access |
A patient's ability to obtain medical care.
The ease of access is determined by components
such as the availability of medical services
and their acceptability to the patient, availability
of insurance, the location of health care facilities,
transportation, hours of operation, affordability
and cost of care. |
accreditation
|
Approval by an authorizing
agency for institutions and programs that meet
or exceed a set of pre-determined standards.
|
activities
of daily living (ADLs)
|
Activities
performed as part of a person's daily routine
of self-care such as bathing, dressing, toileting
and eating. |
acute
care
|
Hospital
care given to patients who generally require
a stay of several days that focuses on a physical
or mental condition requiring immediate intervention
and constant medical attention, equipment and
personnel. |
administrative
costs
|
Costs
related to activities such as utilization review,
marketing, medical underwriting, commissions,
premium collection, claims processing, insurer
profit, quality assurance and risk management
for purposes of insurance. |
advanced
practice nurse (APN)
|
A
registered nurse who is approved by the Board
of Nursing to practice
nursing in a specified area of advanced nursing
practice. APN is an umbrella term given to a
registered nurse who has met advanced educational
and clinical practice requirements beyond the
two to four years of basic nursing education
required of all RNs. There are four types: 1)
certified registered nurse anesthetist (CRNA);
2) clinical nurse specialist (CNS); 3) certified
nurse practitioner (CNP); and 4) certified nurse
midwife (CNM). |
adverse
drug event (error)
|
Any
incident in which the use of medication (drug
or biologic) at any dose, a medical device,
or a special nutritional product may have resulted
in an adverse outcome in a patient.
|
adverse
event
|
An
injury resulting from a medical intervention
that is not due to the underlying condition
of the patient. |
adverse
selection
|
Among
applicants for a given group or individual health
insurance program, the tendency for those with
an impaired health status, or those who are
prone to higher-than-average utilization of
benefits, to be enrolled in disproportionate
numbers in lower deductible plans. |
aftercare
|
Services
following hospitalization or rehabilitation,
individualized for each patient's needs. Aftercare
gradually phases the patient out of treatment
while providing follow-up attention to prevent
relapse. |
Agency
for Healthcare Research and Quality
(AHRQ)
|
A
federal agency within the Public Health Service
responsible for research on quality, appropriateness
and cost of health care. AHRQ also centralizes
access to state inpatient data. www.ahrq.gov |
allied
health personnel
|
Specially
trained and often licensed health workers other
than physicians, dentists, optometrists, chiropractors,
podiatrists and nurses. The term is sometimes
used synonymously with paramedical personnel,
which are all health workers who perform tasks
that must otherwise be performed by a physician,
or health workers who do not usually engage
in independent practice. |
allopathic
|
One
of two schools of medicine that treat disease
by inducing effects opposite to those produced
by the disease. The other school of medicine
is osteopathic. |
allowable
costs
|
Charges
for services rendered or supplies furnished
by a health provider that qualify as covered
expenses for insurance purposes.
|
alternative
delivery
|
An
alternative to traditional inpatient care system
such as ambulatory care, home health care and
same-day surgery. |
alternative
medicine
|
Treatment
procedures that are not supported by mainstream
medicine, often due to lack of supporting experimental
data. |
am.
|
Amended.
A designation sometimes found before a House
or Senate bill number showing that formal changes
have been made to an introduced piece of legislation
during the legislative process. |
ambulance
restocking
|
The
practice of a hospital replenishing certain
drugs and supplies used by an ambulance service
during transport of a patient to the hospital.
|
ambulatory
care
|
Care
given to patients who do not require overnight
hospitalization. |
ambulatory
patient group (APG) |
The Medicare program's
prospective payment system for outpatient services
and procedures. Each APG is a classified medical
service or procedure. Unlike diagnosis related
group reimbursement for inpatient care, where
medical events are condensed into one diagnostic
related group, an outpatient visit can combine
several different APGs. |
ambulatory
payment classification (APC)
|
Groups or groupings of medical procedures and
services used as a basis for reimbursement under
the Medicare outpatient prospective payment
system. |
ambulatory
setting
|
An
institutional health setting in which organized
health services are provided on an outpatient
basis, such as a surgery center, clinic or other
outpatient facility. Ambulatory care settings
also may be mobile units of service (e.g., mobile
mammography, MRI). |
ambulatory
surgical facility |
see
freestanding outpatient surgical center
|
American
Accreditation Healthcare Commission (AAHC)
|
An independent not-for-profit corporation that
develops national standards for utilization
review and managed care organizations. www.urac.org
|
American
College of Healthcare Executives
(ACHE)
|
An
international professional society of nearly
30,000 health care executives based in Chicago.
www.ache.org
|
American
Health Care Association (AHCA)
|
A
trade association representing nursing homes
and long-term care facilities in the U.S. based
in Washington, D.C. www.ahca.org
|
American
Hospital Association (AHA)
|
A national association that represents allopathic
and osteopathic hospitals in the U.S. AHA is
based in Washington, D.C., with operational
offices in Chicago. www.aha.org
|
American
Medical Association (AMA)
|
A
national association organized into local and
regional societies that represents over 700,000
medical doctors in the United States. AMA is
based in Chicago. www.ama-assn.org
|
American
Osteopathic Association (AOA)
|
A
national association organized into local and
regional societies that represents over 43,000
osteopathic physicians in the United States.
AOA is based in Chicago and also provides accreditation
for hospitals and colleges of osteopathic medicine.
www.osteopathic.org |
American Society for Clinical
Laboratory Science (ASCLS) |
An
organization for clinical laboratory science
practitioners, providing leadership and promoting
all aspects of clinical laboratory science
practice, education and management to ensure
cost-effective laboratory services for health
care consumers. www.ascls.org
|
American Society for Clinical
Pathology (ASCP) |
A national resource
for the enhancement of the quality of the practice
of pathology and laboratory medicine.
www.ascp.org |
Americans
with Disabilities Act (ADA)
|
A
federal law that prohibits employers of more
than 25 employees from discriminating against
any individual with a disability who can perform
the essential functions, with or without accommodations,
of the job that the individual holds or wants.
www.usdoj.gov/crt/ada/adahom1.htm
|
ancillary
|
A
term used to describe additional services performed
related to care, such as lab work, X-ray and
anesthesia. |
anti-kickback
statute
|
A
federal law that prohibits the paying or receiving
of remuneration in exchange for the referral
of patients or business paid by a federal health
care program. |
antitrust
|
A
situation in which a single entity, such as
an integrated delivery system, controls enough
of the practices in any one specialty in a relevant
market to have monopoly power (e.g., the power
to increase prices). |
any
willing provider
|
A
term used to describe legislation requiring
a health plan to accept on its provider panels
every physician, hospital or other practitioner
that wants to participate in the health plan’s
products. |
approved
health care facility or program
|
A
facility or program that is licensed, certified
or otherwise authorized pursuant to the laws
of the state to provide health care and that
is approved by a health plan to provide the
care described in a contract. |
associate
degree in nursing (ADN)
|
A
degree received after completing a two-year
nursing education program at a college or university
that qualifies a nurse to take a national licensing
exam (NCLEX) to become a registered nurse.
|
attorney
general |
Chief law enforcement
officer of a state, responsible for advising
the state or nation of legal matters. |
average
adjusted per capita cost (AAPCC)
|
Payment
rates used by the Centers for Medicare &
Medicaid Services to reimburse managed care
organizations for care delivered to Medicare
enrollees.
|
average
length of stay (ALOS) |
A standard hospital statistic used to determine
the average amount of time between admission
and departure for patients in a diagnosis related
group, an age group, a specific hospital or
other factors. |
avian (or bird) flu |
Caused
by influenza viruses that occur naturally among
wild birds. The H5N1 variant is deadly to domestic
fowl and can be transmitted from birds to humans.
