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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Abuse - When the legal term used in the business of healthcare, it usually refers to actions that do not involve intended misrepresentations in billing but which, nevertheless, result in improper conduct. Consequences can result in civil liability and governmental sanctions. An example of abuse is the excessive use of medical supplies. Access - Generally the patient is able to obtain medical care. The ease of access is determined by such mechanism as the availability of medical services and their suitability to the patient, the location of health care facilities, transportation, and hours of operation and cost of care. An individual is able to obtain appropriate health care services. Barriers to access can be financial, geographic, organizational and sociological. Efforts to improve access often focus on providing or improving health coverage. Accountable Health Plan - AHPs can be IDSs, MCOs, Health Networks, partnerships or joint ventures between practitioners, providers or payers that would presume responsibility for delivering medical care and managing the funds required to pay for the services rendered. Physicians and other providers would employ for, contract with or own these health plans. When an IDS or hospital group or IPA operates one or more health insurance advantage products, or a managed care organization acquires a large scale medical delivery element, it qualifies as an Accountable Health System or Accountable Health Plan. Accountable Health Partnership - An organization of doctors and hospitals that provides concern for people organized into huge groups of purchasers. Accreditation - The process of which an organization recognizes a provider, a program of study or an institution as meeting predetermined standards. Two organizations that authorize managed care plans are the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO). JCAHO also accredit hospitals and clinics. CARF accredits medicinal providers. Accrete - The new recipients added to a health plan is Medicare term. Accrual - The amount of money that is used aside to cover expenses. The increase is the plan's best estimate of what those expenses are, and is based on a combination of data from the authorization system, the claims system, lag studies, and the plan's prior history. Actively-at-Work - This policy describes insurer's policy requirement indicating that coverage will not go into effect until the employee's first day of work on or after the efficient date of coverage. May also relate to dependents disabled on the effective date. Activities of Daily Living - The individual is daily habits such as bathing, dressing and eating. ADLs are often used as an assessment tool to determine that individual is able to function at home, or in a less restricted environment of care. Activity-Based Costing - Activity-based costing defines healthcare expenses in terms of a healthcare organization's processes or activities. The expenses are then associated with significant activities or events. It relies on the following 3 step process: Activity mapping, which involves in mapping actions in an illustrated sequence. Activity analysis, which involves important and assigning a time value to activities and Bill of activities, which involves in generating a cost for each main activity. Actuarial - It refers to the statistical calculations used to establish the managed care company's rates and premiums charged their customers based on projections of use and cost for a defined population. Actuarial Soundness - The requirement that the development of capitation charge meet common actuarial principles and rules. Actuary - The insurance shows that a person trained in statistics, accounting and mathematics who determines policy rates, reserves, and dividends by deciding what assumptions should be made with respect to each of the risk factors involved such as the frequency of occurrence of the peril, the average benefit that will be payable, the rate of investment earnings, if any, expenses, and persistency rates and who endeavors to secure as valid statistics as possible on which to base his assumptions. Proficiently trained individual, usually with experience or education in insurance, who conducts statistical studies such as determining insurance policy rates, dividend reserves and dividends, as well as conducts various other statistical studies. A capitated health supplier would not accept or contract for capitated rates, or agree to a capitated contract without an actuarial determining the reasonableness of the rates. Acute - The sudden beginning of disease or injury, or a sudden change in a person's condition that would require prompt medical attention. Acute Care - A pattern of health care in which a patient is treated for a severe episode of illness, for the succeeding treatment of injuries related to an accident or other trauma, or during recovery from surgery. Specialized people using complex and sophisticated technical equipment and materials frequently give acute care in a hospital. Unlike chronic care, acute care is often needed for only a short