Accreditation - ANSWER-Defined as "a self-assessment and external peer assessment process used by healthcare organizations to accurately assess their
... [Show More] level of performance in relation to established standards and to implement ways to continuously improve"
acute care - ANSWER-Medical attention given to patients with conditions of sudden onset that demand urgent attention or care of limited duration when the patient's health and wellness would deteriorate without treatment. The care is generally short-term rather than long-term or chronic care.
Acute Inpatient Care - ANSWER-A level of healthcare delivered to patients experiencing acute illness or trauma. Acute care is generally short-term (<30 days)
Advance Beneficiary Notice (ABN) - ANSWER-Written notice issued to a fee-for-service (Original Medicare) beneficiary before furnishing items or services that are usually covered by Medicare but are not expected to be paid in a specific instance for certain reasons, such as lack of medical necessity.
advance directive - ANSWER-healthcare directive or a living will, a legal document in which a person has outlined what they would like to be done if they are no longer able to make decisions for themselves due to incapacity or illness.
Ambulatory Services/Same-Day Surgery - ANSWER-Patient receives surgical treatment and is discharged from the facility within four to six hours of procedure. Services can occur in an outpatient hospital department or in a freestanding facility
Ancillary Services - ANSWER-Physician refers patients for scheduled and non-scheduled services such as radiology, laboratory, and/or other services that are performed in a hospital or clinic setting. Patients leave the facility once the services are completed.
Anti-Kickback Statute - ANSWER-Anti-fraud federal criminal statute that prohibits offering or exchange of anything of value in exchange for healthcare business referrals, including cash, rent, expensive hotel stays, etc.
Authorization Requirement - ANSWER-Certain services need authorizations while other procedures might not. Some insurance companies require a CPT code, so make sure you have that available.
batch processing - ANSWER-Execution of a series of jobs in a computer program without manual intervention; it is used to help maximize the use of computer resources and stabilize response time by performing system-intensive work during hours when users are less likely to require access.
Carve Out - ANSWER-A decision to separately purchase a service, which is typically a part of an indemnity of a Health Maintenance Organization (HMO) plan.
case management - ANSWER-Coordination of services to help meet a patient's healthcare needs.
Centers for Medicare and Medicaid Services (CMS) - ANSWER-Federal Agency under the Department of Health and Humans Services (HHS) that administers Medicare and partners with state governments for administration of Medicaid and other programs, including the Children's Health Insurance Program (CHIP)
CHAMPVA - ANSWER-The civilian health program for the Veterans Administration is an insurance program for the families of veterans.
Charity Care - ANSWER-Free or discounted medical care provided to patients who do not have the ability to pay for all or a part of medical costs due to limited income or financial hardship.
Co-insurance - ANSWER-The percentage amount that is payable, per policy provisions, toward medical costs after the deductible has been met.
Condition code 44 - ANSWER-Sometime a Medicare patient is admitted to a hospital as an inpatient but, upon internal review, the hospital determines the services did not meet inpatient criteria and the admission is changed to observation.
Co-payment - ANSWER-A payment that must be made by a covered person at the time of service.
Electronic Protected Health Information (ePHI) - ANSWER-Any protected health information identified under HIPAA that is produced, saved, received or transferred in an electronic format.
Deductible - ANSWER-The amount of eligible expenses a covered person must pay each year from his/her own pocket before the plan will begin to pay for eligible benefits.
DNV-GL Accreditation - ANSWER-DNV Healthcare is an accreditation organization approved by CMS in 2008 that has accredited approximately 500 hospitals.
Downtime - ANSWER-Time the computer system is unavailable to users.
Electronic Health Record (EHR) - ANSWER-A real-time digitized version of a patient's medical history that allows secure information access to authorized users. Standard clinical and medical data is gathered by a provider and stored in electronic files.
Emergency Medical Treatment and Labor Act (EMTALA) - ANSWER-"Anti-Dumping" statute. Federal law protecting patients against discrimination regardless of ability to pay; mandates patients receive a medical screening exam and stabilizing treatment when seeking emergency medical care or when in active labor.
emergency services - ANSWER-Patients examined on an unscheduled emergent basis for immediate treatment in the emergency facilities of a hospital. Depending on the outcome of the exam and treatment, the patient may be admitted as an observation patient, admitted to the facility as an inpatient, or transferred to another facility as deemed necessary by the physician.