There is no human immunity and no vaccine is
available. (see also seasonal
flu and pandemic
flu) |
bachelor
of science in nursing (BSN)
|
A
degree received after completing a four-year
college or university program that qualifies
a graduate nurse to take a national licensing
exam (NCLEX) to become a registered nurse.
|
bad debt |
Results
when patients do not pay bills for which payment
was expected. It occurs for a variety of reasons,
such as when uninsured patients have incomes
above the guidelines for charity care, but
still cannot afford the cost of their care. |
balance
billing
|
A
provider's billing of a covered person directly
for charges above the amount reimbursed by the
health plan. This may or may not be allowed,
depending upon the contractual arrangements
between the parties. |
Balanced
Budget Act of 1997 (BBA)
|
A
federal law enacted by U.S. Congress that makes
numerous changes to various titles of the Social
Security Act, contains significant changes to
the Medicare and Medicaid programs, and creates
a new Title XXI, the State Children's Health
Insurance Program (SCHIP). Payment reductions
and other changes enacted under the BBA likely
will continue to be the focus of advocacy efforts
for hospitals and other providers throughout
the early 21st century. |
Balanced
Budget Refinement Act of 1999 (BBRA)
|
A
federal law enacted by U.S. Congress that restores
an estimated $17 billion to the Medicare program.
The law provides relief for hospitals, and includes
special packages for rural and teaching hospitals,
nursing homes and home health agencies.
|
behavioral
health care
|
Mental
health services, including services for alcohol
and substance abuse. |
benchmarking
|
A
method of comparing the procedures and results
of a process, system or operation under study
with a similar process, system or operation
under study that is generally recognized as
outstanding. |
beneficiary
|
A person designated by an insuring
organization as eligible to receive insurance
benefits. |
Benefits
Improvement and Protection Act of 2000 (BIPA)
|
A
federal law enacted by U.S. Congress that, among
other provisions, restores an estimated $11.5
billion over five years to hospitals under Medicare,
Medicaid and other federal and state health
care programs. |
Blue
Cross and Blue Shield Association (BC/BS)
|
An
organization that offers information, consultation,
representation and operational services for
the Blue Cross and Blue Shield plan members
across the country for purposes of providing
insurance benefits. www.bluecares.com
|
board
certified
|
A
clinician who has passed the national examination
in a particular field. Board certification is
available for most physician specialties, as
well as for many allied medical professions.
|
capitation
(CAP)
|
A
stipulated dollar amount established to cover
the cost of health care delivered for a person
or group of persons. The term usually refers
to a negotiated per capita rate to be paid periodically,
usually monthly, to a health care provider.
The provider is responsible for delivering or
arranging for the delivery of all health services
required by the covered person(s) under the
conditions of the contract. |
captive
insurance |
A wholly owned subsidiary
of a business or other legal entity, including
a group of hospitals or trade associations,
that is formed to insure risk. A captive
is a form of self-insurance that has assumed
the formalities of an insurance company. |
careLearning
|
An
online education service of more than 40 state
hospital associations along with the American
Hospital Association (AHA) for the purpose
of delivering more cost-effective education
to hospitals.
www.carelearning.com |
CARE
System
|
The Core Analysis Research Evolution (CARE)
System is a set of process measures used for
quality improvement. The system meets Joint
Commission and CMS core measurement requirements.
|
carrier |
The Medicare Part
B claims processing contractor. |
case
manager
|
A
health care professional who monitors the allocation
and coordination of a patient's overall care.
|
case
mix index
|
A
measure of relative severity of medical conditions
of a hospital's patients. |
Centers
for Disease Control and Prevention (CDC)
|
An agency within the U.S. Department of Health
and Human Services that serves as the central
point for consolidation of disease control data,
health promotion and public health programs.
www.cdc.gov |
Centers for Medicare & Medicaid Services
(CMS)
|
An agency within the U.S. Department of Health
and Human Services responsible for the administration
of the Medicare and Medicaid programs. Formerly
called the Health Care Financing Administration.
www.cms.gov |
charity care
|
Health
care provided at a substantial discount to
those unable to pay. Hospitals either do not
attempt to collect a portion of charges or
agree to write off charges. Eligibility is
sometimes determined from a sliding scale
based on a percentage of the patient's income
above the federal poverty level. |
Children’s
Health Insurance
Program (CHIP)
|
A
state-administered program funded partly by
the federal government that allows states to
expand health coverage to uninsured, low-income
children not eligible for Medicaid. Also called
State Children’s Health Insurance Program
(SCHIP). www.hcfa.gov/INIT/CHILDREN.HTM
|
Civilian
Health and Medical Program of the Uniformed
Services (CHAMPUS)
|
A
program that provides funds to pay for the treatment
in private institutions for members of
the uniformed services and their families.
(see Tricare)
|
claims-made
insurance policy |
A liability insurance
policy under which coverage applies to claims
filed during the policy period. Medical professional
liability insurance is typically written on
a claims-made basis. |
Clinical
Laboratory Improvement Amendments (CLIA)
|
Federal
law designed to set national quality standards
for laboratory testing. The law covers all laboratories
that engage in testing for assessment, diagnosis,
prevention or treatment purposes. |
clinical
nurse specialist (CNS) |
A
registered nurse with a graduate degree in
nursing who may provide and manage the care
of individuals and groups with complex health
problems and provide health care services
that promote, improve and manage health care
within the nurse’s nursing specialty.
|
closed
panel
|
Medical
services delivered in the health insuring corporation
(HIC)-owned health center or satellite clinic
by physicians who belong to a specially formed,
but legally separate, medical group that only
serves the HIC.
|
Consolidated
Omnibus Budget Reconciliation Act |
see Omnibus
Budget Reconciliation Act |
Code
of Federal
Regulations (CFR)
|
A
publication of the federal government that consists
of all regulations of federal departments and
agencies.
www.gpoaccess.gov/cfr/index.html |
co-insurance
|
A
specified dollar amount or percentage of covered
expenses that an insurance policy or Medicare
requires a beneficiary to pay toward eligible
medical bills. |
community
benefit
|
Hospital
community benefit includes programs or activities
that provide treatment and/or promote health
and healing as a response to identified community
needs. A community benefit must meet at least
one of the following criteria: generates a
low or negative margin, responds to needs
of special populations, supplies services
that would likely be discontinued if considered
on a purely financial basis, responds to public
health needs, and/or involves education or
research that improves overall community health.
www.caringforcommunities.org/caringforcommunities/ |
Community
Health Information Network (CHIN)
|
A
community-based activity that focuses on the
development of a shared information database
and retrieval system of patients, their medical
histories and clinical and diagnostic tests.
|
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. |
computerized
physician order entry (CPOE) |
A system
that allows physicians to write medical orders
for their hospitalized patients using a clinical
software application. |
Congressional
Budget Office |
A non-partisan office
that provides U.S. Congress with cost estimates
of legislative proposals and calculates estimates
related to the federal budget. |
Consolidated
Omnibus Budget Reconciliation Act (COBRA) |
Health benefit provisions
passed by Congress in 1986 amending the Employee
Retirement Income Security Act, the Internal
Revenue Code and the Public Health Service Act
to provide continuation of group health coverage
that otherwise might be terminated. |
continuing
education unit (CEU)
|
A
uniform unit of measurement used to assess
all levels of noncredit continuing education.
