question

Case management

answer

assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client's health

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Case Management Characteristics

answer

advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes.

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Glasgow Coma Scale

answer

Best verbal, best motor. < 8 coma, 13-15 mild injury.

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Strengths Based Model

answer

assesses clients capacities and potential resources as well as problems and current unmet needs.

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Independent Living Model

answer

sees a disability as a construct of society

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Medicare Prospective Payment System

answer

hospitals paid a pre-determined rate for each Medicare admission. Each patient is classified into a DRG.

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PHQ-9

answer

Client assessment tool for depression

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Braden Scale

answer

Client assessment tool for pressure sore risk

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Clinical Pathway

answer

Structured multidisciplinary CM plan designed to support the implementation of specific clinical guidelines and protocols. They are maps that guide the healthcare team on usual treatment patterns related to common diagnoses, conditions and procedures e.g., CHF

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SF-36

answer

Client assessment tool to measure physical and mental health.

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Medicare

answer

Established in 1965 under Title XVIII or Social Security Act. Four Parts A-hospital insurance, B-medical insurance (doctors visits), C-Medicare Advantage program in a private plan such as HMO, D-prescription drug benefit

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Medicare Benefits and Cost Sharing

answer

Not covered are: Acupuncture, chiropractor, cosmetic, custodial home care, dental care, DME convenience, hearing aids, eyeglasses, foot care, meals on wheels, personal convenience, prescription drugs, private nurses, routine physical, vision

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areas of accountability of case management

answer

clinical/outcome financial functional/outcome satisfaction behavior process *episode or continuum **individual or population

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Measuring performance: Process

answer

The measure of how many pts receive a treatment or service i.e. vaccinations, screenings, ex. diabetic foot exam ALSO practitioner's practice conforming to practice standards.

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Measuring performance: Functional outcome

answer

The measure reflects the health state of a patient as a result of health care ex. increased independency in ADLs, mobility

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Measuring performance: Clinical outcome

answer

The measure reflects the health state of a patient as a result of health care ex. blood pressure goals ex. HgA1c level, wound healing

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Measuring performance: behavioral 'process'

answer

ex. self-monitoring of blood sugar

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Measuring performance: Financial

answer

ex. fewer ED visits, ALOS decreased

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Women's Health and Cancer Rights Act of 1998

answer

1. Part of Omnibus Appropriations Bill. 2. required group health plans to provide coverage for mastectomies and provide certain reconstructive related services following mastectomies.

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Women's health and cancer rights act coverage

answer

1. reconstruction of the breast. 2. surgery and reconstruction of the other breast 3. breast prothesis 4. treatment for physical complications attendant to the mastectomy

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Women's health and cancer rights act prohibitions

answer

Health plans are not allowed to deny anyone coverage for the sole reason of avoiding the requirements of the act AND cannot induce a physician to limit the care that is required under the act by penalizing or limiting reimbursement to the physician.

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Can states modify HIPAA's portability requirement

answer

Yes. HIPAA requirements do not supercede state requirements. Stricter laws prevail. States can 1. shorten the 6 month look back period. 2. shorten 12 month maximum pre-existing condition exclusion period.3. increase the 63 day/significant break in coverage 4. increase 30 day period for newborns, adopted children, children placed in adoption and pregnant women. 5. Expand the prohibitions on conditions and people to whom a pre-existing condition exclusion period may be applied beyond exceptions. 6. reduce additional special enrollment periods. 7. reduce maximum HMO affiliation period to less than 2 months.

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Break in coverage

answer

63 days or longer that a subscriber has been without health insurance coverage (not including waiting periods)

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Waiting period

answer

period of time specified by health insurance contract that occurs between signing up for insurance and the beginning of health insurance coverage. Cannot be counted as creditible coverage time. Individuals can use COBRA from their previous employers for health insurance

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Establishing waiting period

answer

HIPAA does not prohibit plans from establishing a waiting period. But the waiting period and the pre-existing conditions exclusions must start at the same time and run concurrently.

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Creditable Coverage

answer

For the purpose of the Health Insurance Portability and Accountability Act, coverage under virtually any type indivual or group health care plan without a break in coverage of 63 days or more. Cannot be taken into account when determining a significant break in coverage. Only coverage after the 63 day break will be counted. Any coverage before the 63 day break will not be considered.

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COBRA

answer

Consolidated Omnibus Budget Reconciliation Act; law to provide terminated employees or those who lose insurance coverage because of reduced work to be able to buy group insurance for themselves and their families for a limited amount of time.

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Certification of creditable coverage

answer

Documentation that is provided automatically by the plan or issuer when the individual loses coverage or becomes entitled to elect COBRA continuation coverage and when an individual's COBRA continuation covearage ceases ; Be provided if requested before loss of coverage or within 24 months of loss of coverage. May be provided through use of model certificate

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Nondiscrimination requirements

answer

Inividuals cannot be excluded from coverage under the terms of the plan based on specified factors related to health status. Health plans cannot establish rules of eligibility based on healht status related factors" such as health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability or disablity. Insurer cannot drop a patient from coverage because it knows that the patient will require a liver transplant next year. Cannot charge more for premiums based on health status.

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Security of health information and electronic signature standards

answer

provides a uniform level of protection of all health information that is housed or transmitted electronically. pertains to the individual.

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Tax Equity and Fiscal Responsibility ACT of 1982

answer

the purpose of this act is to control the rising cost of providing health care services to medicare beneficiaries and has incentives for cost containment. The act:1. established a case based reimbursement system (DRG) payment system determined the cost of care for selected diagnoses while also placing limits on rate increases in hospital venues. 2. Exempted medical rehabilitation from DRGs. Rehabiliation would continue as a cost based reimbursement system with limits. 3. Amended social security act so that group health plans pay before medicare for active employees 65-69 years old and for their spouses in the same age group. 4. revised Age discrimination act by requiring employers to offer health benefits to active employees 65-69 and their spouses in the same age bracket. 5. establish peer review organizations to reduce costs associated with the hospital stays of medicare and medicaid patients. Also established hospice benefit.

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The Mental Health Parity Act of 1996

answer

A statute that forbids health plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits. Excluded substance abuse. If a plan does cover mental health, it cannot set a separate dollar limit from medical care. Other limits allowed: limited number of annual outpatient visits; Limited number of annual inpatient days; a per visit fee; Higher deductibles and copayments without parity in medical and surgical benefits. If a parity would require an increase of 1% or more in its health care costs, the plan would be exempt.

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The Pregnancy discrimination act

answer

is an amendment to Title VII stating that employment discrimination based on pregnancy, childbirth, or related medical conditions is prohibited as a form of sex discrimination

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Newborns and Mother's Health Protection Act of 1996

answer

Health plans may not restrict benefits for any hospital length of stay in connection with child birth for new born or her bother to less than 48 hours following a normal vaginal delivery or less than 96 hours following a delivery by cesarean section. They may not require providers to request for authorization for up to 48/96 hours . May not increase an individuals coinsurance for any later portion of a 48 hour /96 hour hospital stay. 3. they cannot provide monetary payments to encourage a mother to accept less than minimum protections available under NMHPA. They cannot penalizeor other wise reduce or limit the reimbursement of an attending provider because the provider furnished care to a mother or newborn in accordance to NMHPA. They cannot provide monetary or other incentives to an attending provier to induce the provider to furnish care to a mother or new born in a manner inconsistent with the NMHPA.

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The Mental Health Parity and Addiction Equity Act of 2008

answer

MHPAEA preserves the MHPA protections and adds significant new protections, such as extending the parity requirements to substance use disorders. Although the law requires a general equivalence in the way MH/SUD and medical/surgical benefits are treated with respect to annual and lifetime dollar limits, financial requirements and treatment limitations, MHPAEA does NOT require large group health plans or health insurance issuers to cover MH/SUD benefits. The law's requirements apply only to large group health plans and health insurance issuers that choose to include MH/SUD benefits in their benefit packages. However, the Affordable Care Act builds on MHPAEA and requires coverage of mental health and substance use disorder services as one of ten EHB categories

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Exceptions to MHPAEA 2008

answer

Except as noted below, MHPAEA requirements do not apply to: Non-Federal governmental plans that have 100 or fewer employees; Small private employers that have 50 or fewer employees; Group health plans and health insurance issuers that are exempt from MHPAEA based on their increased cost (except as noted below). Plans and issuers that make changes to comply with MHPAEA and incur an increased cost of at least 2% in the first year that MHPAEA applies to the plan or coverage or at least one percent in any subsequent plan year may claim an exemption from MHPAEA based on their increased cost. If such a cost is incurred, the plan or coverage is exempt from MHPAEA requirements for the plan or policy year following the year the cost was incurred. These exemptions last one year. After that, the plan or coverage is required to comply again; however, if the plan or coverage incurs an increased cost of at least 1% in that plan or policy year, the plan or coverage could claim the exemption for the following plan or policy year; Large, self-funded non-Federal governmental employers that opt-out of the requirements of MHPAEA.