Ethnicity - ANSWER-a social group that shares a common and distinctive culture, religion, language, or the like
Exclusions - ANSWER-Certain procedures are excluded from the plan. Asking the insurance company will let you know what services are not included and covered in the plan.
Fair Debt Collection Practices Act (FDCPA) - ANSWER-Federal law prohibiting debt collectors from using unfair, abusive or deceptive practices while attempting to collect from a consumer.
False Claims Act - ANSWER-Federal law targets fraud against the government. "Whistleblower's"/ qui tam provision allows non-government individuals to "blow the whistle" in good faith on fraud against the government who may receive up to 30 percent of any recovered damages.
HCAHPS - ANSWER-Also known as Hospital CAHPS, it stands for Hospital Consumer Assessment of Healthcare Providers and Systems and is a standardized survey of hospital patients that will capture patients' unique perspectives on hospital care for the purpose of providing the public with comparable information on hospital quality.
Health Exchange - ANSWER-Health Insurance Marketplace or "Exchange" - organizations that facilitate structured and competitive markets for purchasing health coverage.
Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) - ANSWER-Federal law stimulating the adoption of electronic health records and providing financial incentives for demonstrating meaningful use; also expanded HIPPA security and privacy rules and increased penalties; established data breach notification rules.
Health Insurance Portability and Accountability Act (HIPAA) - ANSWER-Originally focused on regulations related to health insurance portability' focused on administration simplification and reduction of cost through the protection and standardization of electronic and financial records. Most know for the privacy rule and security rule, these rules defined standards for healthcare and protected healthcare information (PHI)
HITECH Omnibus of 2013 - ANSWER-This update revised provisions that focused on an individual's right to request restrictions on the disclosure of PHI (restricted disclosure) and on an individual's right to access his or her PHI stored in an EHR.
Hospice - ANSWER-A non-profit organization dedicated to patients and families facing serious illness or death.
Icon - ANSWER-A graphic symbol for an application, file or folder
Important Message from Medicare (IMM) - ANSWER-A form given to all Medicare beneficiaries who are inpatients in participating hospitals explaining their rights and what to do if they feel they are being discharged early.
Insurance eligiblity - ANSWER-the person entitled to benefits and is covered. The date they became eligible for the plan is important to know since information can change from month to month along with the termination date of coverage.
level of service - ANSWER-The type of care a patient need for their stay. Intensive Care (ICU), step down, floor, observation and outpatient.
Lifetime Maximum - ANSWER-Many payers have a calendar year and a maximum limit on benefits paid.
Living Will - ANSWER-also known as medical directive, healthcare directive or an advance directive, a legal document in which a person has outlined what they would like to be done if they are no longer able to make decisions for themselves due to incapacity or illness.
Long Term Care - ANSWER-Generally provided to the chronically ill or disabled in a nursing facility or rest home. Among the services provided by nursing facilities: 24-hour nursing care, rehabilitative services such as physical and occupational therapy and speech therapy, as well as assistance with activities of daily living. Coverage for nursing facility care is available under both the Medicare and Medicaid programs. Medicare beneficiaries are eligible for up to 100 days of skilled nursing or rehabilitative care. Medicaid coverage is available for those who have exhausted their own resources and require public assistance to help pay for their care.
Meaningful Use (MU) - ANSWER-An incentive program established to provide monetary incentives for the adoption of health information technology and qualified electronic health records.
Medicaid - ANSWER-Covers low-income adults, children, pregnant women, elderly adults and individuals with disabilities.
Medically necessary - ANSWER-According to Medicare.gov, "medically necessary" is defined as "healthcare services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine."
Medicare Administrative Contractor (MAC) - ANSWER-A private healthcare insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims for Medicare Original beneficiaries.
Observation Notice - MOON - ANSWER-A form given to Medicare beneficiaries to inform them of their outpatient observation status and to explain to them what that may mean financially.
Medicare Savings Program - ANSWER-A program in which Medicaid pays Medicare premiums, deductibles and/or coinsurance costs for beneficiaries eligible for both programs. When a patient has this program, they are referred to as being dual eligible.