One CEU is equivalent to 10 contact hours
of participation in an organized continuing
education experience. |
coordination
of benefits
|
Provisions
and procedures used by third-party payers to
determine the amount payable when a claimant
is covered under two or more health plans.
|
copayment
|
A
type of cost-sharing that requires the insured
or subscriber to pay a specified flat dollar
amount, usually on a per-unit-of-service basis,
with the third-party payer reimbursing some
portion of the remaining charges.
|
corporate campaign |
A strategy whereby
a labor union aggressively attacks the public
reputation of a target employer with a goal
of forcing management to yield to the union's
demands or risk the company's financial well-being. |
corporate
practice of medicine
|
A
state law doctrine that prohibits any person
or entity other than a licensed physician from
holding itself out as a provider of professional
medical services, from billing in its name for
such professional medical services, or from
owning or controlling a professional medical
delivery system. |
cost |
The price a
hospital must pay to provide a service, including
the price of providing facilities, technology
and workforce. |
credentialing
|
The
process of reviewing a practitioner’s
academic, clinical and professional ability
as demonstrated in the past to determine if
criteria for clinical privileges are met.
|
critical
access hospital (CAH)
|
A
federal designation under which hospitals receive
cost- based reimbursement for Medicare services.
Hospitals must meet certain criteria, such as
size, length of stay and proximity to other
facilities. |
critical
pathway
|
Standardized
specifications for care developed by a formal
process that incorporates the best scientific
evidence of effectiveness with expert opinion.
|
deductible
|
An amount which
a policyholder agrees to pay, per claim or per
accident, toward the total amount of an insured
loss. Under a health insurance policy, the out-of-pocket
expenses paid by the health insurance subscriber
before the insurer will begin reimbursing the
subscriber for additional medical expenses.
|
diagnostic
related group (DRG)
|
A
classification system that groups patients by
common characteristics requiring treatment.
|
Disability Medical
Assistance
|
A
state administered program that provides limited
medical assistance to persons who are medication-dependent
and ineligible for any category of Medicaid.
There is no federal funding or federal regulation
of this program. |
discharge
planning
|
The
evaluation of patients' health needs for appropriate
care after discharge from an inpatient setting.
|
disproportionate
share hospital (DSH)
|
A
hospital that provides care to a high number
of patients who cannot afford to pay and/or
do not have insurance. |
diversion
|
The
routing of patients to other hospitals because
an emergency room is at maximum capacity.
|
doctor
of osteopathy (DO)
|
A
licensed physician who is a graduate from an
accredited school of osteopathic medicine.
|
do not resuscitate
(DNR)
|
An
advance directive that patients may make to
forego cardiopulmonary resuscitation or other
resuscitative efforts. (see
advance directive) |
durable
medical
equipment (DME)
|
Equipment
that can stand repeated use, is primarily and
customarily used to serve a medical purpose,
generally is not useful to a person in the absence
of illness or injury, and is appropriate for
use at home, such as hospital beds, wheelchairs
and oxygen equipment. |
durable
power of attorney
|
A
document in which individuals select another
person to act on their behalf in the event they
become incapacitated. The document may identify
specific activities, such as managing the incapacitated
person's financial affairs. If the document
allows the agent to make health care decisions,
it must be drafted in a manner that meets statutory
requirements for a "health care durable power
of attorney." (see
advance directive) |
electronic health
record (EHR) |
A
patient’s computerized health information
as recorded and maintained by a provider system.
An EHR is distinguished from a physician health
record (PHR) by control: an EHR is controlled
by the provider’s system while a PHR
is owned and controlled by the patient. |
emergency
medical services (EMS)
|
A
system of health care professionals, facilities
and equipment providing emergency care.
|
emergency
medical technician (EMT)
|
A
person certified to provide pre-hospital emergency
medical treatment. |
Employee
Retirement Income Security Act (ERISA)
|
A
federal law that exempts self-insured health
plans from state laws governing health insurance,
including contribution to risk pools, prohibitions
against disease discrimination and other state
health reforms. |
Environmental
Protection Agency (EPA)
|
A
federal and state agency responsible for programs
to control air, water and noise pollution, solid
waste disposal and other environmental concerns.
www.epa.gov
|
exclusions
|
Specific conditions
or circumstances listed in an insurance contract
for which the policy will not provide benefit
payments. Exclusions can eliminate coverage
for select individuals, groups, locations, properties
or risks. |
experience
rating
|
A
system where an insurance company evaluates
the risk of an individual or group by considering
the applicant's loss history. For health insurance
this would include evaluation of the applicant's
health history. |
Extended
Reporting Period |
An additional period
of time after policy expiration during which
valid claims will be paid under a claims-made
policy of liability insurance. |
failure
mode effect analysis
|
A
systematic method of identifying and preventing
problems (errors) before they occur.
|
False Claims
Act |
A
federal law that imposes liability for treble
damages and fines of $5,000 to $10,000 for
knowingly submitting to the federal government
a false or fraudulent claim for payment.
|
Farmers
Home Administration (FHA)
|
A
division of the U.S. Department of Agriculture
that guarantees hospital mortgages. www.citation.com/hpage/fha.html
|
federal
financial
participation (FFP)
|
The
portion paid by the federal government to states
for their share of expenditures for providing
Medicaid services and for administering the
Medicaid program and certain other human service
programs. Also called federal medical assistance
percentage (FMAP). |
federal
fiscal year (FFY) |
The
federal government's accounting year, which
begins Oct. 1 and ends Sept. 30 (e.g., FFY 2009
begins Oct. 1, 2008, and ends Sept. 30, 2009).
|
federal poverty
guidelines |
The
official annual income level for poverty as
defined by the federal government. Under the
2008 guidelines, the federal poverty level
for a family of four is $21,200.
|
Federal Register
|
An
official publication of the federal government
that provides final and proposed regulations
of federal legislation.
www.gpoaccess.gov/fr/index.html |
Federation
of American Hospitals (FAH)
|
A
trade association composed of proprietary or
investor-owned hospitals.
www.fah.org |
fee
for service
|
A
method in which physicians and other health
care providers receive a fee for services performed.
|
fee
schedule
|
A
comprehensive listing of fees used by either
a health care plan or the government to reimburse
providers on a fee-for-service basis.
|
Fellow
of American College of Healthcare
Executives (FACHE) |
A
credential awarded by the American College of
Healthcare Executives.
|
fiscal
intermediary
|
see
Medicare Administrative Contractor |
fiscal
note
|
An
analysis by the Legislative Budget Office of
the financial impact of proposed state legislation.
|
fiscal
year (FY)
|
Any
entity's accounting year. |
Food
and Drug Administration (FDA)
|
An
agency within the federal government that is
responsible for regulations pertaining to
food and drugs sold in the United States. www.fda.gov
|
freestanding
emergency medical
service center
|
A
health care facility that is physically separate
from a hospital and whose primary purpose is
the provision of immediate, short-term medical
care for minor but urgent medical conditions.
