CCM Glossary of Terms Exam 98 Questions with Verified Answers
Care Mgmt - CORRECT ANSWER A healthcare delivery process that helps achieve better health
... [Show More] outcomes by anticipating and linking clients with the services they need more quickly. It also helps avoid unnecessary services by preventing medical problems from escalating.
Case Mgmt - CORRECT ANSWER A collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes.
Case-Based Review - CORRECT ANSWER The process of evaluating the quality and appropriateness of care based on the review of individual medical records to determine whether the care delivered is acceptable. It is performed by healthcare professional assigned by the hospital or an outside agency (e.g., Peer Review Organization [PRO]).
Continuous Quality Improvement CQI - CORRECT ANSWER a Key component of total quality mgmt that uses rigorous, systematic, organization-wide processes to achieve ongoing improvement in the quality of healthcare services and operation. It focuses on both outcomes and processes of care.
Effectiveness of Care - CORRECT ANSWER The extent to which care is provided correctly (i.e., to meet the patient's needs, improve quality of care, and resolve the pts problems), given the current state of knowledge, and the desired outcome is achieved.
Efficacy of Care - CORRECT ANSWER The potential, capacity or capability to produce the desired effect or outcome, as already shown, e.g. through scientific research (evidence-based) findings.
Efficiency of Care - CORRECT ANSWER The extent to which care is provided to meet the desired effects/outcomes to improve quality of care and prevent the use of unnecessary resources.
Integrated Delivery System IDS - CORRECT ANSWER A single organization or group of affiliated organizations that provides a wide spectrum of ambulatory and tertiary care and services. Care may also be provided across various settings of the healthcare continuum.
Intensity of Service - CORRECT ANSWER An acuity of illness criteria based on the evaluation/treatment plan, interventions, and anticipated outcomes.
Intermediate Outcome - CORRECT ANSWER A desired outcome that is met during a patient's hospital stay. It is a milestone in the care of a patient or a trigger point for advancement in the plan of care.
Managed Competition - CORRECT ANSWER A state of healthcare delivery in which a large number of consumers choose among health plans that offer similar benefits. In theory, competition would be based on cost and quality and ideally would limit high prices and improve quality of care.
Management Service Organization - CORRECT ANSWER A management entity owned by a hospital, physician organization, or third party. It contracts with payers and hospitals/physicians to provide certain healthcare management services such as negotiating fee schedules and handling administrative functions, including utilization management, billing, and collections.
Medical Loss Ratio MLR - CORRECT ANSWER The ratio of healthcare costs to revenue received. Calculated as total
medical expense divided by total revenue.
Medical Necessity on Admission - CORRECT ANSWER A type of review used to determine that the hospital admission is appropriate, clinically necessary, justified, and reimbursable.
Minimum Data Set MDS - CORRECT ANSWER The assessment tool used in skilled nursing facility settings to place patients into Resource Utilization Groups (RUGs), which determines the facilities reimbursement rate.
Outcome and Assessment Information Set OASIS - CORRECT ANSWER A prospective nursing assessment instrument completed by home health agencies at the time the patient is entered for home health services. Scoring determines the Home Health Resource Group (HHRG).
Outcome Indicators - CORRECT ANSWER Measures of quality and cost of care. Metrics used to examine and evaluate the results of the care delivered.
Outcomes Management - CORRECT ANSWER The use of information and knowledge gained from outcomes monitoring to achieve optimal patient outcomes through improved clinical decision making and service delivery.
Outcomes Measurement - CORRECT ANSWER The systematic, quantitative observation, at a point in time, of outcome indicators.
Outcomes Monitoring - CORRECT ANSWER The repeated measurement over time of outcome indicators in a manner that permits causal inferences about what patient characteristics, care processes, and resources produced the observed patient outcomes.
Outlier Threshold - CORRECT ANSWER The upper range (threshold) in length of stay before a patient's stay in a hospital becomes an outlier. It is the maximum number of days a patient may stay in the hospital for the same fixed reimbursement rate. The outlier threshold is determined by the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA).