Medicare Secondary Payer (MSP) - ANSWER-Medicare-required questions to determine if there are any others payers or situations that may pay primary to Medicare.
Medicare Two-Midnight Rule - ANSWER-CMS rule stating that for a hospital admission to be paid for under Medicare Part A, the patient stay had to cross two midnights. Anything less than two midnights is paid for under Medicare Part B.
minimum necessary standard - ANSWER-Concept that people should only access, use or disclose the health information that is minimally necessary to accomplish a given task or purpose.
Modified Adjusted Gross Income (MAGI) - ANSWER-Methodology established by The Affordable Care Act to determine income eligibility based on taxable income and tax filing relationships.
Network - ANSWER-a group of two or more computer systems linked together
Observation Care - ANSWER-Those services furnished on a hospital's premises, including use of a bed and periodic monitoring by a hospital's nursing or other staff. Services should be reasonable and necessary to evaluate the need for a possible admission to the hospital as an inpatient. Observation services usually do not exceed 24 to 48 hours. Hospitals are not expected to substitute outpatient observation services for medically appropriate inpatient admission.
Out-of-pocket maximum - ANSWER-The total payments toward eligible expenses that a covered person funds for him/herself and/or dependents. These expenses may include deductibles, co-pays and coinsurance as defined by the contract.
outpatient care - ANSWER-Treatment received at a hospital, clinic or dispensary, but the patient is not hospitalized. Examples include: ancillary services, emergency services, ambulatory services/same-day surgery, specialty clinics, recurring services, long-term care, respite care, and hospice and palliative care.
palliative care - ANSWER-medical specialty focused on relief of pain, stress, and other debilitating symptoms of illness
Patient Contact Center - ANSWER-A central point in an organization from which all customer contacts are managed, including scheduling, pre-registration, pre-verification, prior authorization, functions, etc.
Patient Experience - ANSWER-The outcome of interactions between an organization and a customer as perceived through the customer's conscious and subconscious mind. It is especially important in determining HCAHPS reimbursement.
Patient Placement - ANSWER-Includes a request for a bed (inpatient, outpatient, observation, etc.). It involves the collection and documentation of the information necessary to determine that the requirements for the requested level of service are met.
patient portal - ANSWER-A secure online website that gives patients convenient 24-hour access to personal health information; patients have a secure user name and password to view their health information.
patient satisfaction - ANSWER-In evaluations of healthcare quality, patient satisfaction is a performance indicator measured in a self-report study and a specific type of customer satisfaction metric.
Personally Identifiable Information (PII) - ANSWER-Any type of information that can be used to identify a person such as name, Social Security number and medical record numbers.
Power of Attorney (POA) - ANSWER-Type of living will; this document authorizes a specific person to make decisions on their behalf when they have become incapacitated.
Pre-certification/Pre-authorization - ANSWER-Certain insurance companies notice from the Primary Care Physician (PCP) prior to services being performed.
Presumptive Eligibility - ANSWER-Hospitals and qualified physicians have the option of screening patients to see if they qualify for Medicaid. Based on the patient's self-attested answers to specific questions, they may be granted this temporary coverage but must complete the application process in order to keep the coverage.
Pricing Transparency - ANSWER-In healthcare, readily available information on the price of healthcare services that, together with other information, helps define the value of those services and enables patients and other care purchasers to identify, compare and choose providers that offer the desired level of value.
Propensity to pay - ANSWER-A means to evaluate payment risk, determine the most appropriate collection policy and initiate financial counseling discussions. Based on a scoring algorithm, programs can predict likelihood of payment. Those with a history of bad debt can be adjusted or forwarded to collections at the earliest point possible.
Protected Health Information (PHI) - ANSWER-Any information, as identified under HIPAA, that is produced, saved, received or transferred.
Recovery - ANSWER-Process of restoring data that has been accidently lost, corrupted or made unavailable, typically from an external storage system used for back-up.
Recurring Services - ANSWER-Physical therapy, occupational therapy, speech therapy, cardiac rehabilitation or pulmonary rehabilitation that occurs over time based on a clinician's order and evaluation by the clinical staff before and during the course of care.
respite care - ANSWER-Short-term care provided at home, in a long-term care facility, at a community based center, or in a hospital when another setting is not available. Allows families caring for elders or other mentally or physically dependent family members time off in their care-giving responsibilities. This type of care is not reimbursable through Medicare or Medicaid.