(see "urgent care")
|
freestanding
outpatient surgical center
|
A
health care facility, physically separate from
a hospital, that provides pre-scheduled, outpatient
surgical services. (see surgicenter
or ambulatory
surgical facility) |
full-time
equivalent (FTE) |
A
standardized accounting of the numbers of full-time
and part-time employees. |
gatekeeper
|
A
primary care physician responsible for overseeing
and coordinating all aspects of a patient’s
medical care and pre-authorizing specialty care.
|
general
practitioner
|
A
physician whose practice is based on a broad
understanding of all illnesses and who does
not restrict his/her practice to any particular
field of medicine. |
going
bare |
The colloquial term
describing the choice of an individual, provider
or other legal entity not to purchase liability
insurance such as medical liability insurance
or have a self-insurance mechanism such as a
trust fund, or captive insurance company.
|
Government
Accountability Office (GAO) |
A non-partisan investigative
arm of U.S. Congress that evaluates federal
programs as an oversight of federal spending,
efficiency and performance. www.gao.gov |
graduate
medical education (GME)
|
Medical
education as an intern, resident or fellow after
graduating from a medical school.
|
group
insurance
|
Any
insurance policy or health services contract
by which groups of employees (and often their
dependents) are covered under a single policy
or contract, issued by their employer or other
group entity. |
group
model HMO
|
An
HMO that contracts with a multi-specialty medical
group to provide care for HMO members. Members
are required to receive medical care from a
physician within the group unless a referral
is made outside the network. |
group
practice association
|
A
formal arrangement of three or more physicians
or other health professionals providing health
services. Income is pooled and redistributed
to the members of the group according to a prearranged
plan. |
health care-acquired
condition |
see
hospital-acquired condition |
health
care durable power of attorney
|
A
document in which individuals select another
individual to make health care decisions for
them in the event they become incapacitated.
A health care durable power of attorney should
be distinguished from a living will, a document
drafted by an individual that provides direction
regarding medical care if the individual becomes
incapacitated by terminal illness or permanent
unconsciousness. (see advance
directive)
|
Health Employer Data and Information
Set (HEDIS) |
A
set of performance measures designed to standardize
the way health plans report data to employers.
HEDIS measures five major areas of health
plan performance: quality, access and patient
satisfaction, membership and utilization,
finance, and descriptive information on health
plan management. |
Health
Insurance Association of America (HIAA)
|
A
corporate member association of health and accident
insurance companies.
www.hiaa.org |
Health
Insurance Portability and Accountability Act
(HIPAA)
|
Federal legislation,
enacted in 1996, mandating regulations governing
privacy, security and administrative simplification
standards for health care information. HIPAA
governs how health care organizations handle
all facets of information management, including
patient records. |
health
maintenance organization (HMO)
|
An
entity that offers prepaid, comprehensive health
coverage for both hospital and physician services
with specific health care providers using a
fixed fee structure or capitated rates.
|
health
savings account |
Formerly
called medical savings accounts (MSAs), a
method of financing health care by giving
tax advantages to individuals who establish
and maintain personal accounts for health
care purposes; similar to an Individual Retirement
Account for retirement purposes. The health
savings account legislation was signed into
law in 2003, making the HSA the next generation
of MSA plans. |
Healthy Start/Healthy
Families
|
A
Medicaid program that provides health care
for pregnant women, children and parents who
are at or below a specified level of income
and age.
|
Hill-Burton
Act
|
Federal
legislation enacted in 1947 to support the
construction and modernization of health care
institutions. No funds have been appropriated
since the late 1960s. |
home
health agency
|
An
organization that provides medical, therapeutic
or other health services in patients' homes.
|
hospice
|
A
facility or program that is licensed, certified
or otherwise authorized by law that provides
supportive care of the terminally ill.
|
hospital-acquired
condition (HAC) |
Conditions that
could reasonably have been prevented through
the application of evidence based guidelines. |
hospital-acquired infection (HAI) |
An infection acquired
by an individual while receiving care or services
in a health care organization. |
hospital
affiliation
|
A
contractual relationship between a health
insurance plan and one or more hospitals whereby
the hospital provides the inpatient benefits
offered by the plan. |
Hospital
Consumer Assessment of Healthcare Providers
and Systems (HCAHPS) |
Standardized survey
instrument and data collection methodology for
measuring patients' perceptions of their hospital
experience.
www.hcahpsonline.org |
Hospital
Incident Command System (HICS) |
An incident management
system based on the Incident Command System
that assists hospitals in improving their emergency
management planning, response and recovery capabilities
for planned and unplanned events. |
Hospital
Insurance Program
|
The
compulsory portion of Medicare that relates
to hospital care. (see Medicare
Part A) |
hospitalist
|
Specialists in the
provision of medical care for hospitalized patients,
who manage the general medical needs of patients
in the hospital. Most at this time are physicians;
however, nurse practitioners and physician assistants
may also be involved in the hospitalist's role,
including managing the medical continuum of
hospital care and the planning of post-hospital
care. |
hospital
market basket
|
Components
of the overall cost of health care used in determining
the consumer price index. |
Hospital
Market Basket Index |
An
inflationary measure of the cost of goods and
services purchased by health care facilities,
often used to determine growth in reimbursement
rates. |
indemnity
insurer
|
An
insurance company that offers selected coverage
within a framework of fee schedules, limitations
and exclusions as negotiated with subscriber
groups, generally paying providers fees according
to services rendered. |
independent
practice association (IPA)
|
A health care delivery model in which an association
of independent physicians
contracts with health maintenance organizations
and preferred provider organizations for physicians'
services. The IPA physicians practice in their
own offices and continue to see fee-for-service
patients. |
indigent
medical care
|
Care
given by health care providers to patients who
are unable to pay for it. |
inpatient
|
An
individual who has been admitted to a hospital
for at least 24 hours. |
integrated
delivery system
|
Collaboration
between physicians and hospitals for a variety
of purposes. Some models of integration include
physician-hospital organization, management-service
organization, group practice without walls,
integrated provider organization and medical
foundation. |
intermediate
care facility |
A
facility providing a level of medical care that
is less than the degree of care and treatment
that a hospital or skilled nursing facility
is designed to provide, but greater than the
level of room and board. |
International
Classification of Diseases, 9th Revision
(ICD-9-CM)
|
The classification of morbidity and mortality
information for statistical purposes and for
the indexing of hospital records by disease
and operations for data storage and retrieval.
