-service basis.2
Service GuidelineA type of practice guideline that presents the appropriate and inappropriate indications for the use of particular diagnostic and therapeutic procedures.40
Service LevelsThe performance standards that an organization sets for its member services activities. See also Service Level Agreement.39
Service QualityA Managed Care Organization\'s success in meeting the non-clinical customer service needs and expectations of plan members.39
Service SubstitutionUse of lower cost, but still effective, service in place of a higher cost service.40
Service-Oriented ArchitectureSOAProvides a set of principles of governing concepts used during phases of systems development and integration. Such an architecture will package functionality as interoperable services: functions provided as a service are available to be used from systems created by other organizations.13
Severity ModifierAn adjustment that reflects patient factors, such as severity of illness, morbidity, or risk of complications, on the relative work required to deliver a service.40
Shadow Controls (Evaluation)Expert and participant judgments used to estimate net impact.2
Shadow Prices (Evaluation)Imputed or estimated costs of goods and services not valued accurately in the marketplace. Shadow prices also are used when market prices are inappropriate due to regulation or externalities.2
Shared RiskAn arrangement in which financial liabilities are apportioned among two or more entities. For example, a Health Maintenance Organization and the medical group may each agree to share the risk of excessive hospital cost over budgeted amounts on a 50/50 basis.40
Shared SavingsA provision of most prepaid health care plans where at least part of the providers\' income is directly linked to the financial performance of the plan. If costs are lower than projections, a percentage of these savings are referred to the providers.40
Sherman Antitrust ActA federal act which established as national policy the concept of a competitive marketing system by prohibiting companies from attempting to (1) monopolize any part of trade or commerce or (2) engage in contracts, combinations, or conspiracies in restraint of trade. The Act applies to all companies engaged in interstate commerce and to all companies engaged in foreign commerce. See also Antitrust Laws.39
Short Stay HospitalsThose hospitals in which the average length of stay is less than 30 days. The American Hospital Association and National Master Facility Inventory (a NCHS dataset) define short-term hospitals as hospitals in which more than half the patients are admi tted to units with an average length of stay of less than 30 days.2
Simple Object Access ProtocolSOAPA protocol specification for exchanging structured information in the implementation of Web Services in computer networks. It relies on Extensible Markup Language (XML) as its message format, and usually relies on other Application Layer protocols (most notably Remote Procedure Call [RPC] and HTTP) for message negotiation and transmission. It can form the foundation layer of a web services protocol stack, providing a basic messaging framework upon which web services can be built.13
Single ContractCoverage for one person as designated on the enrollment or enrollment change card by the enrollee.40
Single PayerSee Single Payer System.
Single Payer SystemMay be known as the Canadian System- A single, government fund pays for everyone\'s health care using tax revenue. [2] A system in which everyone is covered under a publicly run health insurance program under which the government or some other single entity serves as the sole source of payment for a broad range of health care services. [40]2
Single Sign-OnSSOA mechanism whereby a single action of user authentication and authorization can permit a user to access all computers and systems where he/she has access permission, without the need to enter multiple passwords.77
Single Specialty HospitalSSHSpecialized hospitals that provide treatment relating to a single specialty (e.g., cardiac or orthopedic services). Many of the physicians who refer patients to an SSH have an ownership interest in the facility.1
Single-Specialty Group PracticePhysicians in the same specialty pool their expenses, income, and offices.2
Site Appropriateness ListingsA resource for the review of surgery and certain nonsurgical interventions that indicates the most appropriate settings for common procedures.39
Site-Of-Service DifferentialThe difference in the monies paid when the same service is performed in different practice setting or by a different provider. One example would be an examination in an ER versus in a family doctor\'s office.40
Skilled CareThat level of care which: requires the training and skills of a Registered Nurse; and is prescribed by a doctor for the medical care of the patient; and may not be provided by less skilled or less intensive care, such as custodial care or intermediate care.40
Skilled Nursing CareMedical and nursing services, including therapy and social services, provided 24 hours a day under the supervision of a registered nurse.8
Skilled Nursing FacilitySNF1) Provides registered nursing services around the clock; 2) An institution that has a transfer agreement with one or more hospitals, provides primarily inpatient skilled nursing care and rehabilitative services, and meets other specific certification requirements. See Nursing Facility.2
Small Employer Health Insurance Availability ActIn 1994 the General Assembly enacted modifications to the act expanding its scope to firms with 1-50 employees (previously 2-25 employees).40
Small GroupGenerally a group composed of 2 to 99 members for which health coverage is provided by the group sponsor.39
Small Group MarketMeasures aimed at alleviating problem areas in the private insurance marketplace, including guaranteed issuance of policies; limitations or prohibitions on benefit plan limitations or exclusions for preexisting health conditions and an end to experience rating.40
Small Group PoolingAll segments of small group businesses when combined into a pool or pools. Claims are determined by a pool and not on a group-specific basis.40
Small Market Insurance ReformChanges in the marketing of insurance to small businesses that increase the availability and affordability of coverage.2
SOAP note formatA format for medical documentation. SOAP is an acronym for S-Subjective, O-Objective, A-Assessment, P-Plan.77
Social Health Maintenance OrganizationS/HMOA demonstration Health Maintenance Organization under Medicare that provides capitated acute and primary care as well as limited long term care coverage to a broad cross section of the elderly population on a voluntary basis. Enrollees are mostly private pay and generally benefit from lower cost sharing than in traditional fee for services Medicare, thereby eliminating the need for Medigap policies. See also Health Maintenance Organization, Medicare, Medigap.40
Social HMOS/HMOSee Social Health Maintenance Organization.