Restricted Disclosure - ANSWER-A patient's right to restrict PHI disclosure.
Server - ANSWER-a central computer dedicated to sending and receiving data from other computers (on a network).
Specialty Clinics - ANSWER-A patient is seen for specialized medical or surgical services and is discharged following treatment or care. This could be a series of recurring visits based on the duration of care according to the physician's order.
Telephone Consumer Protection Act (TCPA) - ANSWER-A federal law regulating the use of prerecorded messages and auto-dialers; safeguards consumer privacy by restricting unwanted telemarketing communications.
The joint Commission (TJC) - ANSWER-An independent, nonprofit organization that evaluates and accredits more than 21000 healthcare organizations in the United States.
The Patient Protection and Affordable Care Act or 2010 (PPACA) - ANSWER-Known as Obamacare, included reforms to affordability, quality and availability. It aimed to greatly increase the amount of Americans who have access to affordable health insurance; provided assistance for those with pre-existing conditions; extended dependent coverage up to age 26; required coverage of preventative services and immunizations; eliminated lifetime limits on benefits and expanded Medicaid coverage to more low-income Americans.
The Stark Law - ANSWER-A group of several federal laws that prohibit physician self-referral.
TRICARE - ANSWER-A healthcare program for military active, reservists, and retirees and families.
Unbundling - ANSWER-Fraudulent practice of breaking down services currently bundled together in one CPT code into individual codes for the purpose of higher reimbursement.
Upcoding - ANSWER-Process of assigning an inaccurate billing code for a medical procedure or treatment to increase reimbursement, considered to be a fraudulent billing practice.
Verification of Physician - ANSWER-Be sure to verify that the physician who will be treating the patient is on the panel of providers for the patient's insurance. This is especially important when a patient comes in who is unassigned (does not have a primary care physician) and will be accepted by the physician on call.
Veterans Administration (VA) - ANSWER-Largest integrated healthcare system in America serving veterans who served in the active military for at least 24 continuous months and were discharged or released under any condition other than dishonorable (some exceptions exist).
Veterans Choice Program - ANSWER-Program where the VA enrolled member is authorized to receive care from community-based providers.
Accepting Assignment - ANSWER-When a provider agrees to accept the allowable charges as the full fee and cannot charge the patient the difference between the insurance payment and the provider's normal fee.
access - ANSWER-The patient's ability to obtain medical care.
account number - ANSWER-A number assigned to each episode of care. This number is used to identify all charges and payments received.
Add-ons - ANSWER-Patients who are scheduled for services less than 24 hours in advance of the actual service time.
adjustor - ANSWER-Insurance company representative.
Administrative costs - ANSWER-Costs associated with creating and submitting a bill for services, which could include: registration, utilization review, coding, billing, and collection expenses.
Admission Authorization - ANSWER-The process of third party payer notification of urgent/emergent inpatient admission within specified time as determined by payers (usually 24-48 hours or next business day).
Admission Date - ANSWER-The first date the patient entered the hospital for a specific visit.
admitting diagnosis - ANSWER-Word, phrase, of International Classification of Disease (ICD10) code used by the admitting physician to identify a condition or disease from which the patient suffers and for which the patient needs or seeks medical care.
Admitting Physician - ANSWER-The physician who writes the order for the patient to be admitted to the hospital. This physician must have admitting privileges at the facility providing the healthcare services.
Adverse Selection - ANSWER-Among applicants for a given 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 disproportionate numbers and lower deductible plans.
alias - ANSWER-Name by which the patient is also "known as", or formerly known as.
All Patient Diagnosis Related Groups Assignment of Benefits (APDRG) - ANSWER-A prospective hospital claims reimbursement system currently utilized by the federal government Medicaid program.
alphanumeric - ANSWER-Letters, numbers, punctuation marks and mathematical symbols, as opposed to "numeric" which is numbers only. Term typically related to the kind of data accepted in a computer field or in coding.
ambulatory care Patient - ANSWER-Patient receives medical or surgical care in an outpatient setting that involves a broader, less specialized range of care.
