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Pohlys - Glossary of Health Care Terms
Category: Health and Medicine > Health Care
Date & country: 13/09/2007, USA
Words: 952


Board Eligible
Describes a physician who is eligible to take the specialty board examination by virtue of being graduated from an approved medical school, completing a specific type and length of training, and practicing for a specified amount of time. Some HMOs and other health facilities accept board eligibility as equivalent to board certification, significant in that many managed care companies restrict referrals to physicians without certification.

Bonus Payment
An 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. This is not to be confused with other payments to hospitals, such as the disproportionate share payment or the settlement made to facilities at the end of a cost report year.

Broker
A 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. One who represents an insured in solicitation, negotiation, or procurement of contracts of insurance, and who may render services incidental to those functions. By law, the broker may also be an agent of the insurer for certain purposes such as delivery of the policy or collection of the pr…

Bundled Payment
A single comprehensive payment for a group of related services. Bundled payments have become the norm in recent years and CMS and other payers investigate unbundled services closely. Unbundling service charges has been a common form of fraud as defined by CMS.

Business Associate
Under HIPAA rules, this term refers to an outside person/entity that performs a service on behalf of the health care provider (including a researcher) or the health care institution during which individually identifiable health information is created, used, or disclosed. For example, web hosting or data storage companies will be business associates if they receive protected health information. In addition, third parties that handle billing for a research study, or recruitment and screening, will…

Cafeteria Plan
Arrangements under which employees may choose their own benefit structure. Sometimes these are varying benefit plans or add-ons provided through the same insurer or 3rd party administrator, other times this refers to the offering of different plans or HMOs provided by different managed care or insurance companies.

Call Center
See Referral Center.

Capital Cost Report
Similar to the above review but normally produced retrospectively rather than prospectively.

Capital Costs
Capital costs usually involve equipment and physical plant costs, not consumable supplies. Included in these costs can be interest, leases, rentals, taxes and insurance on physical assets like plant and equipment. Capital costs are usually reimbursed to cost based facilities through submission of these costs on annual cost reports to the CMS intermediaries. Depreciation schedules apply.

Capital Expenditure Review
A review of proposed capital expenditures of hospitals or providers to determine the need for, and appropriateness of, the proposed expenditures. The review is usually done by a designated regulatory agency and has a sanction attached that prevents or discourages unneeded expenditures. Often this is related to CMS or Medicare and the willingness of the federal government to provide allowances for capital costs.

Capitation (Cap, Capped, Capitated)
Specified amount paid periodically to health provider for a group of specified health services, regardless of quantity rendered. Amounts are determined by assessing a payment 'per covered life' or per member. The method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered. The cost of providing an individual with a specific set of services over a set period of time, usually a month or a year. A payment sys…

Capped Fee
See Fee Schedule.

Captive Agents
Agents that represent only one health plan or insurer.

Carrier
An insurer; an underwriter of risk that finances health care. Also refers to any organization, which underwrites or administers life, health or other insurance programs. When an employer has a “self-insured� plan, the carrier (such as Aetna or Blue Cross) may not serve as carrier in this case, but may serve only as “third party administrator�.

Carve-In
A generic term that refers to any of a continuum of joint efforts between clinicians and service providers; also used specifically to refer to health care delivery and financing arrangements in which all covered benefits (e.g., behavioral and general health care) are administered and funded by an integrated system.

Carve-Out
The separation of a medical service (or a group of services) from the basic set of benefits in some way. Normally, the practice of excluding specific services from a managed care organization's capitated rate. In some instances, the same provider will still provide the service, but they will be reimbursed on a fee-for-service basis. In other instances, carved out services will be provided by an entirely different provider. A payer strategy in which a payer separates ('carves-out') a portion of t…

Case Management
The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services. Method designed to accommodate the specific health services needed by an individual through a coordinated effort to achieve the desired health outcome in a cost effective manner. The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services. The process by which all health-related matters o…

Case Manager
A nurse, doctor, or social worker who 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.

Case Mi
xThe 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. Measurement reflecting servicing needs, uses of hospital capabilities, and the general rate of hospital admissions. The types of inpatients a hospital or post acute facility treats. The more complex the patients' needs, the greater the amount spent for patient care. Case mix is generally established by estimating the rela…

Case Rate
Flat fee paid for a client's treatment based on their diagnosis and/or presenting problem. For this fee the provider covers all of the services the client requires for a specific period of time. Also bundled rate, or Flat Fee-Per-Case. Very often used as an intervening step prior to capitation. In this model, the provider is accepting some significant risk, but does have considerable flexibility in how it meets the client's needs. Keys to success in this mode: (1) properly pricing case rate, if …

Case Severity
A measure of intensity or gravity of a given condition or diagnosis for a patient. May have direct correlation with the amount of service provided and the associated costs or payments allowed.