Social IndicatorPeriodic measurements designed to track the course of a social problem over time.2
Social Security ActLaw that created Medicare,Medicaid and other federal programs under the following titles: II = Old Age, Survivors and Disability Insurance Benefits (Social Security or OASDI); IV -A = Aid to Families with Dependent Children (AFDC); IV-B = Child Welfare; IV-D = Child Support; IV-E - Foster Care; IV-F = Job Opportunities and Basic Skills Training; V = Maternal and Child Health Services; XV = Supplemental Security Income (SSI); XVIII = Medicare; XIX = Medicaid; XX = Social Services Block Grant (SSBG); XXI = Child Health Insurance Program (CHIP).40
Social Service Block GrantSSBGA capped entitlement program established in Title XX of the Social Security Act. Thus, States are entitled to their share, according to a formula, of a nationwide funding ceiling or \'cap\' specified in statute. Block grant funds are given to states to help them achieve a wide range of social policy goals, which include preventing child abuse, increasing the availability of child care, and providing community-based care for the elderly and disabled. Funds are allocated to the states on the basis of population.94
Software As A ServiceSaaSthe Social Services Block Grant (SSBG), is a capped entitlement13
Software Engineering InstituteSEIprogram. Thus, States are entitled to their share, according to13, 60
Sole Community HospitalSCHa formula, of a nationwide funding ceiling or ``cap,\'\' which is2
Solo Practicespecified in statute. Block grant funds are given to States to2
Special Committeeshelp them achieve a wide range of social policy goals, which
Specialty Health Maintenance Organizationinclude preventing child abuse, increasing the availability of39
Specialty HMOchild care, and providing community-based care for the elderly
Specialty Servicesand disabled. Funds are allocated to the States on the basis of39
Specific Stop-Loss Coveragepopulation.
SpecificityExtent to which the criteria used to identify the target population results in the exclusion of persons, groups, or objects not at risk.2
Specified Disease InsuranceInsurance providing benefits, subject to a maximum amount, for expenses incurred in connection with the treatment of specified diseases, such as cancer.40
Specified Low Income Medicare BeneficiariesSLMBMedicare premiums (but not cost sharing) paid by Medicaid on behalf of certain low income eligibles. See also Qualified Medicare Beneficiary.40
Speech RecognitionThe ability of a computer to understand the spoken word for the purpose of receiving commands and transforming speech into text.77
Spend DownProcedure whereby Medicaid applicants use a portion of savings and other resources on medical expenses in order to meet Medicaid resource eligibility requirements. Can also apply to income spend down for states with a medically needy component to Medicaid. See also Medically Needy.40
Spider Graphs/ChartsA technique or tool developed by Ernst & Young, to combine analyses of a market\'s level of managed care evolution with an internal readiness review. It involves three steps: Market Assessment, Internal Analysis and Gap Analysis. Components of the graph include: Network formation, Managed care penetration, Utilization levels, Reimbursement, Excess inpatient capacity, Geographic distribution, Commercial premium, Physician integration, Managed care characteristics, Employer and purchaser base, Outcomes management, Strategic alignment, Organization and Governance, Access to markets, Delivery systems, Medical management, Finance, Performance management, and Information technology.2
SponsorAn organization which selects and manages the choice of health insurance products for a group of individuals. Sponsors include employers, government and quasi-public organizations established to manage insurance choice (e.g., HIPCs).40
Spousal DiscountA premium reduction, usually from 10% to 25% of the premium, that some insurers provide when both a wife and husband purchase long-term care policies. Insurers offering such discounts sometimes do so for two people who permanently reside together whether or not they are spouses.40
Staff Model HMOA Health Maintenance Organization that delivers health services through a group in which physicians are salaried employees who treat HMO members exclusively. See also Group-Model HMO, Health Maintenance Organization.40
Staffing RatiosRatios that relate the number of providers in the network to the number of enrollees in the health plan.39
Standard Benefits Package(1) A core set of health benefits that everyone in the country should have - either through their employer, a government program, or a risk pool; (2) A defined set of health insurance benefits that all insurers are required to offer. See also Benefit Package; Also called Minimum Benefits, Uniform Benefits.2
Standard Class RateSCRA base revenue requirement on a per member or per employee basis, multiplied by group demographics information to calculate monthly premium rates.40
Standard Community RatingA type of community rating in which an Managed Care Organization considers only community-wide data and establishes the same financial performance goals for all risk classes. Also called Pure Community Rating.39
Standard DeviationSDUsed in probability theory and statistics to describe the average difference of the scores in a set of data from the mean of distribution, how far they are away from the mean. A low standard deviation indicates that the data points tend to be very close to the mean, whereas high standard deviation indicates that the data are spread out over a large range of values.13
Standard Industry CodeSICSee North American Industry Classification System.
Standard Metropolitan Statistical AreaSMSASee Metropolitan Statistical Area.
Standard Of CareA diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.39
Standardized AmountAn amount used as the basis for payment under PPS. It is intended to represent the national average operating cost of inpatient treatment for a typical Medicare patient in a reasonably efficient hospital in a large urban or other area. Standardized amount are based on Medicare costs reported by hospitals for cost reporting periods ending in 1982, adjusted for geographic location and certain hospital characteristics, such as teaching activity. The adjusted amounts are updated to the year of payment by an annual update factor. See also Update Factors.2
StandardsAuthoritative and accepted measures of comparison having quantitative or qualitative value.2, 39
Standards Developing OrganizationsSDOAny entity whose primary activities are developing, coordinating, promulgating, revising, amending, reissuing, interpreting, or otherwise maintaining Standards that address the interests of a wide base of users outside the SDO.13
Standing CommitteesLong-term advisory bodies on ongoing issues such as finance management, compliance, quality management, utilization management, strategic planning, and compensation.39
Standing ReferralA referral to a specialist provider that covers routine visits to that provider. It is a common practice to permit the gatekeeper to make referrals for only a limited number of visits (often 3 or fewer). In cases where the circumstances requires regular visits to a specialist, this type of referral eliminates the need to return to the gatekeeper each time the initial referral expires.40
Stark LawPart of the Omnibus Budget Reconciliation Act of 1989, the Stark Law prevents hospitals from purchasing EMR software and other equipment for private practice physicians in an effort to attract referrals. Phase 2 of the law is called Stark II.78
State Action DoctrineFirst articulated in Parker v. Brown, the state action doctrine shields certain anticompetitive conduct from federal antitrust scrutiny.1
State Board Of Medical ExaminersSee Board Of Medical Examiners.
