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


Group Practice without Walls (GPWW)
Similar to an independent practice association, this type of physician group represents a legal and formal entity where certain services are provided to each physician by the entity, and the physician continues to practice in his/her own facility. It can include marketing, billing and collection, staffing, management, and the like. Also called clinic without walls.

Guaranteed Eligibility
A defined period of time (3-6 months) that all patients enrolled in prepaid health programs are considered eligible for Medicaid, regardless of their actual eligibility for Medicaid. A State may apply to CMS for a waiver to incorporate this into their contracts.

Guaranteed Issue
Requirement that health plans offer coverage to all businesses during some period each year.

Guaranteed Issue Rights
Rights that senior citizens have in certain situations when insurance companies are required by law to sell or offer them Medigap policies. In these situations, an insurance company can`t deny someone a policy, or place conditions on a policy, such as exclusions for pre-existing conditions, and can`t charge the citizen more for a policy because of past or present health problems. Also called Medigap Protections.

Guaranteed Renewable
A right that a senior citizen has that requires an insurance company to automatically renew or continue the citizen's Medigap policy, unless the citizen makes untrue statements to the insurance company, commits fraud or doesn't pay your premiums.

HAI
See Hospital-Acquired Infection.

HCFA 1500
The Health Care Finance Administration's standard form for submitting provider service claims to third party companies or insurance carriers. HCFA is now called CMS, see CMS. Also see UB-92.

HCQIA
See Health Care Quality Improvement Act.

HCQIP
See Health Care Quality Improvement Program.

Health
The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It is recognized, however, that health has many dimensions (anatomical, physiological, and mental) and is largely culturally defined. The relative importance of various disabilities will differ depending upon the cultural milieu and the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms or morbidity and mortality.

Health and Human Services (HHS)
The Department of Health and Human Services that is responsible for health-related programs and issues. Formerly HEW, the Department of Health, Education, and Welfare. The Office of Health Maintenance Organizations (OHMO) is part of HHS and detailed information on most companies is available here through the Freedom of Information Act.

Health Benefits Package
The services and products a health plan offers.

Health Care Clearinghouse
A public or private entity that does either of the following (Entities, including but not limited to, billing services, repricing companies, community health management information systems or community health information systems, and “value-added� networks and switches are health care clearinghouses if they perform these functions): 1) Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard d…

Health Care Operations
Institutional activities that are necessary to maintain and monitor the operations of the institution. Examples include but are not limited to: conducting quality assessment and improvement activities; developing clinical guidelines; case management; reviewing the competence or qualifications of health care professionals; education and training of students, trainees and practitioners; fraud and abuse programs; business planning and management; and customer service. Under the HIPAA Privacy Rule, …

Health Care Provider
Providers of medical or health care or researchers who provide health care are health care providers. Normally health care providers are clinics, hospitals, doctors, dentists, psychologists and similar professionals.

Health Care, Healthcare
Care, services, and supplies related to the health of an individual. Health care includes preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, among other services. Healthcare also includes the sale and dispensing of prescription drugs or devices.

Health Data Network
See Health Information Network.

Health Information
Information in any form (oral, written or otherwise) that relates to the past, present or future physical or mental health of an individual. That information could be created or received by a health care provider, a health plan, a public health authority, an employer, a life insurer, a school, a university or a health care clearinghouse. All health information is protected by state and federal confidentiality laws and by HIPAA privacy rules.

Health Information Network (HIN)
A computer network that provides access to a database of medical information. Also known as a health data network.

Health Insurance
Financial protection against the health care costs of the insured person. May be obtained in a group or individual policy.

Health Insuring Organization (HIO)
An organization that contracts with a state Medicaid agency as a fiscal intermediary.

Health Level Seven (HL7)
A data interchange protocol for health care computer applications that simplifies the ability of different vendor-supplied IS systems to interconnect. Although not a software program in itself, HL7 requires that each healthcare software vendor program HL7 interfaces for its products. Also see HIPAA.

Health of Seniors Survey
A CMS survey that measures Medicare patients' functional status.