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hard savings

answer

Examples of "hard" savings are directly linked to Case Management. Examples would be reduction in payer denials or decrease in avoidable days.

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soft savings

answer

Examples of "soft" savings are indirectly linked to Case Management such as lower readmission rates or lower post-op complication rates. These can be converted into dollars.

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1987 Nursing Home Reform Act

answer

The basic objective of the Nursing Home Reform Act is to ensure that residents of nursing homes receive quality care that will result in their achieving or maintaining their "highest practicable" physical, mental, and psychosocial well-being. To secure quality care in nursing homes, the Nursing Home Reform Act requires the provision of certain services to each resident and establishes a Residents' Bill of Rights.

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CARF

answer

Commission on Accreditation of Rehabilitation Facilities

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Wickline v. The State of California

answer

the point of this litigation is that a physician/surgeon is still responsible for negligently discharging a patient even if the financial benefits related to the hospital stay have been exhausted. Wickline also seems to suggest that a physician can be negligent for not acting more aggressively as a patient's advocate with third-party payers

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ADA reasonable accommodations

answer

-Making existing facilities used by employees readily accessible to and usable by persons with disabilities. -Job restructuring, modifying work schedules, reassignment to a vacant position; -Acquiring or modifying equipment or devices, adjusting or modifying examinations, training materials, or policies, and providing qualified readers or interpreters.

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The Individuals with Disabilities Education Act (IDEA)

answer

Public Law 94-142 - a law ensuring services to children with disabilities throughout the nation. IDEA governs how states and public agencies provide early intervention, special education and related services to more than 6.5 million eligible infants, toddlers, children and youth with disabilities.

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Abandonment

answer

termination of a professional relationship without reasonable notice to the patient and without an opportunity for the patient to acquire alternative care or services thereby resulting in injury to the patient.

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Agency

answer

relationship between two or more persons by which one consents that the other (the agent) shall act on his or her behalf. Legal obligations to: 1. use care and skill 2. act in good faith 3. staying within the limits of authority 4. obeying the principal and carrying out all reasonable instructions 5. advancing the interests of the principals 6. acting solely on the principal's benefit. Implies a conflict of interest between the case manager and the employer and the professional duties to the patient.

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Apparent authority

answer

(ostensible agency): When a principal has taken such actions that would indicate to third parties that someone is his or her agent, the principal is held to have given "apparent authority" to the agent. The principal is held responsible for the agent's action

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Bad Faith

answer

attempt to mislead or decieve another or neglect refusal to fulfill some duty or some contractual obligation. Implies a conscious of wrong doing. Example: denying claim to save money.

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Three Components of bad faith claims denials

answer

1. absence of a reasonable basis for denial of benefits. 2. the insurers or agent's knowledge or reckless disregard of the lack of reasonable basis for denying a claim. 3. misfeasance or maladministration in processing of claims for benefits.

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Bill of particulars

answer

Amplification of a legal complaint that supplies more information and detail, thereby giving the defendant a more specific picture of the claims against him.

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Breach of confidentiality

answer

failure of fiduciary duty. Refusal to hold secret a priviledged communication entrusted by one party to another.

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Claim

answer

request for payment from an insurance company. Or a report by the insured provider of care to the insurance company based on notification from the patient or the patient's attorney of an event out of which malpractice has been alleged.

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Comparative negligence

answer

A method of measuring negiligence among participants in a suit (defense and plaintiff) in terms of percentages of culpability. Damages are then diminished in proportion to the amount of negligence attributable to the complaining party.

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Complaint

answer

document by which the plaintiff gives the court and the defendant notice of the transactions, occurrences, or series of transactions or occurences intended to be proved and the material elements of each cause of action or defense.

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Corporate negligence

answer

legal ground of a managed care liability based on the corporate activity of the managed care organization itself rather than on the care related activities of participating healthcare professionals. Examples: Negligent credentialing and negligent supervision .

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Corporate practice of medicine

answer

Legal doctrine that prohibits corporations from engaging in the practice of medicine. Corporates who recognize this doctrine cannot employ physicians.

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Damages

answer

Monetary compensation awarded for acts of tort for both tangible (medical expenses, loss wages) and intangible (pain and suffering)

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Discovery

answer

Ascertainment of what is not previously known. All evidence that is material and necessary in the prosecution or defense of action is produced and exchanged by the parties or as ordered by the court.

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Event (incident)

answer

a situation that is reported by the insured provider to his or her insurance company which may lead to a formal claim or malpractice suit.

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Examination before trial

answer

obtaining information by sworn oral testimony

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False Claims Act

answer

Federal penalties for those who knowingly present false claim or against the government. It is illegal to present a false or fraudulent claim upon or against the US.

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HOld harmless provision

answer

Contract between insurer and provider of services that specifies that the providers assumes liability for covered services even if the managed care organization becomes insolvent.

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Inherent risk

answer

a complication that is commonly associated with a treatment and is not due to negiligence of the provider of the treatment.

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Invasion of privacy

answer

wrongful intrusion into one's private activities which would cause harm to the patient

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Liability

answer

debt, responsibility, obligation

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Liability, joint

answer

Obligation as a group or as a whole and all its individual members. A party that has been harmed can sue the group as a whole or by its individuals but the suer cannot get more compensation by suing individually than by suing as a whole.

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Liability limits

answer

Restriction or upper boundary on the amount of money on insurance company will pay in order to satisfy a claim against an insured. A calim for a sum beond this limit is not protected bt teh insurance policy and is that the responsibility of the defendant

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Liable

answer

bound by law or fairness responsible and accountable

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Malpractice

answer

Act of negligence, 1. negligence: a deviation from the approved and accepted standards of care. 2. injury which damage is to the patient as result of the negligence.

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Most favored nation Clause

answer

provider is obligated to render products or services to the purchaser at the same rate as his most favored customer

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Negligence

answer

Failure to use the degree of care . Ommision and commission.

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Negligent credentialing

answer

When a organization does not exercise care when investigating a provider's credentials. Example when an organization selects a provider who negligently injures a patient, has a history of doing so or is found not to have the appropriate training , experience, skill or licensure to care for the patient.

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Negligent Referral

answer

Referring a patient to a provider who does not posses the right credentials, skills, licensure or who has been known to be negligent in the past.

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Ombudsman

answer

a person who investigates customer complaints against their employer.

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Ostensible agency

answer

A principal gives a third party reason to believe another person is ‎his/her agent; other person is unaware of the appointment.‎ In these cases the "principal" is responsible for the acts of the agent. Principal gives apparent authority to the agent and will be liable for his acts

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Out of Court setllement

answer

Agreement or transaction between two litigants to settle the matter privately and not in court

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Privileged communications

answer

Information that is disclosed by a patient to a provider that remains confidential unless patient waives his privilege. Disclosure of such information may constitute as an invasion of privacy which is an actionable tort

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Res ipsa loquitor

answer

(things speak for itself). Mere proof that an occurence took place is sufficient. Injury was case by the defendants exclusive control and that the accident was one that ordinarily doesn't happen in the absense of negiligence. Example: when a patient is found to hav an surgical instrument left in his abdomen.

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Respondeat Superior

answer

Let the master answer: master is liable for acts of his servant.

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Statutue of limitations

answer

period of time which a plaintiff can bring a lawsuit after an incident has occurred.

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Subpoena

answer

A judicial process requiring a witness to give relevant information or testimony "under penalty" of comtempt for disobedience

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Summons

answer

A document issued by the plaintiff's attorney, which, when properly delivered, commensces a legal action.

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Tort

answer

Implies injury: damage or injury or wrongful act done willngly, negligently or in circumstances involving strict liability, a legal wrong doing commited upon the person or property independant of contract.

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Examples of tort:

answer

a direct invasion of some legal right of the individual.2. the infraction of some public duty by which special damage accrues to the individual. 3. the violation of some private obligation by which like damage accrues to the indiviual

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vicarious liability

answer

the legal liability that a pperson may have for the action of someone else. , Legal doctrine under which a party can be held liable for the wrongful actions of another party.