State Children\'S Health Insurance ProgramSCHIPA program, established by the Balanced Budget Act, to encourage states to provide insurance coverage for to uninsured, low-income children. SCHIP is funded through a combination of federal and state funds, and administered by the states in conformity with federal requirements. [1] It was designed to provide health assistance either through separate programs or through expanded eligibility under state Medicaid programs. [39] Also called CHIP.1, 39
State Defined PlanA Health Maintenance Organization that is not Federally qualified but meets state requirements to contract on a full-risk capitation basis for Medicaid enrollees.40
State Mandated Benefits LawsState laws requiring insurance contracts to provide coverage for certain health services (e.g., in vitro fertilization) or for services provided by certain health care providers (e.g., audiologists). Self-insureds are exempt from these requirements. There are over 800 mandates nationwide.40
State Unit On AgingSUAState Units on Aging are agencies of state government designated by the governor and state legislature as focal points for all matters relating to the needs of older persons within the state. The SUA is responsible for planning, coordinating, funding, and evaluating programs for older persons authorized by both state and Federal governments. The SUA aims to improve the quality of life for older Americans by advocating on their behalf, and by promoting the development of community-based systems of social and health services. See also Area Agency On Aging.40
State/Private Insurer Long-Term Care PartnershipsArrangements between some states and certain private insurance companies to provide long-term care insurance. Subject to the specific legal requirements for each state, these partnerships help protect the assets of enrollees who typically must become nearly impoverished before qualifying for Medicaid assistance for long-term care costs. In general, the state approves the long-term care policies offered by insurers who agree to include state-mandated provisions. Enrollees who purchase the approved policies may protect one dollar in assets for every one dollar in benefits paid by the private insurance coverage. The purpose of these plans is to shift some of the burden for long-term care from Medicaid programs to private insurance while at the same time allowing insurance purchasers to keep assets they would otherwise have to spend in order to qualify for Medicaid when the private insurance benefits are exhausted.40
StatuteRules defined in law. Statutes are issued by legislative authority of the Federal or state government. See also Regulation.40
Statutory SolvencyA Health Maintenance Organization\'s ability to maintain at least the minimum amount of capital and surplus specified by state insurance regulators.39
Step-Down UnitA ward or section of a ward in a hospital that is devoted to delivering sub-acute care to patients following a period of acute care.39
Stock CompanyA company that is owned by the people and organizations who purchase shares of the company\'s stock.39
Stop LossSee Stop Loss Insurance.
Stop Loss InsuranceDescribes two aspects in insurance: 1) The policyholder may be protected by a ceiling on the amount that must be paid out-of-pocket for deductibles and co-insurance for covered services and allowable charges in a policy year and 2) A health plan may purchase insurance to protect itself against costs that exceed specified levels.40
Storage Area NetworkSANAn architecture to attach remote computer storage devices (such as disk arrays, tape libraries, and optical jukeboxes) to servers in such a way that the devices appear as locally attached to the operating system. Although the cost and complexity of SANs are dropping, they are uncommon outside larger enterprises. Network attached storage (NAS), in contrast to SAN, uses file-based protocols such as NFS or SMB/CIFS where it is clear that the storage is remote, and computers request a portion of an abstract file rather than a disk block.13
Strategic Planning CommitteeA committee responsible for directing the organization\'s strategic direction and goals.39
Structural IntegrationThe unification of previously separate providers under common ownership or control.39
Structure MeasuresHealthcare quality indicators related to the nature, quantity, and quality of the resources that a Managed Care Organization has available for member service and patient care.39
Structured DataStructured data is managed by technology that allows for querying and reporting against predetermined data types and understood relationships.77
Structured Query LanguageSQLA computer language aimed to store, manipulate and retrieve data stored in relational databases.78
Subacute CareIs usually described as a comprehensive inpatient program for those who have experienced a serious illness, injury or disease, but who don\'t require intensive hospital services. The range of services considered subacute can include infusion therapy, respiratory care, cardiac services, wound care, rehabilitation services, postoperative recovery programs for knee and hip replacements, and cancer, stroke, and AIDS care. [2] Care given to patients who require less than a 30-day length of stay in a hospital and who have a more stable condition than those receiving acute care. [40]2, 40
Sub-CapitationCapitation for a limited set of medical services. See also Pre-Paid Health Plan.40
Submitted ChargeThe charge submitted by a provider to the patient or a payer. See Paid Amounts.2
SubrogationThe recovery of the cost of services and benefits provided to the enrollee of one Managed Care Organization when other parties are liable.40
SubscriberThe person responsible for payment of premiums or whose employment is the basis for eligibility for members in a Health Maintenance Organization or other health plan.40
Subscriber ContractA written agreement, which may also be called a subscriber certificate or a member certificate, describing an individual\'s health care policy.40
SubsidiaryA company that is owned by another company, its parent.39
Substance-Abuse ProgramsDiagnostic and therapeutic services to people dependent on alcohol or drugs. Includes inpatient or residential program for patients needing intensive care or supervision.8