Ambulatory Payment Classification (APC) - ANSWER-A system of averaging and bundling using Current Procedural Terminology (CPT) procedure codes, Healthcare Common Procedure Coding System (HCPCS) Level II, and revenue codes submitted for payment. The system utilizes groups of CPT codes based on clinical and resource similarity and establishes payment rates for each grouping.
ambulatory surgery center (ASC) - ANSWER-A freestanding facility, other than a physician's office, where surgical, diagnostic, and therapeutic services are provided on an outpatient basis.
Annual Maximum Benefit Amount Deductible - ANSWER-The maximum dollar amount set by a Managed Care Organization (MCO) that limits the total amount the plan must pay for all health care services provided to a subscriber in a year. A deductible is the set amount, per benefit year or period, the third party payor designates as the patient/guarantors responsibility. Usually the deductible must be paid before the benefits will be paid by the payor.
appeal - ANSWER-An appeal is a special kind of complaint made when a beneficiary or provider disagrees with decisions about health care services - typically related to payment issues.
Appropriate Care - ANSWER-A diagnostic or treatment measure whose expected health benefits exceed its expected health risks by a wide enough margin to justify the measure.
Assignment of benefits - ANSWER-Written authorization from the policyholder for their insurance company to pay benefits directly to the care provider. Normally acquired at the time of admission or registration.
attending physician - ANSWER-The physician who writes outpatient orders for tests, or supervises the patient's care during an inpatient stay.
Authorization - ANSWER-Approval obtained from an insurance carrier for a service that represents an agreement for payment.
Authorization to release information - ANSWER-The form authorizing to release information from the medical records to doctors, hospitals, insurance, other agencies, etc.
average daily census - ANSWER-The average number or inpatients maintained in the hospital for each day for a specific period of time
average length of stay - ANSWER-The average number of days of service rendered to each patient during a specific time period.
bad debt - ANSWER-An accounts receivable that is regarded as uncollectible and is charged as a credit loss even though the patient has the ability to pay.
balance billing - ANSWER-The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made.
behavioral health - ANSWER-Assessment and treatment of mental and/or psychoactive substance abuse disorders.
beneficiary - ANSWER-Person designated to receive the proceeds of an insurance policy; the insured under a health insurance policy.
Benefit Period - ANSWER-The number of days that Medicare covers care in hospitals and skilled nursing facilities are measured in benefit periods. A benefit period begins on the first day of services of a patient in a hospital or skilled nursing facility and ends 60 days after discharge from the hospital or skilled nursing facility if 60 days has not been interrupted by skilled care in any other facility.
Benefit Verification - ANSWER-Process of confirming benefits for services. The process of verification of demographic, financial and insurance information is second in importance only to the process of pre-certification.
Benefit Verification Period - ANSWER-The way Medicare measures the use of hospital and skilled nursing facilities. A benefit period begins on the day of admission to a hospital or skilled nursing facility and ends when the beneficiary has not received hospital or skilled nursing care for 60 days in a row. After the 60 days have elapsed a new benefit period begins. No limit on covered benefit periods.
Birthday rule - ANSWER-The rule used to determine whose insurance is primary for a child covered under both parents' insurance. Both insurance carriers must follow the birthday rule. The parent whos birthday falls earliest in the calendar year becomes the primary insurance and the other would be secondary. If both parents are born on the same day, the parent whos insurance has been in effect the longest is the primary insurance.
Capitation - ANSWER-A fixed rate of payment to cover a specified set of health services. The rate is usually provided on a per member/per month basis regardless of the services that are actually rendered.
Carrier - ANSWER-A health insurance plan or another entity that processes and pays healthcare bills. May be called a third party payer, payer, or insurer.
carve out - ANSWER-A decision to separately purchase a service, which is typically a part of an indemnity of a Health Maintenance Organization (HMO) plan. Carve outs may also include medical devices that the plan pays for in addition to the contracted per diem or case rate.
Case Mix Index (CMI) - ANSWER-This is adjusted each fiscal year for all hospitals based upon the case mix data received.
Centers for Disease Control and Prevention (CDC) - ANSWER-This department works with partners throughout the nation and the world to monitor health, detect and investigate health problems, conduct research to enhance prevention, develop and advocate sound public health policies, implement prevention strategies, promote [Show Less]