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HHRG

answer

Home health resource group Medicare A case-mix classification in which Pt characteristics and health status information are obtained from an OASIS assessment in conjunction with projected therapy use during a 60-day episode are used to determine Medicare reimbursement. -Eighty HHRGs -The Outcome & Assessment Information Set (OASIS) determines the HHRG and is completed for each 60-period -A predetermined base payment for each 60-day episode of care is adjusted according to patient's HHRG -No limit to number of 60-day episodes -Payment is adjusted if patient's condition significantly changes

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DRG

answer

Diagnosis-related group Managed care A unit of classifying Pts by diagnosis, average length of hospital stay, and therapy received; the result is used to determine how much money health care providers will be given to cover future procedures and services, primarily for inpatient care. -Primary diagnosis determines assignment to one of 535 DRGs -The DRG payment rate is adjusted based on age, sex, secondary diagnosis and major procedures performed. DRG payment is per stay. -Additional payment (outlier) made only if length of stay far exceeds the norm

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RUG

answer

-Fifty-eight groups -Each beneficiary assigned a per diem payment based on Minimum Data Set (MDS) comprehensive assessment -A specified minimum number of minutes per week is established for each rehabilitation RUG based on MDS score and rehabilitation team estimates

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SNF

answer

A facility that provides 24-hour medical care provided by registered nurses, licensed vocational nurses as well as nurses aides. Licensed Physical Therapists, Occupational Therapists, and Speech Therapists are also available. Typically for patients who require services that can only be given by a licensed provider such as IVABX, IV pain management, wound care, g-tube feeding or physical rehabilitation needed 1-3 hours a day on a daily basis. An M.D. will usually evaluate pt. within the first 72 hours and then monthly thereafter. In order for Medicare to cover (and Medicare only) pt. must have a three-day qualifying stay in the acute setting (think midnights). As long as pt. has a skilled need and a qualifying stay Medicare will cover the first 20 days at 100 percent, day 21-100 is $119.00 a day which the pt. or the pt's secondary insurance is responsible for. Most SNFs also have a custodial side for pts. whose needs can no longer be met at home or at a lower level of care. Other than MediCal, Medicare and most private insurances, (with the exception of long term care insurance) will NOT cover custodial care in a SNF.

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Subacute Care Unit

answer

For patients who no longer require the intensive procedures of an acute care Hospital, but do require the diagnostic or invasive procedures of an inpatient healthcare facility. Patients who are transferred to a sub acute facility may have a trach and require frequent suctioning. Individuals may also need to be weaned from a ventilator. Patients residing in this environment generally need between four and seven hours of skilled nursing/respiratory care each day. Medicare does not recognize the sub acute level of care and will only reimburse on a SNF level, so the determination of acceptance is usually made on a case by case basis by the individual facility. MediCal does recognize the Sub acute level, however, the pt. must have a trach AND another needs i.e. feeding tube, wound care or TPN. Only a few sub cutes have dialysis available on site.

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LTAC

answer

Structured and programmed for medically complex and often catastrophically ill patients. Patients are admitted for acute care, with lengths of stay that average 25-30 days; typical of medically complex patients. The intensity of service will normally exceed the care needs that can be met by a sub-acute or skilled nursing facility. An LTAC will generally be able to provide such services as vent weaning and respiratory care, complicated wound care, TPN; Surgeries such as Tracheotomies, wound debridment, skin flaps, PEG/GT placement, and Central line placement. An LTAC will also have an ICU as well as telemetry units. Pts. will be seen on a daily basis by an M.D. and will be treated by P.T., O.T., and Speech. The patient must have specific and realistic discharge goals from the LTAC. Mainly for Medicare recipients, MediCal does not recognize this level of care, and private insurance is on a case-by-case basis.

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Acute Rehab Unit

answer

Typically for neuro related diagnosis (but not always, this too is decided on a case by case basis dependant on insurance and accepting facility), the pt. must actively participate, tolerate, and benefit from a MINIMUM of three hours of therapy daily (P.T., O.T., and Speech Therapy). The pt. must have a discharge goal of home or an assisted living facility, pt will NOT be accepted if the goal is SNF.

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Accessible

answer

A term used to denote building facilities that are barrier-free thus enabling all members of society safe access, including persons with physical disabilities.

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Barrier - Free

answer

A physical, manmade environment or arrangement of structures that is safe and accessible to persons with disabilities.

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Activity Limitations

answer

Difficulties an individual may have in executing activities. An activity limitation may range from a slight to a severe deviation in terms of quality or quantity in executing the activity in a manner or to the extent that is expected of people without the health condition.

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Developmental Disability

answer

Any mental and/or physical disability that has an onset before age 22 and may continue indefinitely. It can limit major life activities. Individuals with mental retardation, cerebral palsy, autism, epilepsy (and other seizure disorders), sensory impairments, congenital disabilities, traumatic brain injury or conditions caused by disease (e.g. polio and muscular dystrophy) may be considered developmentally disabled.

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Disability

answer

A physical or neurological deviation in an individual makeup. It may refer to a physical, mental or sensory condition. A disability may or may not be a handicap to an individual, depending on one's adjustment to it.

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Disability

answer

Diminished function, based on the anatomic, physiological or mental impairment that has reduced the individual's activity or presumed ability to engage in any substantial gainful activity.

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Disability

answer

Inability or limitation in performing tasks, activities, and roles int he manner or within the range considered normal for a person of the same age, gender, culture and education. Can also refer to any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.

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Disability Case Mangemtn

answer

A process of managing occupational and no-occupational diseases with the aim of returning the disabled employee to a productive work schedule and employment.

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Disability Income Insurance

answer

A form of health insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury or disease

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Handicap

answer

The functional disadvantage and limitation of potentials based on a physical or mental impairment or disability that substantially limits or prevents the fulfillment of one or more major life actives, otherwise considered normal for that individual based on age, sex and social/cultural factors, such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working, etc. Handicap is a classification of role reduction resulting from circumstances that place an impaired or disabled person at a disadvantage compared to other persons.

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Handicapped

answer

Refers to the disadvantage of an individual with a physical or mental impairment resulting in a handicap.

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Learning Disability

answer

A lack of achievement or ability in a specific learning area(s) within the range of achievement of individuals with comparable mental ability. Most definitions emphasize a basic disorder in psychological processes involved in understanding and using language, spoken, or written

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SSDI

answer

Social Security Disability Income: Federal benefit program sponsored by the Social Security Administration. Primary factor: disability and/or benefits received from deceased or disabled parent. Benefit depends upon money contributed to the Social Security program either by the individual involved and/or the parent involved.

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Total Disability

answer

An illness or injury that prevents an insured person from continuously performing every duty pertaining to his/her occupation or engaging in any other type of work

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Case Management

answer

A collaborative process, which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes.

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Key elements to Case Management (9) (a p cs ds l a me er po)

answer

• Assessment • Planning • Coordinate Services • Deliver Services • Linkage • Advocate • Monitoring & Evaluating • Efficient use of Resources • Promote Positive Outcome

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Assessment

answer

Getting the background info

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Planning

answer

Looking ahead

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Coordinate Service

answer

Holistic view of the client, many services must be coordinated

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Deliver Service

answer

CMs often deliver services themselves

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Linkage

answer

Relates to service coordination. Makes sure the client is connected to resources out there

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Advocacy

answer

CM have the responsibility for being the voice of the client

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Monitoring and evaluating

answer

• If providing management, you must assess and assure the delivery of the services are on target • What's the impact of the services - Evaluating (more formal)

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Efficient use of resources

answer

Try to do more with less

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Positive outcome

answer

Trying to bring about a benefit for the client

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Managed care:

answer

• a system of health care (HMO, PPO) that controls costs by placing limits on physicians' fees and by restricting the patient's choice of physicians. • Strong motive for the insurance co. to make profits, managed care optimizing access • Iron Triangle - Access, Cost, Quality - We want to optimize access, minimize cost, and maximize outcome)

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Three-way dilemma in US

answer

• Customer have high need • Health care system has high capacity and horsepower • No one really wants to pay for services

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Iron Triangle

answer

(a term coined to describe the relationship between access, cost, and outcome) • optimizing access • minimizing cost • maximize outcome

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Role of Case Manager

answer

• "Big brother" - CM usually has the big picture on the client - Broad scope of care and management of the client • Balance "Hands off" vs. "hands on" roles • Driven by organizational/agency context • Significant variation in roles across settings • Bridge among PwDs, services, and payers

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History of Case Managers (5 key milestones) Part 1

answer

1. 20s & 30s - Polio treatment centers, first coordinated systems of care 2. 30s & 40s - Antibiotics developed 3. Post WWII, 1946 - physiatry was born & rehab nurses functioned as CMs 4. 54 - Rehab act of 54, established funds for universities to train VR counselors with CM as key curriculum component

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History of Case Managers (5 key milestones) part 2

answer

5. 70s & 80s: (a) Workers Comp provided rehab services (b) rehab facilities became more persuasive (more government money) (c) public mental health deinstitutionalization (d) passage of Rehab Act of 73, beginning of private rehab

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Physiatry

answer

A branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities (AKA: rehabilitation medicine)

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Key Case Manager competencies (Part 1)

answer

• Relationship building and counseling • Assessment/monitoring/evaluating • Planning • Decision making

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Key Case Manager competencies (Part 2)

answer

• Advocacy • Conflict resolution • Payment sources (how, rules and regs, code usage) • Caseload management • Community resources (making connections, who provides)

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Case Manager Credentials

answer

• Certification - CCM (Certified Case Manager) - CDMS (Certified Disability Management Specialist) - LCP (Life Care Planning) • Certification require a base in one's own field first • Adds to credibility

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Rehab Counselor vs. Social Worker

answer

Better understanding of a disability, or VC rehab

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Rehab Counselor vs. Nursing

answer

Nurses better on medical knowledge

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Case Managers vs. Counseling

answer

Counselors more specific service provided ; a CM is more general orientated

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Case Managers Setting (a wide variety) 10 total (Part 1)

answer

• Secondary school (help client move on to higher ed) • University (DRS office for post-secondary) • Corporate (work stations in order, WC claims, health benefits) • Public VR (return client to work quickly) • Private VR (return client to work, take your time)