Practice Guidelines - CORRECT ANSWER Systematically developed statements on medical practices that assist a practitioner in making decisions about appropriate diagnostic and therapeutic healthcare services for specific medical conditions. Practice guidelines are usually developed by authoritative professional societies and organizations such as the American Medical Association.
Primary Care - CORRECT ANSWER The point when the patient first seeks assistance from the medical care system. It also is the care of the simpler and more common illnesses.
Principal Procedure - CORRECT ANSWER A procedure performed for definitive rather than diagnostic treatment, or one
that is necessary for treating a certain condition. It is usually related to the primary diagnosis.
Quality Management - CORRECT ANSWER A formal and planned, systematic, organizationwide (or networkwide) approach to the monitoring, analysis, and improvement of organization performance, thereby continually improving the extent to which providers conform to defined standards, the quality of patient care and services provided, and the likelihood of achieving desired patient outcomes.
Resource Utilization Group (RUG) - CORRECT ANSWER Classifies skilled nursing facility patients into 7 major hierarchies and 44 groups. Based on the MDS, the patient is classified into the most appropriate group, and with the highest reimbursement.
Risk Management - CORRECT ANSWER The science of the identification, evaluation, and treatment of financial (and
clinical) loss. A program that attempts to provide positive avoidance of negative results.
Severity of Illness - CORRECT ANSWER An acuity of illness criteria that identifies the presence of significant/debilitating symptoms, deviations from the patient's normal values, or unstable/abnormal vital signs or laboratory findings.
Subacute Care Facility - CORRECT ANSWER A healthcare facility that is a step down from an acute care hospital and a step up from a conventional skilled nursing facility intensity of services.
Transitional Planning - CORRECT ANSWER The process case managers apply to ensure that appropriate resources and services are provided to patients and that these services are provided in the most appropriate setting or level of care as delineated in the standards and guidelines of regulatory and accreditation agencies. It focuses on moving a patient from most complex to less complex care setting.
Actionable Tort - CORRECT ANSWER A legal duty, imposed by statute or otherwise, owing by defendant to the one
injured.
Actuarial Study - CORRECT ANSWER Statistical analysis of a population based on its utilization of healthcare services and demographic trends of the population. Results used to estimate healthcare plan premiums or costs.
Capitation - CORRECT ANSWER A fixed amount of money per-member-per-month (PMPM) paid to a care provider for covered services rather than based on specific services provided. The typical reimbursement method used by HMOs. Whether a member uses the health service once or more than once, a provider who is capitated receives the same payment.
Captive - CORRECT ANSWER An insurance company formed by an employer to assume its workers' compensation and other risks, and provide services.
Carve out - CORRECT ANSWER Services excluded from a provider contract that may be covered through arrangements with other providers. Providers are not financially responsible for services carved out of their contract.
Case Rates - CORRECT ANSWER Rate of reimbursement that packages pricing for a certain category of services. Typically combines facility and professional practitioner fees for care and services.
Case Reserve - CORRECT ANSWER The dollar amount stated in a claim file which represents the estimate of the amount unpaid.
Coordination of Benefits (COB) - CORRECT ANSWER An agreement that uses language developed by the National Association of Insurance Commissioners and prevents double payment for services when a subscriber has coverage from two or more sources.
Current Procedural Terminology (CPT) - CORRECT ANSWER A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by health care providers and usually used for billing purposes.
Days per Thousand - CORRECT ANSWER A standard unit of measurement of utilization. Refers to an annualized use of the hospital or other institutional care. It is the number of hospital days that are used in a year for each thousand covered lives.
Demand Management - CORRECT ANSWER Telephone triage and online health advice services to reduce members' avoidable visits to health providers. This helps reduce unnecessary costs and contributes to better outcomes by helping members become more involved in their own care.