|
International Classification
of Diseases, 10th Revision (ICD-10-CM)
|
The proposed revised
classification of morbidity and mortality information
for statistical purposes and for the indexing
of hospital records by disease and operations
for data storage and retrieval. ICD 10th revision
contains a significant increase in codes over
ICD-9, including the addition of a sixth character,
codes relevant to ambulatory and managed care
encounters, expanded injury codes and greater
specificity in code assignment. |
intractable
pain
|
Pain
for which there is no cure. |
IRS Form 990 |
The tax-exempt return
most charitable organizations, including hospitals,
file with the IRS each year. It includes income,
expenditures and activities, as well as compensation
of high-level employees and lobbying expenditures
and certain other activities. |
Joint
Commission |
Founded
in 1951, the Joint Commission evaluates and
accredits health care organizations in the U.S.,
including hospitals, health plans, and other
care organizations that provide home care, mental
health care, laboratory, ambulatory care and
long-term services. Formerly called the Joint
Commission on Accreditation of Healthcare Organizations.
www.jointcommission.org
|
Joint
Commission Resources (JCR)
|
A
subsidiary of the Joint Commission designed
to distribute consulting and publication services.
www.jcrinc.com |
joint
venture
|
A
loose form of affiliation, essentially contractual
in nature, that preserves the prior legal identity
of each party participating in the venture.
|
The
Leapfrog Group
|
A
group of Fortune 500 employers and other purchasers
of health care, sponsored by the Business Roundtable,
focused on patient safety issues. www.leapfroggroup.org
|
length
of stay (LOS)
|
The
number of days a patient stays in a hospital
or other health care facility. |
licensed
practical nurse (LPN)
|
A
graduate from a one-year vocational or technical
nursing program who has been licensed by the
state. |
licensed
social
worker (LSW)
|
An
individual who is licensed by the state to practice
social work. |
Life Safety
Code |
Standards
of construction, protection and occupancy
that are necessary to minimize danger to life
from fire, smoke, fumes and panic. The Joint
Commission and the Centers for Medicare
&
Medicaid
Services
require compliance with the code. The code
is adopted and published by the National Fire
Protection Association and is also known as
the NFPA 101. |
limited-service,
physician-owned hospital |
A
health care provider designed to provide principally
one or two specialties of medical care (such
as orthopedic or cardiac care), whose practicing
physicians are also owners or investors. Also
called a niche or specialty hospital. |
living will
|
A
legal document generated by an individual to
guide providers on the desired medical care
in cases when the individual is unable to articulate
his or her own wishes. (see advance
directive) |
long-term acute care hospital (LTCH or LTACH)
|
A
hospital that specializes in treating patients
with serious and often complex medical conditions
requiring a longer length of stay than customarily
provided by a traditional acute care hospital.
LTCHs provide care for such conditions as respiratory
failure, non-healing wounds, and other medically
complex diseases. |
long-term
care (LTC) |
Care given to patients
with chronic illnesses who usually require a
length of stay longer than 30 days. |
low-level
radioactive waste
|
Waste that has
a low intensity of radioactivity, most of which
decays to acceptable levels within a few months,
but a few of which contain radioactivity for
hundreds of years. |
Magnet Hospital Recognition Program
|
A
designation through the American Nurses Credentialing
Center that recognizes those institutions that
act as a “magnet” by creating a
work environment that recognizes and rewards
professional nursing. |
Magnetic
Resonance Imagining (MRI)
|
A
diagnostic technique that uses radio and magnetic
waves, rather than radiation, to create images
of body tissue and to monitor body chemistry.
|
major
diagnostic category (MDC) |
A hospital classification
system that groups patients by diseases and
disorders of each major body system. Diagnostic
related groups are classified underneath each
MDC. |
malpractice
|
The
improper treatment of a patient, as by a physician
or nurse, resulting in injury. |
managed
care
|
A
system of health care delivery that influences
utilization and cost of services, and often
includes a capitated payment structure and a
limited choice of health care providers.
|
Management Service Organization
(MSO) |
A
legal entity that provides practice management,
administrative and support services to individual
physicians or group practices. An MSO may
be a direct subsidiary of a hospital, a joint
venture with physicians, a physician-owned
organization or an investor-owned expertise.
|
market basket
|
|
Market Basket
Index
|
|
Medicaid
|
A
state-administered program funded partly by
the federal government that provides health
care services for certain low-income persons
and certain aged, blind or disabled individuals.
The program is approximately a 40/60 state/federal
match. |
Medical
Consumer Price Index |
An
inflationary statistic that measures the cost
of all purchased health care services.
|
medical
doctor (MD)
|
A
licensed physician who is a graduate of an accredited
medical school and practices allopathic medicine.
|
medical error
|
The
failure of a planned action to be completed
as intended (error of execution) or the use
of a wrong plan to achieve an aim (error of
planning). |
medical
malpractice insurance
|
Insurance
purchased by a person or entity, such as a
doctor or hospital, to
protect the person or entity from claims from
third parties for medical error or medical
malpractice. Also known as medical professional
liability insurance. |
medical
savings account (MSA)
|
A
method of financing health care by giving tax
advantages to individuals who establish and
maintain personal accounts for health care purposes;
similar to an Individual Retirement Account
for retirement purposes A news health savings
account legislation was signed into law in 2003,
making the HAS the next generation of MSA plans.
(see health
savings account). |
Medicare
|
A
federally funded program that provides health
insurance primarily for individuals entitled
to Social Security who are age 65 or older.
www.cms.hhs.gov/home/medicare.asp |
Medicare
Advantage |
Also
referred to as “Medicare Part C,”
or “Medicare+Choice,” a Medicare
program under which eligible Medicare enrollees
can elect to receive benefits through a managed
care program that places providers at risk
for those benefits. |
Medicare
Dependent |
A
Medicare reimbursement category for a hospital
that is located in a rural area, has no more
than 100 beds, and has had at least 60 percent
of its inpatient days or discharges attributed
to Medicare beneficiaries during a cost report
year beginning in federal fiscal year 1987.
|
Medicare
Modernization Act of 2003 (MMA) |
Federal law that provided a prescription drug
benefit under the Medicare program. MMA made
various other adjustments to the Medicare
and Medicaid programs affecting providers,
including payment and regulatory improvements
for hospitals. Also known as the Medicare
Prescription Drug Bill.
|
|
The part of the Medicare program covering
inpatient hospital services and services furnished
by other health care providers such as nursing
homes, home health agencies and hospices.
Part A coverage is automatically provided
for individuals entitled to Medicare.
|
Medicare Part
B
|
The
part of the Medicare program that covers outpatient,
physician and medical supplier services. Part
B coverage is optional and must be paid for
separately through monthly premium payments. |
Medicare
Part C |
see Medicare
Advantage |
Medicare
Part D |
The part of the Medicare program that covers
prescription drug coverage. Beginning in 2006,
beneficiaries have access to partial prescription
drug coverage paid mainly through state payments,
premiums and general revenue. Some assistance
for low-income beneficiaries is available
for premiums and co-pays.
|
Medicare Payment Advisory Commission (MedPAC)
|
A non-partisan congressional advisory body charged
with providing policy advice and technical assistance
concerning the Medicare program and other aspects
of the health system. It conducts independent
research, analyzes legislation, and makes recommendations
to U.S. Congress. The Physician Payment Review
Commission has been merged with the Prospective
Payment Assessment Commission to create MedPAC.