time. Adjudication - Processing claims regarding to contract. Adjusted Admissions - Adjusted admissions are equal to the sum of inpatient admissions and an estimate of the volume of outpatient services. This evaluates that all patient care activity undertaken in a hospital, both inpatient and outpatient. This estimate is calculated by multiplying outpatient visits by the proportion of outpatient charges per visit to inpatient charges per admittance. Adjusted Average Per Capita Cost (AAPCC) - The basis for HMO or CMP compensation under Medicare-risk contracts. The average monthly amount expected per enrollee is currently calculated as 95 percent of the average costs to deliver medical care in the fee-for-service sector. CMS's best estimation for the amount of money care costs for Medicare recipients under fee-for-service Medicare in a given area. The AAPCC is made up of 122 different rate cells and 120 of them are factored for age, sex, Medicaid eligibility, institutional status, and whether a person has both part A and part B of Medicare. Separate AAPCCs are calculated usually by the county level and for Part A services and Part B services for the aged, disabled, and people with ESRD. Medicare pays risk plans by applying modification factors to 95 percent of the Part A and Part B AAPCCs. Adjustments are made so that the AAPCC represents the level of expenses that would occur if each county contained the same mix of beneficiaries. Medicare pays health plans 95 percent of the AAPCC, used for the characteristics of the enrollees in each plan. Adjusted Community Rate (ACR) - Health plans and insurance companies approximate their ACRs annually and adjust succeeding year supplemental benefits or premiums to return any excess Medicare revenue above the ACR to enrollees. This are the estimated payment charges 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 correspondence and service use. Adjusted drug benefit list - A small amount of medications often prescribed to long-term patient it is also called as drug maintenance list. A health plan, CMS or 3rd party administrator can change it from time to time. Adjusted per capita cost (APCC) - Medicare profit estimation for a person in a given county using sex, age, institutional status, Medicaid disability, and end stage renal disease position as a basis. Adjusted Community Rating (ACR) - ACR is a ranking by community influenced by certain group demographics. Estimated payment charge that health plans with Medicare risk contracts would have received for their Medicare enrollees if paid their private market premiums, adjusted for differences in profit packages and service use. Health plans estimate their ACRs yearly and adjust subsequent year supplemental benefits or premiums to return any excess Medicare income above the ACR to enrollees. Adjusted Payment Rate (APR) - The Medicare capitated expense to risk-contract HMOs. For a given health plan, the APR is explained by adjusting county-level AAPCCs to reflect the relative risks of the plan's enrollees. Administrative Code Sets - Code sets that illustrate a general business situation, rather than a medical condition or service. Under HIPAA, these are occasionally referred to as non-clinical or non-medical code sets. Administrative Costs - Costs which are related to utilization review, insurance marketing, medical underwriting, agent's commissions, premium collection, claims processing, insurer profit, quality assurance programs, and risk management. Administrative costs also refer to assured allowable costs on hospital CMS cost reports, usually considered overhead. Rules exist which prohibit certain expenses, such as marketing. Costs not linked straight away to the provision of medical care which includes marketing, claims processing, billing, and medical record keeping, among others. Administrative Services Organization (ASO) - The contract between an insurance company and a self-funded plan where the insurance company which performs administrative services only. And the self-funded unit assumes all risk. Administrative Services Only (ASO) - A relationship between an insurance company or other management unit and a self-funded plan or group of providers in which the insurance company or management unit performs administrative services only, such as billing, practice management, marketing, etc., and does not presume any risk. The client bears the economic risk for the claims. Clients contracting for ASO can contain health plans, hospitals, delivery networks, IPAs, etc. A provider system wishes to capitate might contract with a TPA for ASO for certain services for which the provider group does not want to transport in house. This is a structure of outsourcing. Administrative Simplification - HIPAA which authorizes HHS to adopt values for transactions and code sets that are used to exchange health data. Adopt standard identifiers for health plans, health care provider, employers, and individuals for use on standard transactions. Finally adopt standards to guard the security and privacy of personally identifiable health information. Admission Certification - The methods that assure only those patients who hospital needs care can admit. Certification