Diagnosis-Related Group (DRG) - CORRECT ANSWER A patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital. DRGs demonstrate groups of patients using similar resource consumption and length of stay. It also is known as a statistical system of classifying any inpatient stay into groups for the purposes of payment. DRGs may be primary or secondary; an outlier classification also exists. This is the form of reimbursement that the CMS uses to pay hospitals for Medicare and Medicaid recipients. Also used by a few states for all payers and by many private health plans (usually non-HMO) for contracting purposes.
Experience: - CORRECT ANSWER A term used to describe the relationship, usually in a percentage or ratio, of premium to claims for a plan, coverage, or benefits for a stated period of time. Insurance companies in worker's compensation report three types of experience to rating bureaus: 1) policy year experience; 2) calendar year experience; and 3) accident year experience. *Policy year experience: Represents the premiums and losses on all policies that go into effect within a given 12 month period. *Calendar Year Experience: Represents losses incurred and premiums earned within a given 12-month period. *Accident Year Experience: Represents accidents that occur within a given 12-month period and the premiums earned during that time.
Experience Rating: - CORRECT ANSWER The process of determining the premium rate for a group risk, wholly or partially on the basis of that group's experience.
Experience Refund: - CORRECT ANSWER A provision in most group policies for the return of premium to the policyholder because of lower than anticipated claims.
Group Model HMO: - CORRECT ANSWER The HMO contracts with a group of physicians for a set fee per patient to provide many different health services in a central location. The group of physicians determines the compensation of each individual physician, often sharing profits.
Health Maintenance Organization (HMO): - CORRECT ANSWER An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium. There are four basic models of HMOs: group model, individual practice association (IPA), network model, and staff model. Under the Federal HMO Act an organization must possess the following to call itself an HMO: (1) an organized system for providing healthcare in a geographical area, (2) an agreed-on set of basic and supplemental health maintenance and treatment services, and (3) a voluntarily enrolled group of people.
Home Health Resource Group (HHRG): - CORRECT ANSWER Groupings for prospective reimbursement under Medicare for home health agencies. Placement into an HHRG is based on the OASIS score. Reimbursement rates correspond to the level of home health provided.
Hospital-Issued Notice of Noncoverage (HINN): - CORRECT ANSWER A letter provided to patients informing them of insurance noncoverage in case they refuse hospital discharge or insist on continued hospitalization despite the review by the peer review organization (PRO) that indicates their readiness for discharge.
Indemnity: - CORRECT ANSWER Security against possible loss or damages. Reimbursement for loss that is paid in a predetermined amount in the event of covered loss.
Indemnity Benefits: - CORRECT ANSWER Benefits in the form of payments rather than services. In most cases after the provider has billed the patient, the insured person is reimbursed by the company.
Individual Practice Association (IPA) Model HMO: - CORRECT ANSWER An HMO model that contracts with a private practice physician or healthcare association to provide healthcare services in return for a negotiated fee. The IPA then contracts with physicians who continue in their existing individual or group practice.
Loss Expense Allocated: - CORRECT ANSWER That part of expense paid by an insurance company in settling a particular claim, such as legal fees, by excluding the payments to the claimant.
Managed Care: - CORRECT ANSWER A system of healthcare delivery that aims to provide a generalized structure and focus when managing the use, access, cost, quality, and effectiveness of healthcare services. Links the patient to provider services.
Medicaid Waiver: - CORRECT ANSWER Waiver Programs, authorized under Section 1915(C) of the Social Security Act, provide states with greater flexibility to serve individuals with substantial long-term care needs at home or in the community rather than in an institution. The federal government "waives" certain Medicaid rules. This allows a state to select a portion of the population on Medicaid to receive specialized services not available to Medicaid recipients.
Network Model HMO: - CORRECT ANSWER This is the fastest growing form of managed care. The plan contracts with a variety of groups of physicians and other providers in a network of care with organized referral patterns. Networks allow providers to practice outside the HMO.
Preferred Provider Organization (PPO): - CORRECT ANSWER A program in which contracts are established with providers of medical care. Providers under a PPO contract are referred to as preferred providers. Usually the benefit contract provides significantly better benefits for services received from preferred providers, thus encouraging members to use these providers. Covered persons are generally allowed benefits for nonparticipating provider services, usually on an indemnity basis with significant copayments.