|
medigap |
A policy guaranteeing
to pay a Medicare beneficiary’s co-insurance,
deductible and co-payments and provide additional
health plan or non-Medicare coverage for services
up to a predefined benefit limit. In effect,
the product pays for the portion of the cost
of services not covered by Medicare.
|
morbidity
|
Incidents of illness
and accidents in a defined group of individuals.
|
mortality
|
Incidents of death
in a defined group of individuals. |
most-favored-nation (MFN)
clause
|
A
provision requiring the contracting physician,
hospital or group to provide an insurer with
the lowest price it charges any other insurer.
|
National Accrediting
Agency for Clinical Laboratory Science (NAACLS) |
A
division within the U.S. Department of Health
and Human Services that supports analyses
and evaluations of the health care system
and its financing, and underwrites the development
and testing of new approaches to improve the
distribution, use and cost-effectiveness of
services. |
National Board
of Medical Examiners (NBME)
|
A nonprofit organization responsible for preparing
and administering qualifying examinations
for physicians. www.nbme.org
|
National
Cancer Registry
|
A unit within the National Institutes of Health
that provides updates on the latest cancer diseases,
research and diagnosis. www.ncra-usa.org |
National
Center for Health Statistics (NCHS)
|
A division within the U.S. Department of Health
and Human Services that is responsible for gathering
data on illness and disability, producing the
vital statistics of the nation and tracking
the use and availability of health services
and resources.
www.cdc.gov/nchs |
National
Committee for Quality Assurance (NCQA)
|
A nonprofit organization created to improve
patient care quality and health plan performance
in partnership with managed care plans, purchasers,
consumers, and the public sector. www.ncqa.org
|
National Credentialing Agency
for Laboratory Personnel (NCA) |
A
peer-established agency providing practice-driven
credentials for laboratory professionals.
www.nca-info.org
|
National Incident Management
System (NIMS) |
A standardized approach
to incident management and response that establishes
a uniform set of processes and procedures that
emergency responders at all levels of government
will use to conduct response operations. Currently
there are 14 elements that are specific to hospitals
and health care organizations. |
National Information Center on
Health Services Research and Health Care Technology
(NICHSR) |
A division within
the U.S. Department of Health and Human Services
that supports analyses and evaluations of the
health care system and its financing, and underwrites
the development and testing of new approaches
to improve the distribution, use and cost-effectiveness
of services. www.nlm.nih.gov/nichsr/
|
National
Institutes of Health (NIH)
|
A division within the U.S. Department of Health
and Human Services that is responsible for most
of the agency's medical research programs.
www.nih.gov |
National
Quality Forum (NQF) |
A not-for-profit
membership organization created to develop and
implement a national strategy for health care
quality measurement and reporting.
www.qualityforum.org |
Never Event |
see
preventable
adverse event |
Nuclear
Regulatory Commission (NRC)
|
A
federal commission created in 1974 to protect
the public health and safety by regulating civilian
uses of nuclear materials. www.nrc.gov |
Nursing 2015 |
Legislation signed
by Gov. Ted Strickland on June 12, 2008, that
requires hospitals to develop staffing committees
that will make recommendations to hospital administration
for adoption of staffing plans. |
nursing
quality indicators |
A
set of 10 nursing-sensitive indicators that
link nursing interventions to patient outcomes.
|
Occupational
Safety and Health Administration (OSHA)
|
A
federal agency within the U.S. Department of
Labor that is responsible for setting standards
to promote and enforce employee safety in the
workplace.
www.osha.gov |
Office
of Inspector General (OIG)
|
The enforcement arm within the U.S. Department
of Health and Human Services that oversees investigations
of alleged violations of Medicare and Medicaid
laws and rules. (Most federal agencies have
their own OIG.) www.hhs.gov |
Office
of Management and Budget (OMB)
|
A
federal agency responsible for providing fiscal
accounting and budgeting services for the federal
government.
www.whitehouse.gov/omb
|
Office
of Professional Standard Review Organizations
|
The
health standards and quality bureau of the Centers
for Medicare & Medicaid Services.
|
Office
of the Assistant Secretary for Preparedness
and Response (ASPR) |
The
federal agency within the U.S. Department of
Health and Human Services that provides health
care preparedness grants. www.hhs.gov/aspr
|
Omnibus Budget Reconciliation
Act (OBRA)
|
An
amendment to the federal budget that outlines
new federally funded programs or revisions to
existing programs. |
operating margin |
The ratio of operating
costs to revenue that are directly related to
patient care. |
organ
procurement organization (OPO)
|
A
nonprofit, federally funded organization that
aids in the organ transplantation process.
|
ORYX
|
The integration of performance measurement into
the Joint Commission's accreditation process.
Each accredited facility must select vendors that
have been approved by the Joint Commission for
the performance measurement system.
|
osteopathic
|
One of two schools
of medicine that uses manipulative measures in
treating patients in addition to the diagnostic
and therapeutic measures of medicine. The other
school is allopathic.
|
outcome
measures
|
Assessments
to gauge the results of treatment for a particular
disease or condition. Outcome measures include
the patient's perception of restoration of function,
quality of life and functional status, as well
as objective measures of mortality, morbidity
and health status. |
outlier
|
A patient case that falls outside of the established
norm for diagnosis related groups.
|
out-of-area benefits
|
The coverage allowed to HMO members for emergency
and other situations outside of the prescribed
geographic area of the HMO. |
outpatient
|
A
person who receives health care services without
being admitted to a hospital. |
outpatient
prospective payment system
(OPPS) |
A
method of financing health care that mandates
payments in advance for the provision of outpatient
services and is based on ambulatory payment classification.
|
palliative
care
|
Care
for not only physical symptoms, but also for emotional,
social, spiritual, psychological and cultural
symptoms to achieve the best possible quality
of life. Palliative care is usually provided at
the end of life or to help deal with chronic conditions.
|
pandemic
flu
|
Virulent
human flu that causes a global outbreak, or pandemic,
of serious illness. Because there is little natural
immunity, the disease can spread easily from person
to person. Currently, there is no pandemic flu.
see also avian flu and
seasonal flu |
participating provider |
A
health care provider who has a contractual arrangement
with a health care service contractor, HMO,
PPO, IPA, or other managed care organization. |
Patient Safety
Organization (PSO) |
An entity certified by the Secretary
of Health and Human Services that contracts
with providers to collect and review patient
treatment data for the purpose of improving
health care quality, outcomes, and patient safety.
The framework creating a national network of
PSOs was established by the Patient Safety and
Quality Improvement Act of 2005.
|
Patient
Self-Determination Act
|
A
federal law that requires health care facilities
to determine if new patients have a living will
and/or durable power of attorney for health care
and take patients' wishes into consideration in
developing their treatment plans.
|
payer
|
A
public or private organization that pays for or
underwrites coverage for health care expenses.
|
payment |
Reimbursement a hospital
receives for care provided; usually less than
the standard charge and sometimes less than the
cost of providing care. |
peer
review
|
The
evaluation of quality of total health care provided
by medical staff with equivalent training.
|
peer
review organization (PRO)
|
An entity established by the Tax Equity and Fiscal
Responsibility Act of 1982 to review quality of
care and appropriateness of admissions, readmissions
and discharges for Medicare and Medicaid. These
organizations are held responsible for maintaining
and lowering admission rates, and reducing lengths
of stay while insuring against inadequate treatment.