Health Oversight Agency
Under HIPAA rules, this refers to a person or entity at any level of the federal, state, local or tribal government that oversees the health care system or requires health information to determine eligibility or compliance or to enforce civil rights laws.

Health Plan
An entity that assumes the risk of paying for medical treatments, i.e. uninsured patient, self-insured employer, payer, or HMO.

Health Promotion Programs
Preventive care programs designed to educate and motivate members to prevent illness and injury and to promote good health through lifestyle choices, such as smoking cessation and dietary changes. Also known as wellness programs.

Health Service Agreement (HSA)
Detailed explanation of procedures and benefits provided to an employer by a health plan. See also Statement of Benefits.

Health Status
The state of health of a specified individual, group, or population. It may be measured by obtaining proxies such as people's subjective assessments of their health; by one or more indicators of mortality and morbidity in the population, such as longevity or maternal and infant mortality; or by using the incidence or prevalence of major diseases (communicable, chronic, or nutritional). Conceptually, health status is the proper outcome measure for the effectiveness of a specific population's medi…

Healthcare Provider Taxonomy Codes
An administrative code set that classifies health care providers by type and area of specialization. The code set will be used in certain adopted transactions. (Note: A given provider may have more than one Healthcare Provider Taxonomy Code.)

Healthcare Quality
According 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.' See also Quality Improvement.

HEDIS
See Health Plan Employer Data and Information Set.

HHS
See Health and Human Services, above.

High-Cost Case
A patient whose condition requires large financial expenditures or significant human and technological resources.

High-Risk Case
A patient who has a complex or catastrophic illness or injury or who requires extensive medical interventions or treatment plans.

HIN
See Health Information Network.

HIO
See Health Insuring Organization.

HIPAA
See Health Insurance Portability and Accountability Act of 1996, above.

HIPC
See Health Insurance Purchasing Cooperative.

HL7
See Health Level Seven.

HMO
See Health Maintenance Organization.

HMSA
Health Manpower Shortage Area.

Home Health Care
Full range of medical and other health related services such as physical therapy, nursing, counseling, and social services that are delivered in the home of a patient, by a provider.

Hospice or Hospice Care
Facility or program providing care for the terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional and spiritual needs of the patient. Hospice also provides support to the patient`s family or caregiver as well. Hospice care is covered under Medicare Part A (Hospital Insurance).

Hospital
Any institution duly licensed, certified, and operated as a Hospital. In no event shall the term 'Hospital' include a convalescent facility, nursing home, or any institution or part thereof which is used principally as a convalescence facility, rest facility, nursing facility, or facility for the aged.

Hospital Affiliation
A contractual agreement between a health plan and one or more hospitals whereby the hospital provides the inpatient services offered by the health plan.

Hospital Alliances
Groups of hospitals joined together to share services and develop group-purchasing programs to reduce costs. May also refer to a spectrum of contracts, agreements or handshake arrangements for hospitals to work together in developing programs, serving covered lives or contracting with payers or health plans. See also Network, Integrated Delivery System, PHO, or Provider Health Plan.

Hospital Audit Companies
Retrospective audit providers that typically achieve a 15-20 percent savings of billed claims

Hospital Based Infection
Also called Hospital-Acquired Infection. See Nosocomial Infection

Hospital-Acquired Infection (HAI)
Hospital-acquired infections encompass almost all clinically evident infections that do not originate from patient's original admitting diagnosis. Within hours after admission, a patient's flora begins to acquire characteristics of the surrounding bacterial pool. Most infections that become clinically evident after 48 hours of hospitalization are considered hospital-acquired. Infections that occur after the patient's discharge from the hospital can be considered to have a nosocomial origin if th…

Hospitalists
Physicians who spend a substantial amount of their time in a hospital setting where they accept admissions to their inpatient services from local primary care providers. In most cases, hospitalists are employees of the hospital.

HPMS
See Health Plan Management System.

HPSA
See Health Professional Shortage Area.

HRA
See Health Risk Appraisal.

HSA
See Health Service Agreement.