Sudden Infant Death SyndromeSIDSThe sudden and unexpected death of an apparently healthy infant, not explained by careful postmortem studies. It typically occurs between birth and age 9 months, with the highest incidence at 3 to 5 months. Called also crib death or cot death because the infant often is found dead in the crib.18
Summary Plan DescriptionA description of the entire benefits package available to an employee as required to be given to persons covered by self-funded plans.40
SuperbillA modified claim form that lists specific and/or specialty medical services provided by a physician.40
Supplemental Medical BenefitsHealth care reform plans normally allow the acceptance of supplemental benefits, which are normally not covered by a standard benefit package. These include services not usually medically necessary such as organ transplant, or enhanced psychiatric services. Consumers would have to pay an additional premium for these benefits.40
Supplemental Medical InsuranceSMIPrivate health insurance, also called Medigap, designed to supplement Medicare benefits by covering certain health care costs that are not paid for by the Medicare program. [40] It covers the costs of physicians\' services, outpatient laboratory and X-ray tests, durable medical equipment, outpatient hospital care, and certain other services. This voluntary program requires payment of a monthly premium, which covers 25 percent of pro-ram costs. Beneficiaries are responsible for a deductible and coinsurance payments for most covered services. Also called Part B Coverage or Benefits. [2]2, 40
Supplemental Security IncomeSSIA federal program of income support for low income, aged, blind and disabled persons established by Title XVI of the Social Security Act. Qualification often is used to establish Medicaid eligibility [40]. Eligibility for the monthly cash payments is based on the individual\'s current status without regard to previous work or contributions. [2]2, 40
Supplemental ServicesOptional services that a health plan may cover or provide in addition to its basic health services.40
Supplementary Medical InsuranceSMIPart of the federal Medicare program for additional coverage on a voluntary basis. It provides physician services to those over 65, and their dependents, who have enrolled in the program. Those enrolled in the program pay half the cost, and the U.S. Government pays the other half.49
SupplierA provider of health care services, other than a practitioner, that is permitted to bill under Medicare Part B. Suppliers include independent laboratories, durable medical equipment providers, ambulance services, orthotist, prosthetist, and portable X-ray providers.2
SupportsTerm used in the disability community to refer to a service that promotes independence and does not treat the individual as a passive recipient of care.40
SureScriptsElectronic exchange that links pharmacies and healthcare providers. Founded in 2001 by the National Association of Chain Drug Stores (NACDS) to make the prescribing process safer and more efficient.78
SurgicenterA separate, freestanding medical facility specializing in outpatient or same-day surgical procedures. Surgicenters drastically reduce the costs associated with hospitalizations for routine surgical procedures because extended inpatient care is not required for the specific disorders treated by them.40
SurplusThe amount that remains when an insurer subtracts its liabilities and capital from its assets.39
SurveySystematic collection of information from a defined population, usually by means of interviews or questionnaires administered to a sample of units in the population.2
Survey And Utilization ReviewsSURSMedicaid unit that reviews claims and utilization to ensure that Medicaid funds are being used appropriately.40
Sustainable Growth RateThe target rate of expenditure growth set by the Sustainable Growth Rate System. Similar to the performance standard under the Volume Performance Standard system, except that the target depends on growth of gross domestic product instead of historical trends. See also Sustainable Growth Rate System, Volume Performance Standard System, Performance Standard.2
Sustainable Growth RateSGRSection 1848 of the Social Security Act requires the Secretary of the Centers for Medicare & Medicaid Services (CMS) to make available to the Medicare Payment Advisory Commission (MedPAC) and the public by March 1 of each year, an estimated Sustainable Growth Rate (SGR) and estimated conversion factor applicable to Medicare payments for physicians\' services for the following year and the data underlying these estimates.93
Sustainable Growth Rate SystemThe target rate of expenditure growth set by the Sustainable Growth Rate System. Similar to the performance standard under the Volume Performance Standard system, except that the target depends on growth of gross domestic product instead of historical trends. See also Sustainable Growth Rate System, Volume Performance Standard System, Performance Standard.2
Swing BedsAcute care hospital beds that can also be used for long-term care.40
Swing-Bed HospitalA hospital participating in the Medicare swing-bed program. This program allows rural hospitals with fewer than 100 beds to provide skilled post-acute care services in acute care beds.2
Systematized Nomenclature Of MedicineSNOMEDA systematically organized computer processable collection of medical terminology covering most areas of clinical information such as diseases, findings, procedures, microorganisms, pharmaceuticals etc. It allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. It also helps organizing the content of medical records, reducing the variability in the way data is captured, encoded and used for clinical care of patients and research. [13] It was originally created by the College of American Pathologists (CAP) and, as of April 2007, is owned, maintained, and distributed by the International Health Terminology Standards Development Organisation (IHTSDO), a non-for-profit association in Denmark. CAP continues to support SNOMED CT operations under contract to the IHTSDO and provides SNOMED-related products and services as a licensee of the terminology. [44]13, 44
Systematized Nomenclature Of Medicine -- Clinical TerminologySNOMED CTSee Systematized Nomenclature Of Medicine.
T1 Line(Pronounced \'tee-one line\'). The T1 carrier is a commonly used digital Internet connection line in the US supporting data rates of 1.544 Mbits per second.77
Table RatesSee Age/Sex Rates.