can be approved before admission (preadmission) or shortly after (concurrent). Length-of-stay for the patient's diagnosed problem is usually assigned upon admittance under a certification program. Admissions Per 1,000 - The number of patients admitted to a hospital or hospitals per 1,000 health plan members. A pointer calculated by taking the total number of inpatient and outpatient admissions from a specific group, employer group. HMO population at risk, for a specific period of time, dividing it by the average number of enclosed members in that group during the same period, and multiplying the result by 1,000. This pointer can be calculated for behavioral health or any disease in the collective and by modality of treatment such as inpatient, residential, and partial hospitalization, etc. Admitting Physician - A physician who has the essential privileges at a hospital to admit patients for treatment care. Adverse Event - An injury to a patient resulting from a medical involvement. Adverse Selection- The problem of attracting members who are sicker than the common population. Specifically, members who are sicker than was anticipated when raising the budget for medical costs. An inclination for utilization of health services in a population group to be higher than average or the tendency for a person who is in poor health to be enrolled in a health plan where he or she is below the usual risk of the group. Some population parameter such as age that increases the potential for higher utilization and often increases expenses above those covered by a payer's capitation rate. Among applicants for a specified group or individual program, the tendency for those with an impaired health status, or who are prone to higher than average utilization of benefits, to be enrolled in uneven numbers and lower deductible plans. Affiliated Provider - A health care provider or facility which is part of the HMO's network frequently having formal arrangements to provide services to the HMO member. Affiliation - A contract between two or more otherwise independent entities or individuals that defines how they will relate to one another. Agreements between hospitals may identify procedures for referring or transferring patients. Agreements between providers may contain joint managed care contracting. Age/Sex Factor - To underwrite measurement representing the medical risk costs of one population compared to a different based on age and sex factors. Age/Sex rates (ASR) - It is also called as table rates. They are given group products' set of rates where every grouping, by age and sex, has its own rates. Rates are used to estimate premiums for group billing and demographic changes are adjusted automatically in the group. Admitting Physician - The method of establishing health insurance premiums whereby an insurer's premium is based on the age of persons when they first purchased health insurance coverage. This is an older form of actuarial measurement. Age-Attained Rating - Same as the above, this method is for establishing health insurance premiums whereby an insurer's premium is based on the present age of the beneficiary. Age-attained-rated premiums enlarge in price, as the purchasers grow older. Agency for Health Care Policy and Research (AHCPR) - The agency of the Public Health Service responsible for enhancing the quality, correctness and efficiency of health care services. Agent - A licensed individual who represents several insurance companies and sells their products. Aggregate Margin - This is actually computed by subtracting the sum of expenses for all hospitals in the collection from the sum of revenues and dividing by the sum of revenues. The total margin compares revenues to expenses for a group of hospitals, rather than one single hospital. Aggregate PPS Operating Margin/Aggregate Total Margin - This is calculated by subtracting the sum of expenses for all hospitals in the collection from the sum of revenues and dividing by the sum of revenues. A PPS operating margin or total margins that evaluate revenues to expenses for a group of hospitals, rather than a single hospital. Aggregate Stop Loss - The form of excess risk coverage that provides fortification for the employer against accumulation of claims exceeding a certain level. This is protection against abnormal occurrence of claims in total, rather than abnormal severity of a single claim. Aid to Families with Dependent Children (AFDC) - The centralized AFDC program provides cash welfare to the need for children who have been poor of parental support. And help certain others in the household of such child. States manage the AFDC program with funding from both the federal government and state. The Personal Responsibility & Work Responsibility Act of 1996, enacted in August 1996, replaced AFDC with a new plan called Temporary Assistance for Needy Families (TANF). All Inclusive Visit Rate - Total costs for any one patient visit based upon annual working costs divided by patient visits per year. This charge incorporates costs for all services at the visit. Allowable Charge - The most charge for which a third party will repay a provider for a given service. An allowable charge is