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Case Managers Setting (a wide variety) 10 total (Part 2)

answer

• Community (MH, substance abuse, VR) • Public Health (HIV resources) • Hospital (community support post release) • Insurance (Utilization & physician work review) • Forensic (Testifying)

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Mental Health Case Manager (Part 1) 5 total

answer

• Residential • Pre-discharge planning (post release needs reapply) • Day support • Medication management

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Mental Health Case Manager (Part2) 5 total

answer

• Intensive Case Manager - (serve most needy people ; take the team to the client rather than the client coming to the community because they could not do so) • Homelessness Case Manager - Search for mentally ill homeless people - Blend in & build relationships w/ the homeless

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Future of Case Managers

answer

• Increasing recognition • Increasing professionalization and credentialing • Decreasing the proverbial "CM burden" - Second class citizen compared to the clinician or other providers

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CM Outcomes in Practice Settings: Acute Care

answer

ALOS; readmissions;satisfaction;CMS & JCAHO quality 'core' measures; d/c planning; no denial days; clinical resource management; progression of care 'throughput'. DRG

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CM Outcomes in Practice Settings: Home Care

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# visits; level of care; accurate OASIS assessments; outcome measures in clinical, functional and readmission domains. HHRG

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CM Outcomes in Practice Settings: Skilled Nursing (SNF)

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LOS; level of care;accurate assessments of clinical & functional measures. RUG

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CM Outcomes in Practice Settings: Health Plan

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level of care; clinical measures for chronic disease; satisfaction; NCQA & URAC CM standards if accredited; cost avoidance; adherence to guidelines

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ALOS: avg length of stay

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affects ratings and ability to negotiate new contracts with medicare, hmo's or commercial plans

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DRG/HHRG/RUG

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Identify severity of illnes for payment AND used for data collection on clinical outcomes.

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Critical pathways/Clinical pathways/Care Maps

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multidisciplinary, evidence-based foundation for care delivery. Facilitates longitudinal care.

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Variances from pathways

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can be operational, health care provider, patient/family, clinical

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McGill Pain Questionaire

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The 3 major measures are: (1) the pain rating index, based on two types of numerical values that can be assigned to each word descriptor, (2) the number of words chosen; and (3) the present pain intensity based on a 1-5 intensity scale.

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Visual Analog Scale

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faces for description

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PHQ-9 tool

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measures depression: Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression

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morisky medication adherence questionaire

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Do you sometimes forget to take your medicine? People sometimes miss taking their medicines for reasons other than forgetting. Thinking over the past 2 weeks, were there any days when you did not take your medicine? Have you ever cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it? When you travel or leave home, do you sometimes forget to bring along your medicine? Did you take all your medicines yesterday? When you feel like your symptoms are under control, do you sometimes stop taking your medicine? Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan? How often do you have difﬁculty remembering to take all your medicine? __ A. Never/rarely __ B. Once in a while __ C. Sometimes __ D. Usually __ E. All the time

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Tools for child development assessment

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HELP, Bayley and Denver

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Tools for brain injury

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Glasgow Coma Scale Rancho Los Amigos

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Braden scale

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pressure sore risk

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MDS for SNF

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Categories of MDS (Minimum Data Set) 1) Cognitive patterns 2) Communication and hearing patterns 3) Vision patterns 4) Physical functioning and structural problems 5) Continence 6) Psychosocial well-being 7) Mood and behavior patterns 8) Activity pursuit patterns 9) Disease diagnoses 10) Other health conditions 11) Oral/nutritional status 12) Oral/dental status 13) Skin condition 14) Medication use 15) Treatments and procedures

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Short form-36

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Quality of life perception tool The RAND 36-Item Health Survey (Version 1.0) laps eight concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, emotional well-being, social functioning, energy/fatigue, and general health perceptions. It also includes a single item that provides an indication of perceived change in health.

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Subacute

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a broad range of medical and rehabilitative services and settings that provide care to post-acute patients

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Acute Care

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Acute care is a care setting where a patient is treated for a brief but severe episode of illness. The term is generally associated with care rendered in an emergency department, ambulatory care clinic, or other short-term stay facility. The most common acute care setting is a traditional hospital, which typically offers both inpatient and outpatient care in specialty areas including but not limited to emergency care, intensive care, coronary care, cardiology, surgical services, psychiatric care and childbirth and pediatric care. The function and goal of acute medical care is to diagnose and treat the presenting condition or illness and return the person to his/her state of health prior to the episode. Acute care settings often have full-time physicians and hospital staff who are available 24 hours a day. They may offer higher nurse-to-patient ratios, including licensed nursing staff especially trained in acute care. Acute care hospitals often also have social workers, dieticians, physician specialists, pharmacists and rehabilitation staff on-site.

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long-term acute care hospital

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A long-term acute care hospital is an acute care hospital that specializes in the treatment and rehabilitation of medically complex patients who require an extended stay in a hospital setting. LTACs are focused on patients with serious medical problems that require intense, special treatment for a long time (usually about 20-30 days). These patients often transfer from intensive care units in traditional hospitals. It would not be unusual for a LTAC patient to need ventilator or other life support medical assistance. The typical LTAC patient is older with three to six concurrent active diagnoses, or someone who has suffered an acute episode on top of several chronic illnesses.

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Long term care

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Long-term care is a concept that encompasses a full continuum of care provided in a wide variety of settings. It includes everything from long term acute care to nursing home care to assisted living and even hospice care. Such care can be provided in almost every conceivable setting, from an individual's home to a retirement community or even a long-term acute care hospital. Long-term care settings provide a variety of services and supports to meet health or personal care needs over an extended period of time. Most long-term care is non-skilled personal care assistance, such as help performing everyday activities of daily living (ADLs), which are: bathing dressing using the toilet transferring (to or from bed or chair) caring for incontinence eating. The goal of long-term care services is to help you maximize your independence and functioning at a time when you are unable to be fully independent.

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SNFs

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Nursing homes, also called skilled nursing facilities (SNF) or convalescent care facilities, provide a wide range of services, including nursing care, 24-hour supervision, assistance with activities of daily living, and rehabilitation services such as physical, occupational, and speech therapy. Some people need nursing home services for a short period of time for recovery or rehabilitation after a serious illness or operation, while others need longer stays because of chronic physical, health, or cognitive conditions that require constant care or supervision

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Acute inpatient rehabilitation

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A special type of rehab care often required when an individual's medical status requires more intense services that can't reasonably be provided in an alternative setting. Such care settings might be in a hospital or skilled nursing facility or a free-standing facility and are licensed and certified and primarily promote special rehabilitative health care services rather than general medical and surgical services. Examples of conditions requiring acute inpatient rehabilitation include, but are not limited to, individuals with significant functional disabilities associated with stroke, spinal cord injuries, acquired brain injuries, major trauma and burns. The goal is the restoration of a disabled person to self-sufficiency or maximal possible functional independence. An inpatient rehabilitation program utilizes an inter-disciplinary coordinated team approach that typically involves a minimum of three (3) hours of rehabilitation services daily. These services may include physical therapy, occupational therapy, speech therapy, cognitive therapy, respiratory therapy, psychology services, prosthetic/orthotic services, or a combination thereof.

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FIM (Functional Independence Measure)

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is the most widely accepted functional assessment measure in use in the rehabilitation community. The FIM(TM) is an 18-item ordinal scale, used with all diagnoses within a rehabilitation population. It is viewed as most useful for assessment of progress during inpatient rehabilitation.

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What is Case management

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it is a cross-disciplinary and interdependent specialty practice.

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Case management is

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a means for improving clients' health and promoting wellness and autonomy through advocacy, communication, education, identification of service resources, and facilitation of service. Case management is guided by the principles of autonomy, beneficence, nonmaleficence, and justice

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primary function of case managers

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to advocate for clients/support systems

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Case managers' first duty

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coordinating care that is safe, timely, effective, efficient, equitable, and client-centered.

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Case Management Process

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Screening, Assessing, Stratifying Risk, Planning, Implementing (Care Coordination), Following-Up, Transitioning (Transitional Care), Communicating Post Transition, and Evaluating

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Case Management Plan of Care

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Describes: The client's problems, needs, and desires, as determined from the findings of the client's assessment. The strategies, such as treatments and interventions, to be instituted to address the client's problems and needs. The measurable goals - including specific outcomes - to be achieved to demonstrate resolution of the client's problems and needs, the time frame(s) for achieving them, the resources available and to be used to realize the outcomes, and the desires/motivation of the client that may have an impact on the plan

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Level of Care

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The intensity and effort of health and human services and care activities required to diagnose, treat, preserve, or maintain clients' health. Level of care may vary from least to most complex, least to most intense, or prevention and wellness to acute care and services

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The High Level Case Management Process

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Case managers navigate the phases of the process with careful consideration of the client's cultural beliefs, interests, wishes, needs, and values. By following the steps, they help clients/support systems to: Evaluate and understand the care options available to them Determine what is best to meet their needs Institute action to achieve their goals and meet their interests/expectations At the same time, case managers apply: Relevant state and federal laws. Ethical principles and standards such as the CCMC's Code of Professional Conduct for Case Managers with Standards, Rules, Procedures, and Penalties (CCMC, 2009), which applies to persons holding the CCM® credential. Accreditation and regulatory standards. Standards of care and practice such as the CMSA Standards of Practice for Case Management (CMSA, 2010) Evidence-based practice guidelines. And at every phase of the Case Management Process, case managers provide vital documentation.