Human Subject
Under HIPAA rules, this term refers to a living subject participating in research about whom directly or indirectly identifiable health information or data are obtained or created. IBNR

ICD-9-CM or ICD-10-CM
See International Classification of Diseases, below.

IDS or ISN
see Integrated Delivery System, below.

In-Plan Services
Services that are covered under the state Medicaid plan and included in the patient's managed care contract and/or are furnished by a participating provider.

Incentives
Profit sharing arrangements offered by HMOs and managed care plans that permit hospitals, providers, subcontractors and physicians to share in amounts earned from plan savings through reduced hospital and specialty referral usage. Normally, clinicians involved in profit-sharing will increase personal income or profit by reducing the quantity of care, supplies or services provided to patients. Consumers sometimes view these incentives as suspect, claiming profit sharing between health plans and p…

Incidence
In epidemiology, the number of cases of disease, infection, or some other event having their onset during a prescribed period of time in relation to the unit of population in which they occur. Incidence measures morbidity or other events as they happen over a period of time. Examples include the number of accidents occurring in a manufacturing plant during a year in relation to the number of employees in the plant, or the number of cases of mumps occurring in a school during a month in relation …

Incorporation by Reference
The method of making a document a part of a contract by referring to it in the body of the contract.

Incurred But Not Reported (IBNR)
Refers to a financial accounting of all services that have been performed but, as a result of a short period of time, have not been invoiced or recorded. Estimates of costs for medical services provided for which a claim has not yet been filed. Refers to claims that reflect services already delivered, but, for whatever reason, have not yet been reimbursed. These are bills 'in the pipeline.' This is a crucial concept for proactive providers who are beginning to explore arrangements that put them …

Incurred Claims
All claims with dates of service within a specified period.

Incurred Claims Loss Ratio
Incurred claims divided by premiums.

Indemnify
To make good a loss through compensation or reimbursement.

Indemnity
Health insurance benefits provided in the form of cash payments rather than services. Insurance program in which covered person is reimbursed for covered expenses. An indemnity insurance contract usually defines the maximum amounts that will be paid for covered services. Indemnity insurance plans may have a PPO option, UR and case management features, or include a network or other preferred provider restrictions, but will not have an HMO plan. Indemnity is the traditional form of insurance. Norm…

Indemnity Carrier
Usually an insurance company or insurance group that provides marketing, management, claims payment and review, and agrees to assume risk for its subscribers at some pre-determined rate.

Indemnity Wraparound Policy
An out-of-plan product that an HMO offers through an agreement with an insurance company.

Independent Agents
Agents that represent several health plans or insurers.

Independent External Review
An 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. Also see Appeal.

Individual Market
A market segment composed of customers not eligible for Medicare or Medicaid who are covered under an individual contract for health coverage.

Individual Plans
A type of insurance plan for individuals and their dependents who are not eligible for coverage through employer group coverage.

Individual Stop-Loss Coverage
A type of stop-loss insurance that provides benefits for claims on an individual that exceed a stated amount in a given period. Also known as specific stop-loss coverage.

Informed Consent
Refers to requirements (by HIPAA, Medicare, State and Federal Laws) that healthcare providers and researchers explain the purposes, risks, benefits, confidentiality protections, and other relevant aspects of the provision of medical care, a specific procedure or participation in medical research. Informed consent is also required for the authorization of release or disclosure of individually identifiable health care information, under HIPAA.

Inpatient Care
Health care given to a registered bed patient in a hospital, nursing home, skilled nursing, or other medical or post acute institution.

Insolvency
A legal determination occurring when a managed care plan no longer has the financial reserves or other arrangements to meet its contractual obligations to patients and subcontractors.

Institutional Review Board (IRB)
A group of medical professionals formed together for the purpose of providing peer review to protect the rights of human subjects in medical research and clinical trials. HIPAA privacy regulations require an IRB also to protect the privacy rights of research subjects in specific ways.

Intensive Care Management
Intensive community services for individuals with severe and persistent mental illness that are designed to improve planning for their service needs. Services include outreach, evaluation, and support.