not essentially the same as either a reasonable, customary, maximum, actual, or prevailing charge. Allowed Amount - Highest dollar amount assigned for a procedure based on various pricing mechanisms. It is also known as a maximum allowable. Allowed Charge - This is the amount Medicare approves for expense to a physician, but may not match the amount the physician gets paid by Medicare and usually does not equal to the physician charges patients. Medicare normally pays 80 percent of the standard charge and the beneficiary pays the remaining 20 percent. The allowed rate for a nonparticipating physician is 95 percent of that for a participating physician. Non-participating physicians may check beneficiaries for an additional amount above the allowed charge. The CMS agent in each state publishes these rates. Allowable Costs - Allowable cost is a covered expenses within a given health plan. Items or elements of an institution's costs, which are reimbursable below a payment formula. Allowable costs may exclude for luxury travel or marketing. Normally the costs which are not reasonable expenditures, which are unnecessary and for the efficient delivery of health services to persons covered under the program in question, are not reimbursed. The most general form of cost repayment is the "cost report" methodology used for DRG-exempt services, such as many out-patient hospital based programs, long-term care and skilled nursing units, physical rehab, psychiatric and essence abuse inpatient programs. Some specialty hospitals get all of their CMS repayment as cost based reimbursement. All Patient Diagnosis Related Groups (APDRG) - An improvement of the original DRGs, designed to relate to a population broader than that of Medicare beneficiaries, who are predominately older persons. The APDRG set includes groupings for pediatric and maternity cases as well as of services for HIV-related situation and other special cases. All-Payer System A system in which prices for strength services and payment methods are the same, regardless of who is paying. For example, in an all-payer system, federal or state government, a private insurer, a self-insured employer plan, an individual, or any other payer could give the same rates. The identical fee bars health care providers from changing costs from one payer to another. Alternate Delivery Systems - Health services provided in addition to an inpatient, acute-care hospital or private practice. An expression used to describe all forms of health care deliverance except traditional fee-for-service, private practice. The terms include HMOs, PPOs, IPAs, and other systems of providing health care. Alternate delivery systems are intended to provide needed services in a more cost-effective manner. Most of the services provided by the people mental health centers fall into this category. Ambulatory Care - Health services provided exclusive of the patient being admitted. It is also called outpatient care. The services of ambulatory care centers, hospital outpatient departments, physicians' offices and home health care services fall under this heading provided that the patient residue at the facility less than 24 hours. No all night stay in a hospital is required. Ambulatory Surgery - The surgery performed on a non-hospitalized patient. The patients depart home the same day as the surgery. Ancillary Services (Ancillary Charges) - Supplemental services, together with laboratory, radiology, physical therapy, and inhalation therapy that are provided in combination with medical or hospital care. Anniversary Date - The starting date of an employer group's benefit year. The first day of effective exposure as contained in the policy Group Application and subsequent annual anniversaries of that date. An insured has the choice to transfer from a protection plan which may have maximum benefit levels to an HMO. Anonymized Data - Previously particular data that have not been identified and for which a code or other link no longer exists. A contributor, third party or researcher would not be able to link anonymized information back to a specific individual. Anonymous Data - Under HIPAA, this is refers to data that were collected without identifiers and that were never associated to an individual. Coded data are not unspecified. ANSI - American National Standards Institute is a national organization founded to develop voluntary business standards in the United States. Antitrust - A legal term around a variety of efforts on the part of government to guarantee that sellers do not plot to restrain trade or fix prices for their goods or services in the market. Any Willing Provider - A condition that a health plans convention for the delivery of health care services with any other provider in the area who would like to provide such services to the plan's enrollees. Any Willing Provider Laws - The Laws that require managed care plans to contract with all health care providers that meet their terms and conditions. Appeal/Appeal Process - The formal procedure a provider and/or a Member can use to request review of a Health Plan decision. Application Integrators - The software which transparently provides application-to-application