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Case Management Process:Screening

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The Screening phase focuses on the review of key information related to an individual's health situation in order to identify the need for health and human services (case management services). The case manager's objective in screening is to determine if a client would benefit from such services. Screening promotes early intervention and the achievement of desired outcomes. Key information gathered during screening may include - to the extent available - risk stratification category or class, claims data, health services utilization, past and current health condition, socioeconomic and financial status, health insurance coverage, home environment, prior services, physical/emotional/cognitive functioning, psychosocial network and support system, and self-care ability.

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Case Management Process: Assesssing

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The Assessing phase involves the collection of information about a client's situation similar to those reviewed during screening, however to greater depth. This information may include past and current health conditions, service utilization, socioeconomic and financial status, insurance coverage, home condition and safety, availability of prior services, physical/emotional/cognitive functioning, psychosocial network system, self-care knowledge and ability, and readiness for change. The case manager has two primary objectives while assessing: Identifying the client's key problems to be addressed, as well as individual needs and interests. Developing a comprehensive case management plan of care that addresses these problems and needs. Additionally, the case manager seeks to confirm or update the client's risk category based on the information gathered. Using standardized assessment tools and checklists, the case manager gathers information telephonically or through face-to-face contact with the client, the client's support system, and the clinicians involved in the client's care. The case manager also collects necessary information through a review of current and past medical records, personal health records

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Case Management Process: Stratifying Risk (1)

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The Stratifying Risk phase involves the classification of a client into one of three risk categories - low, moderate, and high - in order to determine the appropriate level of intervention based on the client's situation and interests. This classification allows the implementation of targeted risk category-based interventions and treatments that enhance the client's outcomes

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The Case Management Process: Stratifying Risk (2)

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When stratifying a client's risk, a case manager completes a health risk assessment and biomedical screening based on specific risk factors. These risk factors include the client's blood pressure, substance use, alcohol use, tobacco use, nutrition habits, exercise habits, blood sugar level, lipids profile/cholesterol, emotional health, physical health, access to care and utilization of healthcare services (e.g., emergency department visits or hospitalizations), psychosocial, financial (e.g., limited income, no insurance, underinsurance), and other factors, depending on the risk assessment tool/model applied.

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The Case Management Process: Planning

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Planning phase establishes specific objectives, goals (short- and long-term), and actions (treatments and services) necessary to meet a client's needs as identified during the Assessing phase. During the Planning phase, the case manager develops a case management plan of care that considers inputs and approvals of the client and the client's healthcare providers. The plan is action-oriented, time-specific, and multidisciplinary in nature. It addresses the client's self-care management needs and care across the continuum, especially services needed after a current episode of care. In addition, the case management plan of care identifies outcomes that are measurable and achievable within a manageable time frame and that apply evidenced-based standards and care guidelines. Planning is completed after authorization for the health and human services to be rendered has been given by the payor source and after the services and resources needed have been identified.

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The Case Management Process: Implementing: Care Coordination

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The Implementing phase centers on the execution of the specific case management activities and interventions that are necessary for accomplishing the goals set forth in a client's case management plan of care. This role is commonly known as care coordination. During this phase, the case manager organizes, secures, integrates, and modifies (as needed) the health and human services and resources necessary to meet the client's needs and interests. The case manager shares information on an ongoing basis with the client and the client's support system, the healthcare providers/clinicians, the insurance company/payor, and community-based agencies.

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The Case Management Process: Following-up

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The Following-Up phase focuses on the review, evaluation, monitoring, and reassessment of a client's health condition, needs, ability for self-care, knowledge of condition and treatment regimen, and outcomes of the implemented treatments and interventions. The case manager's primary objective is to evaluate the appropriateness and effectiveness of the case management plan and its effect on the client's health condition and outcomes. During this phase, the case manager gathers sufficient information from all relevant sources; shares information with the client, healthcare providers, and others as appropriate; and documents in the client's health record the findings, modifications made to the case management plan, and recommendations for care. These activities are repeated at frequent intervals and as needed. Following-up may indicate the need for a minor modification or a complete change in the case management plan of care.

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The Case Management Process: Transitioning: Transitional Care

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The Transitioning phase focuses on moving a client across the health and human services continuum or levels of care depending on the client's health condition and the needed services/resources. During this phase, the case manager prepares the client and the client's support system either for discharge from the current care setting/facility to home or for transfer to another healthcare facility or a community-based clinician for further care. These activities are commonly known today as transitional care or transitions of care. In order to maintain continuity of care, this phase's activities entail the complete execution of the client's transition through communication with key individuals (including sharing of necessary information) at the next level of care or setting, the client and client's support system, and members of the healthcare team. Additionally, the case manager educates the client about post-transition care and needed follow-up, summarizes what happened during an episode of care, secures durable medical equipment (e.g., glucose meter, scale, walker) and transportation services (if needed), and communicates these to the client, to the client's caregiver, and to key individuals at the receiving facility or home care agency (if applicable) or those individuals assuming responsibility for the client's care

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The Case Management Process: Communicating Post Transition

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The Communicating Post Transition phase involves communicating with a client/support system for the purpose of checking on how things are going post transition from an episode of care. The case manager inquires about the client's comfort with self-care, medications intake, availability of post-transition services (e.g., visiting nurse services), and presence of any issues or concerns. The case manager solicits feedback regarding the client's experience and satisfaction with services during the care episode. During this phase, the case manager also follows up on issues and problems identified during the post-transition communication and seeks resolution on these issues. In addition, the case manager reports the feedback gathered during the communication to key stakeholders such as payors and providers of care. Depending on the issue or concern identified, the case manager may engage other healthcare professionals to reach resolution.

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Case Management Concepts

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The Case Management Concepts domain consists of knowledge associated with the Case Management Process, resources, and skills needed to ensure the effective and efficient delivery of safe, quality health and human services to clients/support systems.

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ACO

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An acronym for Accountable Care Organization

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Actuary

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A person in the insurance field who decides insurance policy rates and reserves dividends, as well as conducts various other statistical analyses

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Parternship for Health ACT 1966

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recognized health promotion and illness prevention as a " State of complete physical, mental, social well being

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Assessment tool and diagnostic tests

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tools used for evaluating risk and outcomes asessment tool

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Glascow coma scale and Ranchos Los Amigos( cogitive scale)

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tools used to access brain injured patients

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psychiatric disability

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term that can be associated with various types of illness or injury not just psych

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HAART

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highly active antiretroviral therapy

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Psychiatric Disablity

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a silent comborid condition can affect a patients physical health and quality of life

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Dual Diagnosis

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Substance abuse and mental health combined diagnosis

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polypharmacy

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unintended duplication of drugs that usually results when patients see multiple physicians or frequent numerous pharmacies using homeopathic, supplemental,or OTC or herbal medcicnes also put individuals at risk for what?

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unintentional polypharmacy

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seeking competitive drug pricing or when useing various pharmacies with locations near work, home, social events. See it in older adults who visist mutliple physicians

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Managed Care OrganIzation ( MCO)

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what can help prevent polypharmacy

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intentional polypharmacy

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addicted to drugs is an example of

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IT software systems

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IT software now can notify ordering MD about potential abuses ie polypharmacy. Can interface with disease managment where pharmacy daa and claims data are used to stratify health patterns and health profiles of patients

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Blinking light for MD's

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taking 5 or more medications using different pharmacies to fill scripts

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chronic pain

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people you have chronic pain develop a dependency fro a pain med regimen that allows them to tolerat their daily living activites and lead a fairly normal life. they do get the label of addicted drug-seeking patients

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BASIS 32

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a common and effective assessment tool for the patient suspected of having substance abuse/mental health

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Identification of patient

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First step in CM process

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utilization management

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computer software helps ID cases for CM flag the ones that exceed a certain amount of money or hospitalization is found in which department

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consultation

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the act of conferring with another individual for the purpose of gaining an opinion or advice is known as

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physician

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keep decision maker

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autocratic

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sole responsbility legally and ethically for physicians can be

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Medication Thearpy Managment

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used in Medicare and Medicaid part B

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collaboration/communication

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The glue that binds all the process of Case management together

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frontal lobe injury

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problems with activities involving planning, organizing and problem solving poor attention personality changes

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occipital lobe

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visual problems

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Temporal lobe

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short term memory loss inablity to process information smell and sound deficienies

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Left parietal lobe

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written spoken language problem