Now called quality improvement organizations. |
per
diem
|
A
method of payment in which a provider receives
a fixed payment for each day of service provided
to a patient. |
per
member per month (PMPM)
|
The
amount of money paid or received on a monthly
basis for each individual enrolled in a managed
care plan, often referred to as capitation.
|
physician-hospital
organization (PHO)
|
A
legal entity formed and owned by one or more hospitals
and physician groups in order to obtain payer
contracts and to further mutual interests; one
type of integrated delivery system.
|
point-of-service
(POS)
|
An
insurance plan where members need not choose how
to receive services until the time they need them,
also known as an open-ended HMO.
|
political
action committee (PAC)
|
A
group of people organized to collect and distribute
contributions to political candidates.
|
pre-admission
testing (PAT)
|
Patient
tests performed on an outpatient basis prior to
admission to the hospital.
|
pre-existing
condition
|
An
illness or other medical condition that a patient
has experienced before the effective date of insurance
coverage.
|
preferred
provider organization (PPO)
|
A
panel of physicians, hospitals and other health
care providers of services to an enrolled group
for a fixed periodic payment.
|
prenatal
care
|
Services
to pregnant women designed to ensure that both
the expectant mother and the newborn are in the
best health. |
present on admission (POA) |
Conditions known at
the time of admission to the hospital, as well
as conditions clearly present before, but not
diagnosed until after admission. |
preventive
care
|
Comprehensive
care emphasizing priorities for prevention, early
detection and early treatment of conditions, generally
including routine physical examination and immunizations.
|
preventable
adverse event |
An event that results
in death, loss of a body part, disability, or
loss of bodily function lasting more than seven
days or still present at the time of discharge
from an inpatient health care facility. Also referred
to as a never event. |
primary
care
|
Entry-level
care which may include diagnostic, therapeutic
or preventive services. |
professional liability |
see medical
malpractice insurance |
prospective
payment system (PPS)
|
A
method of financing health care that mandates
payments in advance for the provision of services
and is based on diagnostic related groups.
|
provider
|
A
hospital, physician, group practice, nursing home,
pharmacy or any individual or group of individuals
that provides a health care service.
|
Provider
Reimbursement Review Board
|
A
federal board responsible for making decisions
regarding provider appeals on Medicare reimbursement
issues.
http://www.cms.hhs.gov/PRRBReview/
|
provider-sponsored
organization (PSO)
|
A
provider-owned entity that is certified by the
Centers for Medicare & Medicaid Services to
participate in the Medicare+Choice program and
to assume risk for benefits provided to Medicare
beneficiaries. |
Public
Health Service |
A
federal agency responsible for public health services
and programs including biomedical research.
http://phs.os.dhhs.gov |
quality
assurance |
A
formal set of activities to review and improve
the quality of services provided. Quality assurance
includes quality assessment and corrective actions
to remedy any deficiencies identified in the quality
of direct patient, administrative and support
services. |
quality
improvement |
A
continuous effort to provide services at the highest
level of quality at the lowest level of cost. |
quality improvement
organization (QIO) |
An
independent organization responsible for ensuring
that medical care paid under the Medicare program
is reasonable and medically necessary, that
it meets professionally recognized standards
and that it is provided in the most economical
setting. |
radiographer |
The preferred title
for health care workers who take X-rays and have
a degree to provide complication radiological
services. |
rate-setting
|
The
determination by a government body of rates a
health care provider may charge private-pay patients. |
Recovery Audit Contractor (RAC) |
A national provider
bill and medical services review project authorized
by Congress and managed by the Centers for Medicare
& Medicaid Services to detect and correct
improper payments in the Medicare fee-for-service
program. |
refined
diagnosis related group (RDRG)
|
An
expanded list of diagnosis-related groups to take
into account a patient's severity of illness.
|
reinsurance |
A type of insurance
purchased by primary insurers from secondary insurers.
A commercial or captive insurance company purchases
reinsurance to protect against part of all losses
the primary insurer might assume in honoring claims
of its policyholders. Typically, a primary
insurer pays a claim up to a specified amount,
and then a reinsurer pays the remainder of the
claim. |
required
request |
A
system enacted by state lawmakers in 1987 requiring
hospitals to request organs from a deceased’s
family when the deceased is determined to be medically
suitable. |
Research
and Educational Foundation (REF)
|
A
nonprofit foundation of OHA that directs a variety
of research projects. |
Resource-Based
Relative Value Scale (RBRVS)
|
Medicare
fee schedule for physician services that sets
a uniform payment in each geographic area
for most of the approximately 7,000 medical procedures.
|
return on investment
(ROI) |
A measure of a company's ability
to use its assets to generate additional value
for shareholders. It is calculated as net profit
divided by net worth and is expressed as a percentage.
|
risk
|
The
chance or possibility of loss. Also used to refer
to the insured or to the property coverage by
a policy. Risk is also defined in health insurance
terms as the possibility of loss associated with
a given population. In an HMO setting, often employed
as a utilization control mechanism. |
risk classification |
The process by which
a company decides how its premium rates should
differ according to the risk characteristics of
individual insureds. |
risk management |
The practice of identifying
and analyzing loss exposures and taking steps
to minimize the financial impact of the risks
they impose. Traditional risk management, sometimes
called "insurance risk management," has focused
on "pure risks" (i.e., possible loss by fortuitous
or accidental means), but not business risks (i.e.,
those that may present the possibility of loss
or gain). |
root
cause
|
The
most fundamental reason for the failure or inefficiency
of a process. Also called
underlying cause.
|
root
cause analysis (RCA)
|
A
process for identifying the basic factor(s) that
underlie variation in performance, including the
occurrence or possible occurrence of a sentinel
event. |
routine
notification
|
A
system being proposed at the state and national
levels requiring hospitals to call a regional
phone number when death is imminent to determine
if organs are suitable for transplantation.
|
safety
net providers
|
Providers
who have a mission or mandate to deliver large
amounts of care to uninsured or other vulnerable
patients (e.g., public hospitals, teaching hospitals,
community health centers or clinics).
|
seasonal
(or common) flu
|
A
respiratory illness that can be transmitted person
to person. Most people have some immunity, and
a vaccine is available. see also
avian flu
and
pandemic flu
|
selective
contracting
|
The
practice of a managed care organization (MCO)
by which the MCO enters into participation agreements
only with certain providers (and not with all
providers who qualify) to provide health care
services to health plan participants as members
of the MCO's provider panel.
|
sentinel
event
|
An
unexpected occurrence involving death or serious
physical or psychological injury, or the risk,
thereof. |
skilled nursing facility (SNF)
|
A facility, either freestanding or part of a hospital,
that accepts patients in need of rehabilitation
and medical care that is of a lesser intensity
than is received in the acute care setting of
a hospital. |
smallpox
health care team |
Groups of health care
workers identified by hospitals who are vaccinated
and trained to provide direct medical care for
the first smallpox patients requiring hospital
admission and to evaluate and manage patients
with suspected smallpox who are examined at emergency
departments. This team provides 24-hour care for
the first two days or more after patients with
smallpox have been identified, until additional
health care personnel are vaccinated. |
Social
Security Administration
|
The
administrative branch of the federal government
established in 1935 to provide old age and survivor
benefits. www.ssa.gov
|
staff
model HMO
|
An
HMO that delivers health services through a group
in which physicians are salaried employees who
treat HMO members exclusively.
|
Stark |
The
commonly used name for federal laws and regulations
that ban physician referral to entities with
which the physician has a financial relationship.