Prospective Payment System: - CORRECT ANSWER A healthcare payment system used by the federal government since 1983 for reimbursing healthcare providers/agencies for medical care provided to Medicare and Medicaid participants. The payment is fixed and based on the operating costs of the patient's diagnosis.
Relative Weight: - CORRECT ANSWER An assigned weight that is intended to reflect the relative resource consumption associated with each DRG. The higher the relative weight, the greater the payment/reimbursement to the hospital.
Staff Model HMO: - CORRECT ANSWER The most rigid HMO model. Physicians are on the staff of the HMO with some sort of salaried arrangement and provide care exclusively for the health plan enrollees.
Utilization: - CORRECT ANSWER The frequency with which a benefit is used during a 1-year period, usually expressed in occurrences per 1000 covered lives.
Utilization Management: - CORRECT ANSWER Review of services to ensure that they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.
Utilization Review: - CORRECT ANSWER A mechanism used by some insurers and employers to evaluate healthcare on the basis of appropriateness, necessity, and quality.
Withhold: - CORRECT ANSWER A portion of payments to a provider held by the managed care organization until year end that will not be returned to the provider unless specific target utilization rates are achieved. Typically used by HMOs to control utilization of referral services by gatekeeper physicians.
Advance Directives: - CORRECT ANSWER Legally executed document that explains the patient's healthcare-related wishes and decisions. It is drawn up while the patient is still competent and is used if the patient becomes incapacitated or incompetent.
Autonomy: - CORRECT ANSWER A form of personal liberty of action in which the patient holds the right and freedom to select and initiate his or her own treatment and course of action, and taking control for his or her health; that is, fostering the patient's independence and self-determination.
Beneficence: - CORRECT ANSWER The obligation and duty to promote good, to further and support a patient's legitimate interests and decisions, and to actively prevent or remove harm; that is, to share with the patient risks associated with a particular treatment option.
Distributive Justice: - CORRECT ANSWER Deals with the moral basis for the dissemination of goods and evils, burdens and benefits, especially when making decisions regarding the allocation of healthcare resources.
Ex Parte: - CORRECT ANSWER A judicial proceeding, order, injuction, and so on, taken or granted at the instance and for the benefit of one party only, and without notice to, or contestation by, any person adversely interested.
Interrogatories: - CORRECT ANSWER A set or series of written questions composed for the purpose of being propounded to a party in equity, a garnishee, or a witness whose testimony is taken in a deposition.
Living will: - CORRECT ANSWER A legal document that directs the healthcare team/provider in holding or withdrawing life support measures. It is usually prepared by the patient while he or she is competent, indicating the patient's wishes.
Medical Durable Power of Attorney: - CORRECT ANSWER A legal document that names a surrogate decision maker in
the event that the patient becomes unable to make his or her own healthcare decisions.
Nonmaleficence: - CORRECT ANSWER Refraining from doing harm to others; that is, emphasizing quality care outcomes.
Petition: - CORRECT ANSWER An application to a court ex parte paying for the exercise of the judicial powers of the court in relation to some matter that is not the subject for a suit or action, or for authority to do some action that requires the sanction of the court.
Remand: - CORRECT ANSWER To send back, as in sending a case back to the same court out of which it came for purposes of having some action taken on it there.
Remedy: - CORRECT ANSWER The means by which a right is enforced or the violation of a right is prevented, redressed, or compensated.
Respondeat Superior: - CORRECT ANSWER Literally, "let the master respond." This maxim means that an employer is liable in certain cases for the wrongful acts of his/her employees, and the principal for those of his/her agency.
Tort: - CORRECT ANSWER A civil wrong for which a private individual may recover money damages, arising from a breach
of duty created by law.
Tort Liability: - CORRECT ANSWER The legal requirement that a person responsible, or at fault, shall pay for the damages and injuries caused.
Tort-Feasor: - CORRECT ANSWER A wrong-doer who is legally liable for damage caused.