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right partietal lobe

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visual deficits diffculty negotiating new or familar places

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C3 or higher

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vent support

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T6 or higher

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autonomic dysreflexia a life threatening condition that presents with a pounding headache, profuse sweating episodic high blood pressure, bradycardia

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lumbar spine

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paraplegia

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sacral spine

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assistive devices when ambulating( cane walker braces)

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autonomic dysreflexia

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full bladder, fecal impaction, tight clothing

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Benchmarking

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the ongoing process of measuring products, services, and practices against competitors or leaders in a given specialty

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Case Managment

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a managment technique to achieve opitmal otucomes and efficient resource utilization for a given patient population

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continous quality improvement

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the cyclical process to assess, measure, change a process, re-measure, and reassess for ongoing incremental improvments

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Outcomes Managment

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The process of assessing mutliple factors including casre effectiveness, side effects, adminsistrative and geneal costs, and patient satisfaction

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Practice Parameters

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the pulbished guidelines for patient managmened which includes proctocols, critical paths, and algorithms

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Re-engineering

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Fundamental rethinking and radical redesign of business processes to achieve dramatic improvments in measures of preformance

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Value Analysis

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balancing the cost and quality effects of care by improving care delivery processess, and eliminating unnecessary care variances

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Disease Management

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The continous porcess of identigying and delivering the most efficinet combination of resources for the treatment or prevnetion of disease, within a selected patient population

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preclinical

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invivo, invitro

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Phase 1

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first times in humans

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Phase 2

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exploratoy

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Phase 3

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confirmatory

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phase 4

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post marketing

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P-value porpability

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0.0-1.0 < 0.05 statistically significant

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Single Blind

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investigator knows treamtent paitent is receiveing

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open label

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both the patient and investigator know the treatment patient is receiving

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Double blind

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neither investigator nor pt know treament patient is receiving

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Compartive effectiveness

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a rigorous evaluation of the impact of different opitons that are available for treating a given medical condition for apraricualr set of patients

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Comparive effectiveness research

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to assist consumers and clinicians, purchasers, and policy makers to make informed decisions that will imporve health care at both the individual and population level. This helps CM to appropriatley influncene patient decisions

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...

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Case managers need to understand and embarace evidence before teaching others, get in the habit of reviewing pertinent evidence in the literature.

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Accountable Care Organization

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an entity charged with the bundling of care services of hospitals, physicians, other entities and care providers who are delivering services during an episode of care. Providers/organizations share in the cost savings achieved as a result of coordination

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Adjudication

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the process of completing all validity, process, and file edits necessary to prepare a claim for final payment or denial, or the processing of a claim through a series of edits to determine proper payment.

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ADL

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an acronym for " activites of daily living"

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Adminstrative Costs

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The Costs assumed by a managed care plan for administrative servies, such as claims processing, billing, and overhead costs

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Adverse Selection

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The risk of enrolling members who are sicker and will require more medical services than initially assumed and who will utilize more expensive servies more frequently

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Affordabale care Act

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another name for Patient Protection and Affordable care Act

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Aftercare

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services adminsistered after hopsitalization or rehabilitation that are individualized fro each patient's needs

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Age/Sex Rating

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structuring premium payments based on members age and gender

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AHA

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an acronym for American Hospital Association

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AIDS

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an acronym for Acquired Immunodeficiency Syndrome

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Alcoholism

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A mental and/or physical depenence on alcohol due to chronic and habitual use

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Alcoholism or Drug addiction treatment facility

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a legally operated, free standing facility or clinic, or part of a hospital that specializes in alcohol or drug adiction treatment programs. these porgrams operate under the direction of Doctors of Medicine or Doctors of Osteopathy, having nursing servies and are accredited by the Joint Commission ( JCAHO) or meet similar standards

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Allowable Charge

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a charge based on amounts accepted by other providers in the area of similar treatment, care services or supplies. It is the maxium fee that a third pary will reimburse a provider for a given service

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ALOS

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An acronym for " Average length of stay" It is a benchmark average used for analysis of utilization. It is calcualted as the average number of patient hospitalization days for each admission, articulated as an average of population within the plan for a given period of time

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Alternate Care

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meidcal care received in lieu of inpatient hospitalization. Examples include outpatient surgery, home health care, and skilled nursing facility care. It also may refer to non-traditional care delivered by providers such as midwives

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AMA

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an acronym for American Medical Association

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Ambulatory Care

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health services delivered on an outpatient basis. If a patient has an appointment in the doctors office or a surgical center without an overnight, it is considered ambulatory care

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Ambulatory Setting

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A type of health care setting where health servies are provided on an outpatinet basis. Ambulatory setting usually include physician's offices, clinics, and surgery centers

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Ambulatory Surgery

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A surgical procedure in which the paitent is admitted, treated, and released on the same day

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Ambulatory Surgical Center

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a legally operated facility that specializes in surgical procedures and has a staff of Doctors of Medicine or Doctors of Osteopahty, along with RN services. An ambulatory srugical center does not have facilities of patients to stay overnight, and it is acredited by the Accreditation Association for ambulatory healthcare or meets similar standards

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Appeal

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a formal request by a covered person or provider for resconsideration of a decision,k such as a utilization review recommendation, a benfit payment( claim) or administrave action

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ASO

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An acronym for porviding " administrative service only. It is a contract stipulation between a plan and inurance cmpany in which the insurance company assumes no risk and provides only adminstratrive services for a fixed fee per employee

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Assignment

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An arrangement in which the provider submits the claim on behalf of hte aptient and is reimbursed direclty by the patients plan.

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Authoriation ( also called Pre-authoriation or Pre-certification

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In managed care it r3efers to the approval of care, such as a hospitalization, certain diagnositce test, or even non covered medications. Preauthoiration may be required before admisttion takes plan or care is given by non-managed care providers

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AWP

answer

When referring to medications, it is an acronym for " average wholesale price". It is the pulished average cost of a drug product by the pharmacy to the wholesaler. It is psecific to drug strength, dosage from ( capsule, tablet solution, vial) package size, and manufacturer or labeler. When it is not referring to medications, this abbreviation also stands for " any willing provider " Statues requiring a provider network to accept any provider who meets the network's usual selection criteria

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Behavioral Health Care

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Treatment of menatla health and/or substanc abuse disorders

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Beneficiary

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any peson or persons named by a policyholder to receive the policy holder's insurance benefits or coverage

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Benefit Level

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The limit or degree of services a person is entitled to receive based on his or her contract with health plan or insurer

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Benefit Package

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th services an insurer, goverment agency,health plan, or employer offers under the terms of a contract

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Cafeteria Plan

answer

a corporate benefits plan under which all employees are permitted to choose among two or more benefits that consist of cash and certain qualifed benefits. Cafteteria plans are also called flexible benefit plans or flex plans

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Calendar year

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The inclusive period of time from January 1 of any year through December 31 of the same year. This is most often used in connection with deductible amount provisions of major medical plans providng benefits for expenses incurred within the calendar year.

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CapM

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the contract maximum, which is the limit or " cap that the insurance company will pay out for a given individual.

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Capitation

answer

A method of payment used in manged care as per-member monthly payment to a provider that covers contracted servies and is paid in advance of its delivery. In essence, a provider agrees to provide specified services to health plan members usually in a health maintenance organization( HMO) for this fixed, predetermine payment for a specified length of time (usually a year) regardless of how many times the member uses the service. The rate can be fixed for all members or it can be adjusted for the age and sex of the member, based on actuarial projections of medical utilization

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Carrier

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The insurance company which holds the financial risk and is responsible for adminstering the plan benefits

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Certificate of Coveage

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a descripiton of the benefits included in a carrier's plan. The certificate of coverage is required by state laws and respresents the coverage provided under the contract issued to the employer

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CHAMPUS

answer

An acronym of Civilian health and Medical Program of the Unifored Services. Is the federal medical beneifts reimbursment program for dependents of military personnel, military retirees, and others. It is now known as TRICARE

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Charge

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A charge is deemed to incurred on the date on which the treatment, care services or supply is made or given. If it is not shown otherwise and a single charge is made for a series of treatments, servies, supplies, or care sessions each will be deemed to bear a pro rata share of the charge

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Chemical Dependency Services

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Servies and supplies used in the diagnosis and treament of alcoholism, chemical dependency, and drug dependency which is defined and classifed by the US department of Health and Human Services

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Claim Lag

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service and its submission; as well as the time between the incurred date of the claim and its payment.

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Claim Manual

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Th administrative guidelines used by claims processors to process claims according to company policy and procdure.

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Claims Reviewer

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a payer employee who reviews claims like an auditor,looking at coding, prior authorizations, contract viloations etc

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Clinical Peer Reviewer

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A health care professional that holds license in at least one state, who is in the same or similar specialty as the medical condition, procedure, or treatment being subjected to utilization review, and who routinely provides the health care services being subjected to utilization review

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COB

answer

an acronym for " coordination of benefits". It is an agreement that prevents double payment for services when the member is covered by two or more sources. the agreement dictates which organization is primarliy and secondarily responsible for payment.