Case-Mix Adjustment
See Risk Adjustment.

Case-Mix Index (CMI)
The 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. A measure of the relative costliness of treating in an inpatient setting. An index of 1.05 means that the facility's patients are 5 % more costly than average. See also DRG.

Catastrophic Coverage for Drugs
A specific term used in the Medicare Part D plans that refers to the event of a beneficiary's total drug costs reaching a certain maximum (in 2006 that maximum was $5451.25, for example), after which the beneficiary pays a small coinsurance (like 5%) or a small co-payment for covered drug costs until the end of that calendar year.

Catastrophic Health Insurance
Policy that provides protection primarily against the higher costs of treating severe or lengthy illnesses or disabilities. Normally these are 'add on' benefits that begin coverage once the primary insurance policy reaches its maximum.

Catastrophic Health Insurance
Health 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.

Categorically Needy
Medicaid eligibility based on defined indicators of financial need by families with children and pregnant women, and to persons who are aged, blind, or disabled. Persons not falling into these categories cannot qualify, no matter how low their income. The Medicaid statute defines over 50 distinct population groups as potentially eligible, including those for which coverage is mandatory in all states and those that may be covered at a state's option. The scope of covered services that states must…

CCA
See Cost Consequence Analysis.

CCN
See Community Care Network.

CCP
See Coordinated Care Plan.

CDT
see Current Dental Terminology.

Certificate of Authority (COA)
Issued by state governments, it gives a health maintenance organization or insurance company its license to operate within the state.

Certificate of Coverage (COC)
Outlines the terms of coverage and benefits available in a carrier's health plan.

Certificate of Creditable Coverage
A written certificate issued by a group health plan or health insurance issuer (including an HMO) that states the period of time that the beneficiary was covered by that health plan. These certificates are often required by plans prior to waiving or reducing the preexisting clauses in new coverages. Also see Pre-Existing.

Certificate of Need (CON)
In some states, a state agency must review and approve certain proposed capital expenditures, changes in health services provided, and purchases of expensive medical equipment. Before the request goes to the state, a local review panel (the health systems agency or HSA) must evaluate the proposal and make a recommendation. CON is intended to control expansion of facilities and services by preventing excessive or duplicative development of facilities and services. Many states have sunsetted or el…

Certified Health Plan
A 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. Regulations vary by state since some states require only HMOs to certify but not PPOs, IPAs or MSOs. Increasingly these regs are becoming more consistent state by state.

CF
See Conversion Factor.

Chain of Trust Agreement
Referred to in HIPAA rules, this is a contract needed to extend the responsibility to protect health care data across a series of sub-contractual relationships.

CHAMPUS
Civilian Health and Medical Program of the Uniformed Services, a federally managed health benefit plan. Also see TRICARE.

Charges
These are the published prices of services provided by a facility. CMS requires hospitals to apply the same schedule of charges to all patients, regardless of the expected sources or amount of payment. Controversy exists today because of the often wide disparity between published prices and contract prices. The majority of payers, including Medicare and Medicaid, are becoming managed by health plans that negotiate rates lower than published prices. Often these negotiated rates average 40% to 60%…

CHC
See Community Health Center.

CHIN
See Community Health Information Network.

Chronic Care or Chronic Case
Long term care of individuals with long standing, persistent diseases or conditions. It includes care specific to the problem as well as other measures to encourage self-care, to promote health, and to prevent loss of function.

Churning
The practice of a provider seeing a patient more often than is medically necessary, primarily to increase revenue through an increased number of services. Churning may also apply to any performance-based reimbursement system where there is a heavy emphasis on productivity (in other words, rewarding a provider for seeing a high volume of patients whether through fee-for-service or through an appraisal system that pays a bonus for productivity).

Claim
A request by an individual (or his or her provider) to that individual's insurance company to pay for services obtained from a health care professional. An 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.

Claim Form
An application for payment of benefits under a health plan.

Claim Status Codes
A national administrative code set that identifies the status of health care claims. This code set is used in the X12N 277 Claim Status Inquiry and Response transaction, and is maintained by the Health Care Code Maintenance Committee.

Claimant
The person or entity submitting a claim.