Veracity: - CORRECT ANSWER The act of telling the truth.
Case Mix Complexity: - CORRECT ANSWER An indication of the severity of illness, prognosis, treatment difficulty, need for intervention, or resource intensity of a group of patients.
Case Mix Group (CMG): - CORRECT ANSWER Each CMG has a relative weight that determines the base payment rate for inpatient rehabilitation facilities under the Medicare system.
Case Mix Index (CMI): - CORRECT ANSWER The sum of DRG-relative weights of all patients/cases seen during a 1-year period in an organization, divided by the number of cases hospitalized and treated during the same year.
Concurrent Review: - CORRECT ANSWER A method of reviewing patient care and services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form of utilization review that tracks the consumption of resources and the progress of patients while being treated.
Core Therapies: - CORRECT ANSWER Basic therapy services provided by professionals on a rehabilitation unit. Usually refers to nursing, physical therapy, occupational therapy, speech-language pathology, neuropsychology, social work and therapeutic recreation.
Sensory Aphasia: - CORRECT ANSWER Inability to understand the meaning of written, spoken or tactile speech symbols because of disease or injury to the auditory and visual brain centers.
Sentinel Event: - CORRECT ANSWER An unexpected occurrence, not related to the natural course of illness, that results in death, serious physical or psychological injury, or permanent loss of function.
Accreditation: - CORRECT ANSWER A standardized program for evaluating healthcare organizations to ensure a specified level of quality, as defined by a set of national industry standards. Organizations that meet accreditation standards receive an official authorization or approval of their services. Accreditation entails a voluntary survey process that assesses the extent of a healthcare organization's compliance with the standards for the purpose of improving the systems and processes of care (performance) and, in so doing, improving patient outcomes.
Benchmarking: - CORRECT ANSWER An act of comparing a work process with that of the best competitor. Through this process one is able to identify what performance measure levels must be surpassed. Benchmarking assists an organization in assessing its strengths and weaknesses and in finding and implementing best practices.
Credentialing: - CORRECT ANSWER A review process to approve a provider who applies to participate in a health plan. Specific criteria are applied to evaluate participation in the plan. The review may include references, training, experience, demonstrated ability, licensure verification, and adequate malpractice insurance.
Ergonomics (or human factors): - CORRECT ANSWER The scientific discipline concerned with the understanding of interactions among humans and other elements of a system. It is the profession that applies theory, principles, data and methods to environmental design (including work environments) in order to optimize human well-being and overall system performance.
Standards of Care: - CORRECT ANSWER Statements that delineate care that is expected to be provided to all clients. They include predefined outcomes of care clients can expect from providers and are accepted within the community of professionals, based upon the best scientific knowledge, current outcomes data, and clinical expertise.
Standards of Practice: - CORRECT ANSWER Statements of acceptable level of performance or expectation for professional intervention or behavior associated with one's professional practice. They are generally formulated by practitioner organizations based upon clinical expertise and the most current research findings.
Utilization Review Accreditation Commission (URAC): - CORRECT ANSWER A not-for-profit organization that provides reviews and accreditation for utilization review services/programs provided by freestanding agencies. It is also known as the American Accreditation Health Care Commission.
CARF: - CORRECT ANSWER Commission on Accreditation of Rehabilitation Facilities. A private, non-profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards.
Habilitation: - CORRECT ANSWER The process by which a person with developmental disabilities is assisted in acquiring and maintaining life skills to: 1) cope more effectively with personal and developmental demands; and 2) to increase the level of physical, mental, vocational and social ability through services. Persons with developmental disabilities include anyone whose development has been delayed, interrupted or stopped/fixed by injury or disease after an initial period of normal development, as well as those with congenital condition.
Inclusive Education: - CORRECT ANSWER An educational model in which students with disabilities receive their education in a general educational setting with collaboration between general and special education teachers. Implementation may be through the total reorganization and redefinition of general and special education roles, or as one option in a continuum of available services. [Show Less]