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COBRA

answer

An acronym for Consilidated Omnibus Reconciliation Act. IT is the legislation that in part requires employers to offer terminated employees the opportunity to continue buying insurance coverage as part of the employee's group

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Coinsurance

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The percentage of the costs of medical servies paid by the patient. It is a characteristic of different types of insurance plans, including managed care plans. The coinsurance payment is usually about 20 % of the cost of the medical servies after the deductible is paid

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Comorbidity

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Pre-existing conditions that cause an increase in length of stay by at least one day in ~75% percent of case. It is used in DRG reimbursment

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Concurrent review

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a screening method by which a health care provider reviews a procedure or hospital admission performed by a colleague to assess its necessity

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Continuum of care

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Clinical services provided during a single inpatient hospitalization, or for mutliple condition over a lifetime. It provides a basis for evaluating quality , costs, and utilization over the long term

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Co-payment or Co-pays

answer

A nominal, out of pocket fee paid by the patient. It is a fee to help offset paperwork and other administrative costs for each office visit, prescripiotn filled or diagnositc test. Today, nearly all health plans have implemented multi-tiered co-pays particualry for pharmacy benefits. In managed care plans, the member pays the copayment while checkin in for his or her appointment. Services subject to a copayment are not subject to deductible and coinusrance. For example, a prescripiton for a generic drug may be associated with only a $ 7.50 copay; a prescripition for a preferred brand name drug my have a $ 15 co-pay and a co-pay for a nonpreferred brand name drug may be $50

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Covered Charges

answer

Charges for medical care and supplies for which the insurance plan will pay

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CPT code

answer

a unique set of 5 digit identifying numerical code that accompanies a list of medical services performed by physicians and other health care providers. CPT codes are developed and maintained by the American Medical Association. It has become the industry coding standard for reporting.

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CPT Modifers

answer

Additional codes that indicate that a service was altered in some way from the stated CPT description without actually changing the basic definition of the service. Modifiers can indicate: a service or procedure that has both a professional and a technical component; a service or procedure that was preformed by more than one physician; that only part of a service was performed; that an adjunctive service was performed; that a bilateral procedure was preformed; that service or procedure was provided more than once; an unusual event occurred, or a procedure or service was altered in some way. A compete listing of all modifiers used in CPT coding is located in an appendix of CPT

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CQI

answer

an acronym for " continous quality improvment"

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Credentialing

answer

The reviewing of medical degrees, licensure, malpractice and any disciplinary record of medical poroviders to determine if they should be entitled to privileges at a hospital, health system or to contract with a managed cae organIzation. Credentialing is usually preformd for panel and quality assurance purposes

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Critical Care

answer

THE CARE OF CRITCALLY ILL PATIENTS IN A VARIETY OF MEDICAL EMERGENCIES THAT REQUIRES THE CONSTANT ATTENDANCE BY THE PHYSICIAN( CARDIAC ARREST, SHOCK, BLEEDING, RESPIRATORY FAILURE, POSTOPERATIVE COMPLICATIONS, OR CRITICALLY ILL NEONATE

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D/C

answer

An abbreviation used for either " discharge or discontinue

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Days per Thousand

answer

a standard unit of measurement of utiliztion determined by calculating the number of hospital days used in a year of each thousand covered lives

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Deductible

answer

A fixed amount of helath care dollars of which a person must pay 100% before his or her health benefits begin. Most indemnity plans feature a $200 or $1200 deductible, and then pay up to a defined percentage of money spent for covered services above this level

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Dependent

answer

An individual who receives health insurance through a spouse, parent , domestic partner, or other family member

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Diagnosis

answer

The identification of a condition, disease, or syndorme and its implications, via examination

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Disallowance

answer

a denial by a health care payer for portions of the claimed amount. Examples could include coordination of benefits, services that are not covered, or amounts over the fee maximum

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Discharge plan

answer

a plan submitted by a provider to the case manager as part of the treatment arrangement that details follow-up care after discharge

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Disenrollment

answer

The procedure of dismissing individuals or groups from their enrollment with a health care carrier

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DME

answer

an acronym for " durable medical equipment" which includes permanent equipment meant to be used for medical treatment

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DOS

answer

An acronym for " date of service" refers to the date on which the care was provided

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DRG

answer

An acronym for " diagnosis related group"; refers to a statistical system of classifying any inpatient stays into groups, for purposes of payment. DRGs may be primary or secondary, and an outlier classification also exists. It is also the form of reimbursement that the Centers of Medicare and Medicaid services ( CMS )uses to pay hopsitals for medicare patients. They are also used by a few states for all payers and by some private health plans for contracting purposes.

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Drug Addiction

answer

Mental and/or physical dependence on drugs other than alcohol due to chronic and habitual use

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EAP

answer

An acronym for "employee assitance program" refers to employer provided, short-term counsleing that is offered to members to quickly resolve transient emotional problems and to identify on-going mental or substance abuse problems for susequent referral. EAPS are often limited to a handful of visits.

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Economic Waste

answer

any intervention for which the value of expected benefit is less than the expected costs. More common than medical waste b/c of third party payment

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EDI

answer

An acronym for "electronic data interchange" EDI refers to the electronic transference of information such as claims, certifications, quality assurance reviews, and utilization data

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Eligible Dependent

answer

a dependent of a covered employee who meets the requirments specified in the group contract to qualify for coverage

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Eligible Employee

answer

an employee who meets the eligibility requirment specified in the group contract to qualify for coverage

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ELOS

answer

An acronym for " estimated length of stay"; refers to the average number of days of hospitalization required for a given illness or procedure. It is based on prior histories of patients who have been hospitalIzed for the same illness or procedure.

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Emergnecy Medical Treatment

answer

Treatment of patients in emergency medical situations; includes the treatment , care, services or supplies furnished or required to screen for evaluate, and treat a patient until they are stabilized.

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Emergicenter

answer

A health care facility, the primary purpose of which is the provision of immediate, short-term medical care for urgent medical conditions

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Employee Contribution

answer

The portion of the insurance premium paid by the employee

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Enrollee

answer

The person who subscribes to a specific health plan

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EOB

answer

an acronym for " explanation of benefits" It is a statement mailed to the health plan or insured member( and sometimes provider) explaining claim and payment

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Episode of Care

answer

All treatments rendered in a specifed time frame for a specific disease

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EPO

answer

An abbreviation for Exclusive Provider OrganIzation, An EPO is a form of preferred provider organization of PPO, in which patients must visit a caregiver that is on its panel of providers. If a visit to an outside provider is made, the EPO will offer limited or no coverage for the office/hospital visit.

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ERISA

answer

An acronym for Employee Retirement Income Security Act. This act has several provisions protecting both the payer and member, including requiring that payers send the member an EOB when a claim is denied

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Exclusions

answer

Also referred to as exceptions; refers to services or drugs not covered by the health plan/insurance

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Experimental drugs

answer

Drugs that are still being investigated. They are not yet approved by the Food and Drug administration ( FDA) for any use. Additionally, there is not enough accumulated scientific data to establish medically appropriate use of the drug for treatment of a disease. However, the FDA has established programs to allow patients with an immediately life-threatening disease " early access" to new treatments. Since patients who have exhausted standard therapeutic options may be willing to accept additional risks and potentially dangerous side effects from drug products still under study, these programs allow patients access to invesigational drugs. Experimental/investigational drugs are usally excluded benefits in managed care organizations and therefore are not covered for enrollees.

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Extended care Facility

answer

A nursing home or other long-term setting that offers skilled, intermediate, or cusodial care.

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Extension of benefits

answer

A component of some health care insurance ploicies that allows medical coverage to continue past the termination date of the policy for employees not activley at work

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FDA

answer

Anacronym for the United States ( US) Food and Drug Adminstration

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Fee-for-services( FFS)

answer

traditional provider reimbursement in which the physician is paid according to the service performed. this is the reimbursment system used by conventional indemnity insurers

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Fee schedule

answer

The maximum fees a plan will pay for servies, primarly listed by CPT code

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Fee-for-services( FFS)

answer

this is the reimbursment system used by conventional indemnity insurers

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Formulary

answer

A specific list of drugs that are covered within a given health plan ( MCO) , health system or hospital which may be used in patients that are being cared for in that particular setting. The list is continually updated as new information about medications becomes available. When drugs are reviewed for formulary inclusion, efficacy and safety are considered first, follwed by cost. If, however, the safety and efficacy are the same for agents being reviewed, cost may be considered first. the formulary usually includes other information on related products and information, representing the clinical judgement of physicians, pharmacists, and other experts in the diagnosis and/or treatment of disease and health promotion. The most common types of formularies are closed and open formulary. They may also be referred to as a preferred drug list

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freestanding Outpatient Surgical Center

answer

A healthcare facility, that is physically separate from a hospital, which provides pre-scheduled outpatient surgical services. It may also be called a surgicenter.