Claims Administration
The process of receiving, reviewing, adjudicating, and processing claims.

Claims Examiners
Employees in the claims administration department who consider all the information pertinent to a claim and make decisions about the MCO's payment of the claim. Also known as claims analysts.

Claims Investigation
The process of obtaining all the information necessary to determine the appropriate amount to pay on a given claim.

Claims Review
The method by which an enrollee's health care service claims are reviewed prior to reimbursement. The purpose is to validate the medical necessity of the provided services and to be sure the cost of the service is not excessive.

Class Rating
See Community Rating by Class.

CLIA
See Clinical Laboratory Improvement Amendments

Clinic Model
See Consolidated Medical Group.

Clinic Without Walls (CWW)
Similar to an independent practice association and identical to a practice without walls (PWW). Practitioners form CWWs and PWWs when they want the economies of scale and bargaining power offered by centralizing some administrative functions, but still choosing to practice separately. Many of these were formed to allow practitioners the ability to effectively contract with managed care. See Group Practice Without Walls.

Clinical Data Repository
That component of a computer-based patient record (CPR) which accepts, files, and stores clinical data over time from a variety of supplemental treatment and intervention systems for such purposes as practice guidelines, outcomes management, and clinical research. May also be called a data warehouse.

Clinical Decision Support
The capability of a data system to provide key data to physicians and other clinicians in response to 'flags' or triggers which are functions of embedded, provider-created rules. A system that would alert case managers that a client's eligibility for a certain service is about to be exhausted would be one example of this type of capacity. Also a key functional requirement to support clinical or critical pathways.

Clinical or Critical Pathways
A 'map' of preferred treatment/intervention activities. Outlines the types of information needed to make decisions, the timelines for applying that information, and what action needs to be taken by whom. Provides a way to monitor care 'in real time.' These pathways are developed by clinicians for specific diseases or events. Proactive providers are working now to develop these pathways for the majority of their interventions and developing the software capacity to distribute and store this infor…

Closed Access
A provision which specifies that plan members must obtain medical services only from network providers through a primary care physician to receive benefits. Gatekeeper model health plan that requires covered persons to receive care from providers within the plan's coverage. Except for emergencies, the patient may only be referred to and treated by providers within the plan. A managed health care arrangement in which covered persons are required to select providers only from the plan's participat…

Closed Formulary
The provision that only those drugs on a preferred list will be covered. Also see Formulary.

Closed Panel (HMO or PPO)
Medical services are delivered in the HMO-owned health center, individual offices of a closed panel PHO, or satellite clinic by physicians who belong to a specially formed, but legally separate, medical group. This term usually refers to a group or staff HMO models or closed PHO models. See also Any Willing Provider which describes a different model.

Closed Plan
Managed care plans that require covered persons to use participating providers

CMA
See Cost Minimization Analysis.

CMI
See Case-Mix Index.

CMP
See Competitive Medical Plan.

CMS (formerly HCFA)
See Centers for Medicare and Medicaid Services.

CMS (HCFA)
Now called CMS, CMS is the federal government agency within the Department of Health and Human Services which directs and oversees the Medicare and Medicaid programs (Titles XVIII and XIX of the Social Security Act) and conducts research to support those programs. It generally oversees the state's administrations of Medicaid, while directly administering Medicare. See CMS, or Center for Medicare and Medicaid Services.

CMS Hearing Officer
An individual designated by CMS to conduct the appeals process for a claim dispute.

CMS-1450
The uniform institutional claim form. See Centers for Medicare and Medicaid Services.

CMS-1500
The uniform professional claim form. See Centers for Medicare and Medicaid Services.

Co-Insurance (Coinsurance)
A cost-sharing requirement under a health insurance policy that provides that the insured will assume a portion or percentage of the costs of covered services. Health care cost which the covered person is responsible for paying, according to a fixed percentage or amount. A policy provision frequently found in major medical insurance policies under which the insured individual and the insurer share hospital and medical expenses according to a specified ratio. A type of cost sharing where the insu…

Co-Payment, Copayment, Copay
A cost-sharing arrangement in which the health plan enrollee pays a specified flat amount for a specific service (such as $10 for an office visit or $5 for each prescription drug). When first implemented, it was thought that the amount paid must be nominal to avoid becoming a barrier to care. However, the amounts of copays can vary widely from plan to plan, and, many now could be viewed as barriers to care. Copy normally does not vary with the cost of the service and is usually a flat sum amount…

COA
See Certificate of Authority.

COB
See Coordination of Benefits.