Tablet PCA tablet pc is a computer shaped in the form of a notebook except it has the capabilities of being written on through the use of digitizing tablet technology or a touch screen. A user can use a stylus and operate the computer without having to have a keyboard or mouse.77
Target (Evaluation)The unit (individual, family, community, etc.) to which a program intervention is directed.2
TargetingProcess that directs the kinds of services, the concentration of programs and the distribution of funds at defined segments of the population. See also Greatest Economic Need.40
Tax CapThis would limit the amount of employer-sponsored health insurance to be excluded from taxable income. A tax cap could be for individuals or employers tax liabilities. There are two reasons for a tax cap: (1) to provide revenues to pay for the cost of covering uninsured and (2) to increase consumer awareness of costs.40
Tax CreditAmount that can be deducted from the actual tax owed.40
Tax DeductionAmount that can be deducted from taxable income, if spent on a specific purpose.40
Tax Equity And Fiscal Responsibility Act Of 1982TEFRAA Federal law that authorizes health plans to enter into arrangements with HCFA for cost and risk contracts. [40] It established target rate of increase limits on reimbursements for inpatient operating costs per Medicare discharge. A facility\'s target amount is derived from costs in a base year updated to the current year by the annual allowable rate of increase. Medicare payments for operating costs generally may not exceed the facility\'s target amount. These provisions still apply to hospitals and units excluded from PPS. [2] See also Excluded Hospitals, Units.2, 40
Tax IncentivesTax deductions, credits, and rebates affecting insurance benefit decisions.40
Tax-Sheltered AnnuityTSAA type of annuity that allows an employee to make contributions from their income into a retirement plan. The contributions are deducted from the employee\'s income and, as a result, the contributions and related benefits are not taxed until the employee withdraws them from the plan. Because the employer can also make direct contributions to the plan, the employee gains the benefit of having additional tax-free funds accruing.95
Teaching HospitalA hospital that has an accredited medical residency training program and is typically affiliated with a medical school.40
Team-Based PayIs a base or variable program that recognizes group efforts and results.2
Technology AssessmentTAThe term used to describe the evaluation process of new or existing diagnostic and therapeutic devices and procedures. Technology assessment evaluates the effect of a medical procedure, diagnostic tool, medical device, or pharmaceutical product. In the past, technology assessment meant primarily evaluating new equipment, focusing on the clinical safety and efficacy of an intervention, in today\'s health care world, it includes a broader view of clinical outcomes, such as the effect on a patient\'s quality of life, and the effect on society.40
TelemedicineHealth care consultation and education using telecommunication networks to transmit information.40
TemplateOften called a library or dictionary. Templates are pre-defined choices of pick-lists designed to streamline the documentation process.77
Temporary Assistance For Needy FamiliesTANFA state-based, federal cash assistance program for low-income families. It replaces the former cash assistance program known as Aid to Families with Dependent Children (AFDC). Unlike the former AFDC program, eligibility does not automatically convey Medicaid eligibility.40
Temporary Restraining OrderTROA temporary, court order preventing an action which last while a motion for preliminary injunction is being decided, and the court decides whether to drop the order or to issue a preliminary injunction.13
Terminal ServicesMicrosoft\'s method for remote administration tasks that delivers the Windows desktop and Windows-based applications to nearly any personal computing device, even devices that can\'t run Windows.78
Termination ProvisionA provider contract clause that describes how and under what circumstances the parties may end the contract.39
Termination With CauseA contract provision, included in all standard provider contracts, that allows either the Managed Care Organizationor the provider to terminate the contract when the other party does not live up to its contractual obligations.39
Termination Without CauseA contract provision that allows either the Managed Care Organization or the provider to terminate the contract without providing a reason or offering an appeals process.39
Tertiary CareHighly specialized care given to patients who are in danger of disability or death often requiring sophisticated technologies (e.g., neurosurgeons or intensive care units).40
Tertiary CenterA large medical care institution, usually a teaching hospital, that provides highly specialized care.2
The WebSee World Wide Web.
Therapeutic AlternativesA drug that is believed to be therapeutically equivalent (i.e., will achieve the same outcome) to the exact drug prescribed by a physician is substituted by the dispensing pharmacist without the need to obtain the physician\'s permission.40
Therapeutic DevicesMay include hospital beds, crutches, wheelchairs, ramps, intravenous pumps and respirators. See also Durable Medical Equipment, Assistive Technology.40
Therapeutic EquivalentsSee Therapeutic Alternatives.
Therapeutic SubstitutionThe dispensing of a different chemical entity within the same drug class of a drug listed on a pharmacy benefit management plan\'s formulary. Therapeutic substitution always requires physician approval.39
Thin ClientA thin client is a network computer without a hard disc drive, as opposed to a fat client which includes a disc drive.77
Third Party PaymentPayment by a private insurer or government program to a health care provider for care given to a patient.40
Third-Party AdministratorTPAA firm that performs administrative functions (e.g., claims processing, membership) for a self-funded plan or a start-up Managed Care Organization. [1] It has no financial responsibility for paying benefits. [39] It may collect premiums, determine employee eligibility, determine covered services, pay claims, prepare management information reports and provide other administrative services. It is often able to provide reinsurance brokering, cost containment programs, and a full range of employee communication programs. Insurers may sell administrative services to self-insured employers, but this is described as \'administrative services only\'. [40]1, 39, 40
Third-Party PayerAn organization (private or public) that pays for or insures at least some of the health care expenses of its beneficiaries. Third-party payers include Blue Cross/Blue Shield, commercial health insurers, Medicare, and Medicaid. The individual receiving the health care services is the first party, and the individual or institution providing the service is the second party.2
Three-Tier Copayment StructureA pharmacy benefit copayment system under which a member is required to pay one co-payment amount for a generic drug, a higher co-payment amount for a brand-name drug included on the health plan\'s formulary, and an even higher co-payment amount for a non-formulary drug.39
Three-Tier RateA rate structure that sets monthly premiums based on 1) single person coverage, 2) two-person coverage and 3) family coverage.40
Threshold StandardsRate or level of illness or injury in a community or population which, if exceeded, should signal alarms for renewed or redoubled action.2
TIA-942See Classification of Data Centers.
Time-Series Analysis (Evaluation)Reflexive designs that rely on relatively long series of repeated outcome measurements taken before and after an intervention.2
Title XIXSee Medicaid.
Title XVIISee Medicare.
Title XXISee Children\'s Health Insurance Program, Social Service Block Grant.