Interface
A means of communication between two computer systems, two software applications or two modules. Real time interface is a key element in healthcare information systems due to the need to access patient care information and financial information instantaneously and comprehensively. Such real time communication is the key to managing health care in a cost effective manner because it provides the necessary decision-making information for clinicians, providers and payers.

Internal Medicine
Generally, that branch of medicine that is concerned with diseases that do not require surgery, specifically, the study and treatment of internal organs and body systems; it encompasses many subspecialties; internists, the doctors who practice internal medicine, often serve as family physicians to supervise general medical care.

Intervention Strategy
A generic term used in public health to describe a program or policy designed to have an impact on an illness or disease. Hence a mandatory seat belt law is an intervention designed to reduce automobile-related fatalities.

IPA or IPO
See Independent Practice Association.

J-Codes
A subset of the HCPCS Level II code set with a high-order value of 'J' that has been used to identify certain drugs and other items.

JCAHO
See Joint Commission on the Accreditation of Healthcare Organizations, below.

Job-Lock
Laws have now been enacted by congress which include continuance of benefits (COBRA) and other requirements which eliminate pre-existing clauses for those individuals who change coverage plans but have maintained continuance of coverage overall. The inability of individuals to change jobs because they would lose crucial health benefits.

Joint Venture
A type of partial structural integration in which one or more separate organizations combine resources to achieve a stated objective. For example, independent practice associations can share ownership of a venture and responsibility for its operations, but still maintain separate ownership and control over their operations outside of the joint venture.

Justice or Equity
An 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.

Key Contributor Plan
This refers to a little known performance-based program with incentives for the purpose of attracting, motivating and retaining key individuals or small groups.

Large Claim Pooling
System that isolates claims above a certain level and charges them to a pool funded by charges of all groups who share the pool. Designed to help stabilize significant premium fluctuations.

Large Group
A 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 MCO.

Large Local Groups
Accounts that contract on a local basis for group employee health benefits. Contrast with national accounts.

Large Urban Area
An urban statistical region with population of one million or more.

Legacy Systems
Computer applications, both hardware and software, which have been inherited through previous acquisition and installation. Most often, these systems run business applications that are not integrated with each other. Newer systems which stress open design and distributed processing capacity are gradually replacing such systems. This term is used frequently in discussing HIPAA and its computing requirements. See also HIPAA.

Legend Drug
Drug that the law says can only be obtained by prescription.

Length of Stay (LOS)
The duration of an episode of care for a covered person. The number of days an individual stays in a hospital or inpatient facility. May also be reviewed as Average Length of Stay (ALOS).

Licensing
A process most States employ, which involves the review and approval of applications from HMOs prior to beginning operation in certain areas of the State. Areas examined by the licensing authority include: fiscal soundness, network capacity, MIS, and quality assurance. The applicant must demonstrate it can meet all existing statutory and regulatory requirements prior to beginning operations.

Lifetime Limit
A cap on the benefits paid under a policy. For example, many policies have a lifetime limit of $1 million, which means that the insurer agrees to cover up to $1 million in covered services over the life of the policy.

Lifetime Reserve Days
In the Original Medicare Plan, a total of 60 extra days that Medicare will pay for when an enrollee is in a hospital more than 90 days during a benefit period. Once these 60 reserve days are used, the citizen does not get any more extra days during his or her lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.

Limited Data Set
Under HIPAA, this term refers to a set of data that may be used for research, public health or health care operations without an authorization or waiver of authorization. The limited data set is defined as PHI that excludes the following direct identifiers of the individual or of relatives, employers or household members of the individual: names; postal address information, (other than town or city, State and zip code); telephone and FAX numbers; electronic mail addresses; SSN; medical record nu…

Limiting Charge
The maximum amount that a non-participating physician is permitted to charge a Medicare beneficiary for a particularly defined procedure or bundled service. These limits are published by the individual state intermediaries for Medicare and CMS and are usually combined in reports with the allowed charges and regional payment schedules. In 1993, the limiting charge was set at 115 percent of the Medicare-allowed charge. The limiting charge is 15% over Medicare`s approved amount. The limiting charge…