COBRA
See Consolidated Omnibus Budget Reconciliation Act.

COC
See Certificate of Coverage.

Code Set
Under HIPAA, this is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes both the codes and their descriptions.

Coded Data
Data are separated from personal identifiers through use of a code. As long as a link exists, data are considered indirectly identifiable and not anonymous or anonymized. Coded data are not covered by the HIPAA Privacy Rule, but are protected under the Common Rule.

Coding
A 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. A national c…

COI
see Cost of Illness Analysis.

Common Rule
Under HIPAA, it outlines the necessity of obtaining informed consent from patients.

Community Care Network (CCN)
This vehicle provides coordinated, organized, and comprehensive care to a community's population. Hospitals, primary care physicians, and specialists link preventive and treatment services through contractual and financial arrangements, producing a network that provides coordinated care with continuous monitoring of quality and accountability to the public. While the term, Community Care Network (CCN), often is used interchangeably with Integrated Delivery System (IDS), the CCN tends to be commu…

Community Health Center (CHC)
An ambulatory health care program (defined under section 330 of the Public Health Service Act) usually serving a catchment area which has scarce or nonexistent health services or a population with special health needs; sometimes known as the 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 direct…

Community Rating
Setting insurance rates based on the average cost of providing health services to all people in a geographic area, without adjusting for each individual's medical history or likelihood of using medical services. A method of calculating health plan premiums using the average cost of actual or anticipated health services for all subscribers within a specific geographic area. Under the HMO Act, community rating is defined as a system of fixing rates of payment for health services which may be deter…

Comorbid Condition
A medical condition that, along with the principal diagnosis, exists at admission and is expected to increase hospital length of stay by at least one day for most patients.

Competitive Bidding
Can be viewed by some as a pricing method that elicits information on costs through a bidding process to establish payment rates that reflect the costs of an efficient health plan or health care provider. Competitive bidding is also the process of offering reduced rates to health plans to obtain exclusive contracts from payers.

Competitive Medical Plan (CMP)
A type of MCO created by the 1982 Tax Equity and Fiscal Responsibility Act to facilitate the enrollment of Medicare beneficiaries into managed care plans. Competitive medical plans are organized and financed much like HMOs but are not bound by all the regulatory requirements facing HMOs. A health plan can be eligible for a Medicare risk contract if it meets specified requirements for service provision, capital, risk protection, and financial solvency. A status, established by TEFRA and granted b…

Complaint
A health plan member's expression that his expectations regarding the product or the services associated with the product have not been met. Also see Grievance and Appeal.

Compliance
Accurately following the government's rules on Medicare billing system requirements and other federal or state regulations. A compliance program is a self-monitoring system of checks and balances to ensure that an organization consistently complies with applicable laws relating to its business activities. (See also Fraud, FBI, OIG, and DOJ)

Compliance Date
This is specified date by which health plans and providers are to be in compliance with rules. Under HIPAA, this is the date by which a covered entity must comply with a standard, an implementation specification, or a modification. This is usually 24 months after the effective data of the associated final rule for most entities, but 36 months after the effective data for small health plans. For future changes in the standards, the compliance date would be at least 180 days after the effective da…

Complication
A medical condition that arises during a course of treatment and is expected to increase the length of stay by at least one day for most patients.

Composite Rate
Group rate billed to all subscribers of a given group.

Computer-Based Patient Record (CPR)
A term for the process of replacing the traditional paper-based chart through automated electronic means; generally includes the collection of patient-specific information from various supplemental treatment systems, i.e., a day program and a personal care provider; its display in graphical format; and its storage for individual and aggregate purposes. Also called “digital medical record�. See also Electronic Medical Record.

CON
See Certificate of Need.

Concurrent Review
Review of a procedure or hospital admission done by a health care professional (usually a nurse) other than the one providing the care, during the same time frame that the care is provided. Usually conducted during a hospital confinement to determine the appropriateness of hospital confinement and the medical necessity for continued stay. See also Utilization Review, Medical Necessity, Appropriate and Continued Stay Review.

Confidentiality
The protection of individually identifiable information as required by state or federal law or by policy of the healthcare provider.

Consent
See Authorization, and also see Informed Consent.

Consolidated Medical Group
A 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 known as a Medical Group Practice or Clinic Model.

Consumer Health Alliance
Regional cooperatives between government and the public that will oversee the new payment system. Once all health insurance purchasing cooperatives (HIPPC's), the alliance would make sure health plans within a region conformed to federal coverage and quality standards, and oversee costs within any mandated budget.