TortA negligent or intentional civil wrong not arising out of a contract or statute that injures someone in some way and for which the injured person may sue the wrongdoer for damages.40
Tort ReformEfforts to change the procedural or substantive rules for malpractice claims in the judicial system. Examples include reductions in statutes of limitations, mandatory offsets for collateral sources of payment, caps on non-economic damages, periodic payments of large awards, and limits on attorneys\' contingency fees.40
Total Compensation PackageThe total amount of compensation received by a worker for services rendered including wages or salary and fringe benefits.40
Total MarginA measure that compares total hospital revenue and expenses for inpatient, outpatient, and non-patient care activities. The total margin is calculated by subtracting total expenses from total revenue and dividing by total revenue.2
Total Parenternal NutritionTPNFeeding a person completely intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulas containing salts, glucose, amino acids, lipids and added vitamins.13
Total Quality ManagementTQMA business management strategy aimed at embedding awareness of quality in all organizational processes. It has been widely used in manufacturing, education, hospitals, call centers, government, and service industries, as well as NASA space and science programs.13
Touch ScreenAn input device that allows user to interact with the computer by touching the display screen.77
TranscriptionThe process by which medical transcriptionists convert physician\'s dictation into written (typed) words.77
Transport Layer SecurityTLSTLS and its predecessor, Secure Sockets Layer (SSL), are cryptographic protocols that provide security for communications over networks such as the Internet. TLS and SSL encrypt the segments of network connections at the Transport Layer end-to-end.13
Treatment FacilityA residential or non-residential facility or program licensed, certified or otherwise authorized to provide treatment of substance abuse or mental illness pursuant to the law or jurisdiction in which treatment is received.40
Trend FactorAn adjustment factor to represent the predicted change in the level of costs for services from one period to another due to inflation and utilization increases.40
TrendingA calculation used to anticipate future utilization of a group based on past utilization by applying trend factor, the rate at which direct and indirect medical costs are changing.40
TriageThe process by which patients are sorted or classified according to the type and urgency of their conditions.40
TRICAREA Department of Defense, regionally managed health-care program for active duty and retired members of the uniformed services and their families that combines military healthcare resources and networks of civilian healthcare professionals. Formerly known as CHAMPUS (the Civilian Health and Medical Program of the United States).39
TRICARE ExtraA reduced Fee-For-Service Plan similar to the network portion of a Preferred Provider Organization.39
TRICARE PrimeAn enrollment-based managed care option designed to provide coordinated care managed by a primary care manager, who is similar to a primary care provider in a Health Maintenance Organization.39
TRICARE StandardA fee-for-service plan that allows participants to use TRICARE authorized providers or non-network providers.39
Triple Option PlanAn employee health benefit including a Health Maintenance Organization, a Preferred Provider Organization, and \'traditional\' fee-for-service insurance, underwritten by a single insurer. This mechanism enables the insurer to spread its risk. Once the employee elects the coverage option, the decision is locked in for the duration of the policy, usually one year.40
Tumor RegistrarIdentifies, registers and maintains records of all cancer patients by utilizing the tumor registry data system. Analyzes registry data and disseminates information in accordance with professional ethics.40
Turnaround TimeThe amount of time required to complete a particular member-initiated transaction.39
Two-Tier Copayment StructureA pharmacy benefit co-payment system under which a member is required to pay one co-payment amount for a generic drug and a higher co-payment amount for a brand-name drug.39
Two-Tier RateA rate structure that sets monthly premiums based on single person coverage and family coverage.40
Tying ArrangementsAn illegal business practice that occurs when an organization conditions the sale of one product or service on the sale of other products or services.39
U.S. Department Of Health And Human ServicesHHSThe Federal department which regulates and administers health and human service programs in the United States. It was created in 1953 and was known as the Department of Health, Education, and Welfare until 1980 when the U.S. Department of Education was created as a separate department. The Secretary of HHS advises the President on the health, welfare, and income security plans, policies, and programs of the Federal government. See also Health Care Financing Administration.40
U.S. Department Of Housing And Urban DevelopmentHUDEstablished in 1965, the principal Federal agency responsible for programs concerned with housing needs, fair housing opportunities, and improving and developing communities.40
U.S. Per Capita CostUSPCCThe national average cost per Medicare beneficiary, calculated annually by HCFA\'s Office of the Actuary. See Adjusted Average Per Capita Cost, Adjusted Payment Rate, Medicare Risk Contract.2
U.S. Preventative Services Task ForceUSPSTFFirst convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the AHRQ, is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the \'gold standard\' for clinical preventive services. The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care.37
UB-92 FormForm designed for hospitals to file a medical claim with the patient\'s insurance carrier.78
UnbundlingA coding inconsistency that involves separating a procedure into parts and charging for each part rather than using a single code for the entire procedure. [39] Also refers to a trend in insurance benefits contracting where the purchaser unbundles or contracts separately for specific services. [40]39, 40
Uncompensated CareThe charges for services rendered by providers which are not paid for by the recipient and for which there is usually no third-party coverage. Uncompensated care is usually either charity care or bad debt.40
Undergraduate Medical EducationThe medical training provided to students in medical or osteopathy school. See also Graduate Medical Education.2, 40
UnderinsuredPeople with public or private insurance policies that do not cover all necessary medical services, resulting in out-of-pocket expenses that exceed their ability to pay.40
UnderwritingThe process of selecting, classifying, evaluating, and assuming risks according to their insurability. Its fundamental purpose is to make sure that the group covered has the same probability of loss and probable amount of loss, within reasonable limits, as the universe on which premium rates or subscriber fees were based.40
Underwriting ImpairmentsFactors that tend to increase an individual\'s risk above that which is normal for his or her age.39
Underwriting ManualA document that provides background information about various underwriting impairments and suggests the appropriate action to take if such impairments exist.39
Underwriting RequirementsRequirements, sometimes relating to group characteristics or financing measures, that Managed Care Organizations at times impose in order to provide healthcare coverage to a given group and which are designed to balance a health plan\'s knowledge of a proposed group with the ability of the group to voluntarily select against the plan (antiselection).39
Unified Code for Units of MeasureUCUMA code system intended to include all units of measures being contemporarily used in international science, engineering, and business. The purpose is to facilitate unambiguous electronic communication of quantities together with their units. The focus is on electronic communication, as opposed to communication between humans.100
Unified InsuranceHealth insurance coverage that is provided through a single insurance policy.2
Unified Medical Language SystemUMLSA U.S. National Library of Medicine project that develops and distributes multi-purpose, electronic \'Knowledge Sources\' and associated lexical tools for system developers. Researchers will find the UMLS products useful in investigating knowledge representation and retrieval questions.72
Unified Modeling LanguageUMLA standardized general-purpose modeling language in the field of software engineering. UML includes a set of graphical notation techniques to create abstract models of specific systems.13
Uniform BenefitsSee Standard Benefits Package.
Uniform Bill Patient SummaryUBPSThe Patient Summary section of a Uniform Bill. See Uniform Billing.