Named for U.S. Rep. Fortney "Pete" Stark, who
sponsored much of the legislation. |
State
Children’s Health Insurance Program (SCHIP)
|
see
Children’s Health Insurance
Program (CHIP) |
state
fiscal year (SFY) |
The
state government's accounting year, which begins
July 1 and ends June 30 (e.g., SFY 2009 begins
July 1, 2008, and ends June 30, 2009).
|
stop
loss
|
The
point at which a third party has reinsurance to
protect against the overly large single claim
or the excessively high aggregate claim during
a given period of time. Large employers that self-insure
may purchase reinsurance for stop loss purposes.
|
subacute
care
|
Care
given to patients who require less than a 30-day
length of stay in a hospital and who have a more
stable condition than those receiving acute care.
|
supplemental
medical insurance
|
Private
health insurance, also called medigap insurance,
designed to supplement Medicare benefits by covering
certain health care costs that are not paid for
by the Medicare program. |
Supplemental
Security Income (SSI)
|
A
federal program of income support for low income,
aged, blind and disabled persons established by
Title XVI of the Social Security Act. Qualification
for SSI often is used to establish Medicaid eligibility.
|
surgicenter
|
see freestanding
outpatient surgical center |
swing
beds
|
Acute
care hospital beds that can also be used for a
different level of care. |
system
error
|
An
error that is not the result of an individual's
action, but the predictable outcome of a series
of actions and factors that comprise a diagnostic
or treatment process. |
tail
insurance |
Also known as an Extended
Reporting Period, an additional period of time
after policy expiration during which valid claims
will be paid under a claims-made policy of liability
insurance. Most hospital and physician medical
professional liability policies are written on
a claims-made basis. Tail insurance may be needed
when an insured changes insurance companies or
retires. |
Tax
Equity and Fiscal Responsibility Act of 1982 (TEFRA)
|
A
federal law that authorizes health plans to enter
into arrangements with the Centers for Medicare
& Medicaid Services for cost and risk contracts.
|
teaching
hospital |
A
hospital that has an accredited medical residency
training program and is typically affiliated with
a medical school. |
telemedicine |
Health
care consultation and education using telecommunication
networks to transmit information.
|
tertiary
care
|
Highly
specialized care given to patients who are in
danger of disability or death. |
third-party
administrator |
A
person or organization that manages the payment,
processing and settlement of life, health, dental,
disability and self-insured insurance claims for
another person or organization. |
TITLE XVIII
|
A
section of the U.S. Social Security Act that
authorizes and details the parameters of the
Medicare Program. |
TITLE XIX
|
A
section of the U.S. Social Security Act that
authorizes and details the parameters of the
Medicaid Program. |
TITLE XXI
|
A
section of the U.S. Social Security Act that
establishes the Children’s Health Insurance
Program (CHIP). |
tort
|
A
negligent or intentional civil wrong not arising
out of a contract or statute that injures someone
in some way, and for which the injured person
may sue the wrongdoer for damages.
|
total margin |
The ratio of total
revenue to total costs or expenses, including
non-patient care (e.g., parking lots). |
transparency |
A movement toward
providing more information to the public on hospital
operation costs and quality. |
triage
|
The
process by which patients are sorted or classified
according to the type and urgency of their conditions.
|
Tricare
|
A
regionally managed health care program for active
duty and retired members of the uniformed services
and their families; created by the Department
of Defense. (see Civilian
Health and Medical Program of the Uniformed Services)
www.tricare.osd.mil
|
UB-04 |
The revised universal institutional
health insurance data set and data form.
www.nubc.org
|
uncompensated care
|
Health care services
received, but not fully paid for, either out-of-pocket
by individuals or by an insurance provider.
(see charity care) |
underinsured
|
With respect to health
insurance, people who lack sufficient health coverage,
which may affect their ability to access or pay
for needed health services. |
underlying
cause
|
The
most fundamental reason for the failure or inefficiency
of a process. Also called root
cause. |
uniform hospital
discharge
data set
|
A
defined set of data that gives a minimum description
of a hospital discharge. It includes data on age,
sex, race, residence of patient, length of stay,
diagnosis, physicians, procedures, disposition
of the patient and sources of payment.
|
uninsured
|
With respect to health
insurance, people who lack health insurance of
any kind. |
unpreventable
adverse event
|
An
adverse event resulting from a complication that
cannot be prevented given the current state of
knowledge. |
urgent
care
|
see
freestanding emergency
medical service center |
U.S.
Department of Health and Human Services (HHS)
|
A
department within the executive branch of the
federal government responsible for Social Security
and federal health programs in the civilian sector.
www.os.dhhs.gov
|
U.S.
House Committee
on Energy and Commerce
|
A
congressional committee whose primary jurisdiction
includes many health care-related issues, such
as public health, patient protection, food
and drug safety and oversight of Medicaid and
other Health and Human Services programs.
http://energycommerce.house.gov |
U.S. House Committee on Ways and
Means |
A congressional committee with
primary oversight of Medicare, Social Security
and other public welfare programs. Also responsible
for legislation concerning taxes, bonded debt
and tariffs.
http://waysandmeans.house.gov
|
U.S. Senate Committee on Finance
|
A congressional committee dealing
with Medicare, Medicaid, federal bonds, the
customs service and related issues, public moneys,
revenue sharing, health programs funded by specific
taxes, national social security and general
revenue matters. Members of this committee have
significant influence over the development of
federal health care policy and funding. http://finance.senate.gov
|
U.S.
Senate Committee
on Health Education, Labor and Pensions
(HELP)
|
A
congressional committee whose primary jurisdiction
includes many hospital- and health care-related
issues, including public health, labor practices,
workplace safety, care for children and the elderly,
biomedical research and social welfare programs.
http://help.senate.gov/index.html
|
usual,
customary and reasonable charges (UCR)
|
Charges
for health care services in a geographical area
that are consistent with the charges of identical
or similar providers in the same geographic area.
|
utilization
|
The
patterns of use of a service or type of service
within a specified time, usually expressed in
a rate per unit of population-at-risk for a given
period (e.g., the number of hospital admissions
per year per 1,000 persons in a geographic area).
|
utilization
review (UR)
|
An
evaluation of the necessity and appropriateness
of the use of health care services, procedures
and facilities. |
Veterans'
Administration (VA)
|
A
federal agency responsible for veterans including
VA hospitals and veterans' benefits. www.va.gov |
wage
index |
A factor used to adjust
the base Medicare reimbursement rates for an area
to account for geographic differences in wages
paid to health care workers. Some argue
that such differences no longer exist and that
the wage index formula should be changed or eliminated. |
weapons
of mass destruction |
Weapons capable of
inflicting mass casualties and destruction; including
nuclear, biological and chemical weapons or the
means to deliver them. |
well-baby
care
|
Services
provided in the first year of a newborn's life
to identify, treat and prevent health care problems.
|