functionality, primarily through data conversion and transmission, while rejecting the need for custom programming. It is also referred to as application integration gateway, application interface gateway, integration engine, and intelligent gateway. This type of software is a key to developing networks of information systems, making client-specific information available in real time to all members of an IHDS. Appropriateness - Appropriate health care is care for which the predictable health benefit exceeds the expected negative consequences by a wide enough margin to validate treatment. This term is not to be puzzled with "usual and customary" or "approved" service. The amount to which a particular procedure, treatment, test, or service is clearly indicated, not excessive, adequate in quantity, and provided in the setting best suitable to a patient's or member's needs. Approval - A term used extensively to manage care and, to many, implies the primary process of "managing" managed care. Authorization usually is used to describe treatments or procedures that have been certified by utilization review. We can also refer to the status of certain hospitals or doctors, as members of a plan. It describes benefits or services, which will be covered under a plan. Normally, approval is either granted by the managed care organization (MCO), third party administrator (TPA) or by the primary care physician (PCP), depending on the conditions. Approved Charge - Limits of expenses salaried by Medicare in a given area of covered service. Charges accepted by payment by private health plans. Items those are likely to be reimbursed by the insurance company. Approved Health Care Facility, Hospital or Program - A facility or plan authorized to provide health services and permitted by a given health plan to provide services stipulated in contract. Assess/Assessment - Consideration of a problem or condition to estimate or judge the characteristics, qualities or attributes. Assignment of Benefits - The methods which are used when a claimant directs that payment be made directly to the health care provider by the health plan. Assisted Living - Wide range of residential care services, but does not include nursing services. Normally it is lower in cost than nursing homes. Attestation- The condition that the attending physician certify, in writing, the precision and completion of the clinical information used for DRG assignment. Audit of Provider Treatment or Charges - A qualitative or quantitative appraisal of services rendered or proposed by a health provider. The review can be accepted out in a number of ways: a comparison of patient reports and claim form information, a patient questionnaire, a review of hospital and practitioner records, or a pre- or post-treatment clinical examination of a patient. Some audits may engage fee verification. Something we had better obtain used to being subjected to since this is usually first type or "first generation" managed care approach. Autoassignment or Auto Assignment - A term used for Medicaid mandatory managed care enrollment plans. Medicaid recipients who do not identify their choice for a contracted plan within a specified time edge are assigned to a plan by the state. Authorization- Any text designating any permission. The HIPAA Privacy Rule requires authorization or waiver of authorization for the utilization or disclosure of identifiable health information for research. An authorization must include the following specific elements: a explanation of what information will be used and disclosed and for what purposes; a description of any information that will not be disclosed, if applicable; a list of who will disclose the information and to whom it will be disclosed; an termination date for the disclosure; a statement that the authorization can be revoked; a report that disclosed information may be redisclosed and no longer confined; a statement that if the individual does not provide an authorization, she/he may not be able to receive the intended treatment; the subject's signature and date. Authorized Representative - An individual certified by you to act on your behalf in pursuing payment of a claim, obtaining a referral or prior to the authorization or dealing with any level of the grievance process. Auto-Enrollment - The automatic obligation of a person to a health insurance plan, classically done under Medicaid plans. Availability - The amount to which services of the accurate type and quantity exist. Average Length of Stay (ALOS) - It refers to the average length of stay per inpatient hospital visit. It is typically calculated for both profitable and Medicare patient populations. Average Wholesale Price (AWP) - Frequently used in pharmacy contracting, the AWP is generally determined during reference to a common source of information. Average cost of a non-discounted item to a pharmacy provider by general providers. Drug manufacturers commonly publish recommended wholesale prices. Avoidable Hospital Condition - Medical analysis for which hospitalization could have been avoided if ambulatory care had been provided in a timely and proficient manner. |
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