Uniform BillingUBA single billing form (UB-82) and standard data set that is used nationwide by institutional providers and payers for handling health care claims. This was sponsored by the National Uniform Billing Committee (NUBC, part of the American Hospital Association) was accepted by all the major national provider and payer organizations as well as the US States.96
Uniform Billing Code Of 1992UB-92A revised version of the UB-92, a Federal directive requiring a hospital to follow specific billing procedures, itemizing all services included and billed for on each invoice, implemented October 1, 1993.40
Uniform Claim FormAll insurers and self-insurers would be required to use a single claim form and standardized format for electronic claims.2
Uniform Health Data ActAmendment of this act ensures that discharge data currently required of hospitals resides with the state and can be publicly released without prior permission of the hospitals. In addition, the act calls upon the Delaware Health Care Commission to study the feasibility of broadening its scope to apply to other health care facilities, such as nursing homes and ambulatory surgical centers.40
Uniform Hospital Discharge Data SetA defined set of data that gives a minimum description of a hospital discharge. It includes data on age, sex, race, residence of patient, length of stay, diagnosis, physicians, procedures, disposition of the patient and sources of payment.40
Uniform Resouce LocatorURLIn computing, a URL is a type of Uniform Resource Identifier (URI) that specifies where an identified resource is available and the mechanism for retrieving it. In popular usage and in many technical documents and verbal discussions it is often incorrectly used as a synonym for URI. In popular language, a URL is Also called a Web address.13
Uniform Set Of Health ServicesA broad range of health services including: 1) a comprehensive and affordable Uniform Benefits Package of personal health services delivered by competing certified health plans; 2) a variety of services provided through the public health system; and 3) health system support, such as clinical research and health personnel education.2
UninsuredPeople who lack health insurance.40
Uninsured PopulationAn estimated 34 million Americans do not have health insurance. 56% are workers. 28% are children. 16.5% are non-working adults. 83% of workers have private health insurance. 40
Unique Ingredient IdentifierUNIIA unique identifier for substances in drugs, biologics, foods, and devices. It is a non- proprietary, free, unique, unambiguous, non semantic, alphanumeric identifier based on a substance’s molecular structure and/or descriptive information.81
Unique Physician Identification NumberUPINUnique Identification number given to each healthcare provider. Frequently used in insurance billing and is currently being replaced by the NPI number.78
United States Health Information KnowledgebaseUSHIKA metadata registry of healthcare-related data standards funded and directed by the Agency for Healthcare Research and Quality with management support in partnership with the Centers for Medicare & Medicaid Services.33
Universal AccessAccess to health insurance coverage for everyone. The right and ability to receive a comprehensive, uniform, and affordable set of confidential, appropriate, and effective health services.2
Universal CoverageSee Standard Benefit Package.
UNIXA network capable, multi-user operating system used for workstations and servers. Many old practice management, medical billing and EMR software were originally designed under the UNIX operating system.78
Unstructured DataData which is not structured such as free-text. The computer cannot automatically extract properties and relationships from unstructured data.77
UpcodingA coding inconsistency that involves using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider.39
Update FactorThe year-to-year increase in base payment amounts for PPS and excluded hospitals and dialysis facilities. The update factors generally are legislated by the Congress after considering annual recommendations provided by ProPAC and the Secretary of HHS. ProPAC\'s update factors are intended to reflect changes in the prices of inputs used to provide patient care services, as well as changes in productivity, technological advances, quality of care, and long-term cost-effectiveness of services. ProPAC recommends separate update factors for PPS hospital operating payments, PPS hospital capital payments, the TEFRA target amounts for PPS-excluded hospitals and distinct-part units, and composite rate payments to dialysis facilities. See also Market Basket Index.2
Urgent Care Center Or UnitA medical facility where ambulatory patients can be treated without an appointment and receive immediate, non-emergency care. The urgent care center may be opened 24 hours a day; patients calling a Health Maintenance Organization after hours with urgent, but not emergent, clinical problems, are often referred to these facilities. A similar facility is a Medical Aid Unit, which is not usually opened 24 hours a day.40
Urgent NeedsUrgent public health problems and unmet needs in communities. The Health Services Act of 1993 allocated $20 million to enable the public health system to respond to these urgent health needs.2
Usual & CustomaryU&CSee Reasonable And Customary Fee.
Usual And CustomaryUCSee Reasonable And Customary Fee.
Usual, Customary And Reasonable ChargeUCRSee Reasonable And Customary Fee.
UtilizationThe patterns of use of a service or type of service within a specified time, usually expressed in a rate per unit of population-at-risk for a given period (e.g., the number of hospital admissions per year per 1,000 persons in a geographic area).40
Utilization GuidelinesA utilization review resource that indicates accepted approaches to care for common, uncomplicated healthcare services.39
Utilization ManagementUMManaging the use of medical services to ensure that a patient receives necessary, appropriate, high-quality care in a cost-effective manner. [39] The process of evaluating the necessity, appropriateness and efficiency of health care services. A review coordinator gathers information about the proposed hospitalization service or procedure from the patient and/or provider then determines whether it meets established guidelines and criteria. [40]39, 40
Utilization Management CommitteeA Managed Care Organization\'s committee that reviews and updates its utilization management program, establishes Utilization Review protocols, reviews referral and utilization patterns, and reviews utilization decisions for medical appropriateness.39
Utilization ReviewURThe review of services delivered by a health care provider or supplier to determine whether those services were medically necessary; may be performed on a concurrent or retrospective basis. [1] The review of services delivered by a health care provider to evaluate the appropriateness, necessity, and quality of the prescribed services. The review can be performed on a prospective, concurrent, or retrospective basis. [2] An evaluation of the medical necessity, appropriateness, and cost-effectiveness of healthcare services and treatment plans for a given patient. [39] Evaluation of the use of hospital services, including the appropriateness of the admission, length of stay and ancillary services. Review may be conducted concurrently, retrospectively, or in combination. The process uses objective clinical criteria to ensure that the services are medically necessary and provided at the appropriate level of care. UR is conducted by the hospital for its own quality assurance and risk management system, using norms, criteria and standards adopted by its medical staff. Reports summarizing the findings and action taken as a result of the process are regularly provided to the hospital board. Hospitals conduct their own internally accountability system and comply with multiple delegated and non-delegated UR systems simultaneously. This occurs because of the hospital\'s legal responsibilities as well as each payer requiring its covered population to comply with its unique system as a condition of claims payment. [40]1,2, 39, 40
Utilization Review Accreditation CommissionURACA Washington DC-based, not-for-profit corporation formed in 1990 and dedicated to improving the quality of utilization review in the health care industry by providing a method of evaluation and accreditation of utilization review programs.40
Utilization Review OrganizationUROAn external organization that conducts reviews to assess the medical appropriateness of suggested courses of treatment for patients, thereby providing the patient and the purchaser increased assurance of the value and quality of healthcare services.39
Utilization Review, DelegatedAn entity external to the hospital under contract to the payer to review services provided a specific population contracts to use hospital personnel to conduct the review process. The norms, criteria and standards may be those adopted by the hospital medical staff or the external agency may require that its protocols be used. The hospital must report its patient-specific findings to the entity; it may also be required to summarize overall findings from its internal UR process.40
Utilization Review, Non-DelegatedAn entity external to the hospital under contract to the payer to review services provided a specific covered population operates a separate UR system, using its own norms, criteria and standards and relies upon its own personnel to obtain clinical information. It may use information obtained from clinicians, the patient, family, medical records, or claims information submitted for payment after patient discharge. It may be conducted concurrently or retrospectively, in person or the hospital premises, or by telephone, or by review of documentation.40
VariancesThe differences obtained from subtracting actual results from expected or budgeted results.39
VendorSee Provider.
Vertical IntegrationConsolidation or merger of organizations that provide different types of services in a hierarchical continuum such as a hospital acquiring a nursing home and a home health agency. See also Horizontal Integration.40
Veterans AdministrationVAA Federal agency responsible for veterans including VA hospitals and Veterans\' benefits. See also Domicillary Care.40
Veterans Health Information Systems And Technology ArchitectureVistAFully integrated HIS software built for and used at the Veterans\' Administration. It is in the public domain, so it may be downloaded and used free of charge.46
Virtual Lifetime Electronic RecordVLERA combination of Electronic Medical Record and medical benefits that is planned allow sharing of data on military personnel among the DOD, VA and private health care providers.35
Virtual Private NetworkVPNA way to communicate through a dedicated server securely to a corporate network over the internet.77
Virtual Private ServerVPSA method of partitioning a physical server computer into multiple servers such that each has the appearance and capabilities of running on its own dedicated machine. Each virtual server can run its own full-fledged operating system, and each server can be independently rebooted. Also called Virtual Dedicated Server or VDS.13
VirtualizationSee Virtual Private Server.
Vocational RehabilitationVRA program of services designed to enable people with disabilities to become or remain employed. Originally mandated by the Rehabilitation Act of 1973, VR programs are carried out by individually created state agencies. In order to be eligible for VR, a person must have a physical or mental disability that results in a substantial handicap to employment.40
Voice RecognitionSee Speech Recognition.
Volume And Intensity Of ServicesThe quantity of health care services per enrollee, taking into account both the number and the complexity of the services provided.2
Volume OffsetSee Behavioral Offset.
Volume Performance StandardA mechanism to adjust Medicare physician fee updates based on how annual increases in actual Part B expenditures compare to previously predicted rates of increase.40
VoucherA certificate, given usually to low or moderate income individuals that can be used to purchase all or part of a specific item such as insurance or a needed service.40
Wait TimeThe length of time, on average, that members must stay on the telephone before they receive assistance.39
Web PortalA website considered as an entry point to other websites.77
Web SiteA specific location on the Web that provides users access to a group of related text, graphics, and, in some cases, multimedia and interactive files.39
Web-based EMRElectronic Medical Records provided over the internet and accessed using a web browser on a local computer. See also Application Service Provider.
WebinarA lecture, presentation, workshop or seminar that is transmitted over the Web. Short for Web-based Seminar.77
Wellness ProgramAlso called Health Promotion Program. See Health Promotion.
Wide Area NetworkWANA computer network that spans a larger geographical area than a Local Area Network. 77
WirelessA system employing no connecting wire between the transmitting and receiving stations.77
WithholdA percentage of a provider\'s payment that is \'held back\' during the plan year to offset or pay for any cost overruns for referral or hospital services. Any part of the withhold not used for these purposes is distributed to providers.39
Women\'S Health And Cancer Rights ActWHCRAA law which requires health plans that offer medical and surgical benefits for mastectomy to provide coverage for reconstructive surgery following mastectomy.39
Workers\' CompensationWCA state-mandated insurance program that provides benefits for healthcare costs and lost wages to qualified employees and their dependents if an employee suffers a work-related injury or disease.39
Workers\' Compensation Indemnity BenefitsBenefits that replace an employee\'s wages while the employee is unable to work because of a work-related injury or illness.39
WorkflowThe automation of a process, in whole or part, during which documents, information or tasks are passed from one participant to another for action, according to a set of procedural rules.77
Workstation On WheelsWOWA wheeled cart that supports the CPU, display, keyboard and mouse, allowing it to be easily and safely moved. These are available for both desktops and laptops.
World Health OrganizationWHOA specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, and headquartered in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health Organization, which had been an agency of the League of Nations.13
Wound Management ServicesManagement and treatment of long-term unhealed wounds from conditions such as diabetes and poor circulation. May be inpatient or outpatient.8
Year-To-DateYTDThe period of time from the first day of the year to and including today. This is frequently used in analytical (admissions YTD) and financial (revenues YTD) reporting. The year may be a calendar year, fiscal year or some other defined annual period.40
YieldRatio of profit to overall gross income for a given service, insurance product or other business venture.40
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