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Gate Keeper

answer

a practice in which a member's care must be provided by a primary care physician ( PCP), unless the physician refers the memnber to a specialist or approves the care porvided by a specialist. Many health Maintenance Organizations ( HMOs) rely on the PCP to be th "gatekeeper". This health care provider screens patients seeking medical care and effectively eliminates costly and sometimes needless specialty referrals for diagnosis and managment. The gatekeeper is responsible for administration of the patient's treatment and must coordinate and obtain authoriation for all medical service's laboratory studies, specialty referrals, and hopspitalizations. In most HMOs if an enrollee visits a specialist without piror authorization from his or her designated PCP, the enrollee must pay for medical services. Sometimes enrollees have plans that do not require specialist referral; in these cases the enrollee would not be subject to " gatekeeping" by their PCP.

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Generic Drug

answer

A prescription drug which is known by its common name reather than a brand or branded name. Its active ingredient is equivalent to its brand name counterpart. By law, generic durgs must meet the same standards for safety, purity, strength, and effectiveness as brand name drug. Generic drugs are a chemically equivalent copy of the brand name drug whose patent has expired and they are typically less expensive.

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Grace Period

answer

the period of time after a member has terminated employment, for which he or she is still covered.

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GxT

answer

an abbreviation which stand for " graded exercise test"

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Handoff

answer

A type of care transition. Typically refers to a patient changing providers or settings within one level of care. Includes a temporary transfer of care, such as from inpatient, clinic, or ED or to OR, porcedure area, or diagnostic area; can also include a change in provider or change in service, such as nursing staff shift change, resident sign-outs, or house staff rotation change.

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handover

answer

another name for handoff

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HCFA

answer

an acronym for Health care Financing Administration, which is now known as CMS. This is the federal agency that oversees all of the money for Medicare.

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HCPCS

answer

An acronym for the HCFA's common procedural coding system. They are codes used by medicare and other payers to describe products, procedures and supplies

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HCPCS Modifiers

answer

Modifiers should, or in some cases must, be used to idenify circumstances that alter or enhance the description of a service or supply. They are recognized by carriers nationally and are updated annually by CMS. Level II/Local modiferes are assigned by individual Medicare carriers and are distributed to physicians and suppliers through carrier newsletters. The carrier may change, add or delete these local modifiers as needed.

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Health Care and Education Reconciliation Act

answer

Signed into law on March 30,2010. Commonly referred to as " Health care reform" when taken in conjunction with the Patient Protection and Affordable care Act of 2010.

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Health Care Reform

answer

Common term for the collective changes to the health care industry as a result of the Patient Protection and affordable care Act of 2010 in conjunction with the Health care and Education Reconciliation Act of 2010

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Health Maintenance Organization HMO

answer

A form of health insurance in which its members pre-pay a premium for healthservices, which generally includes inpatient and ambulatory care. For the patient, it means reduced out-of-pocket costs( no deductible), no paperwork( insurance forms, and only a small co-payment for each office visit to cover the paperwork handled by the HMO

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Staff Model

answer

Employs providers directly and directs care through clinics, where everything is in one place ( centralized). Physicians are more like employees for the HMO in this setting rather than employees of a group or private practice.

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Group Model

answer

Contracts with a closed panel of physicians which are paid a fixed amount per patient to provide specific sevices to them

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IPA( Independent Physician/Practice Association)

answer

Contracts with independent physicians practicing individually or in single specialty groups; these physicians also usually see fee-for-service patients ( non-HMO) as well. They are paid by capitation for the HMO patients and by traditional means for their non-HMO patients

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POS( Point of Service)

answer

Patients can receive care by both physicians contracting or not contracting with the HMO. This sometimes called an "open-ended" HMO. Physicians not contacting with the HMO but who see HMO patients are paid according to the services provided. The patient is incentivized to see contracted providers within the HMO

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HEDIS

answer

An acronym for Health Plan Employer Data and Information Set. HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. It is a set of performance measures that are utilized to assist employers and other health purchasers in understanding the value of health care purchases and evaluating health plan performance. Considered a quality measurement. this is a way for health plans to simplify and standardize measurement and reporting. Currently , HEDIS consists of 71 measures across eight care domains. HEDIS makes it possible to compare the health plan performance on a comparable basis. Health plans also use HEDIS measures themselves to see where they need to focus their improvement efforts. Some examples of HEIDS measures include: Childhood immunizations, use of appropriate medications in people with asthma, controlling high blood pressure, and flu shots for adults 50 years and older. Physicians are required to comply to HEDIS guidelines for recredentialing with most HMO Plans.

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HHA

answer

an acronym for " home health agency"

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HIV

answer

an acronym for "human immunodeficiency virus"

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Home Health Agency

answer

A legally operated facility that primarily provides skilled nursing services to patients in their homes. It operates under the direction of a Doctor of Medicine or Doctor of Osteopahty. It maintains clinical records and qualifies as a home health agency under Medicare. It does not include any facility that primarily provides care or treatment for mental disorders

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Home Care

answer

In contrast to inpatient and ambulatory care, home care is medical care ordinarily administered in a hospital or on an outpatient basis, however, the patient is not sufficiently ambulatory to make frequent office or hospital visits. For these patients, intravenous therapy, for example is administered at the patient's residence, usually by a health care professional. Home care reduces the need for hospitalization and its associated costs.

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Hospice

answer

A service program, either inpatient or outptient, which offers palliative support, counseling, and daily resources to the terminally ill and their family members, working diligently to make the patient as comforatble and pain-free as possible.

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IBNR

answer

An acronym for " incurred but not reported" Refers to expenses. It is the financial accounting of all services that have been performed but have not yet been invoiced or recorded.

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ICD

answer

An acronym for International Classification of Diseases, which is a statistical classification system consisting of a listing of diagnoses and identifying codes for reporting diagnosis of health plan enrollees identified by physicians. It includes coding and terminology to accurately describe primary and secondary diagnosis and provide for consistent documentation for claims Classification is primarily numeric. The codes are revised periodically by the World Health organIzation; the current version is ICD-10

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ICF

answer

An acronym for " Intermediate care facility". An ICF is a step-down facility for patients leaving the hospital but who cannot be discharge to home because of continuing medical needs

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IDS

answer

An acronym for Integrated Health Care Delivery Systems, which are health care financing and delivery organizations created to provide a " continuum of care" ensuring that patients get the right care at the right time for the right provider. This continuum of care from pirmary care provider to specialist and ancillary provider under a " coroporate roof guarantees that patients get cared for appropriately thus saving money and increasing quality of care

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Indemnity Insurance

answer

Traditional fee-for service ( FFS) coverage in which providers are paid according to the service performed.

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IPA

answer

An acronym for Individual practice association. This is an organization made up of providers who, along with the rest of a group, contract with payers at a discounted fee-for service or capitated rate

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IS

answer

An acronym for " information services", which are the administrators of the computer systems used by payers and providers

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JCAHO

answer

An acronym for the Joint Commission for the accreditation of Health Organizations, now know as the Joint Commission. They are the primary accrediting body for hospitals, outpatient facilities, and other facilities such as freestanding ambulatory care facilities, assisted living facilities, behavioral health care facilities, home care provider facilities, hospital laboratory servies, long-term care organizations, and office-based surgical facilities. This non-profit organization audits these facilities and was previously known as the Joint Commission for the Accreditation of hospitals.

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Legend Drug

answer

another name for a prescription drug. It bears the legend, " Caution: Federal Law prohibits dispensing without a prescription"

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Length of Stay

answer

The number of consecutive days a patient is hospitalized. It is abbreviated as LOS

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Lifestyle Drugs

answer

Drugs designed to improve the quality of life or extend the normal life span. They generally are not used to treat a life-threatening disease. These may include drugs that would restore or improve sexual potency, enchance weight loss, restore hair growth, or reverse the effects of aging. These drugs are often excluded from coverage in MCOs and other insurance plans.

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LOS

answer

An acronym for " length of stay"

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Limits

answer

A term that describes the ceiling for benefits payable under a plan

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Long-Term care facility

answer

Services that ordinarily are provided in a skilled nursing , intermediate care, personal care, supervisory care, or elder care facility.

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Loss Ratio

answer

The ratio between the cost to deliver medical care and the amount of money taken in by the plan

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Mail-Order Pharmacy

answer

A growing number of HMOs and Pharmacy Benefit Managment ( PBM) companies affiliated with corporations or federal contracts use a mail-order pharmacy program to provide their members with discount drug rates delivered through the mail to their home. Mail-order pharmacies can purchase drugs in large volumes, and therefore the prices tend to be cheaper, which they pass on to the enrollees. some HMOs and PBMs mandate mail-order prescripitons for all long-term ( maintenance) medications.

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Mandated Benefits

answer

Services mandated by state or federal law such as in child abuse or rape, and are not necessarily covered by insurers.

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Maximum Allowable Charge MAC)

answer

An amount set by the insurer as the highest amount to be charged for a particular medical service or pharmaceutical product.

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MCO

answer

An acronym for "managed care organization". It is a generic term for exclusive provider organization (EPO), HMO, and others

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Medicaid

answer

Federal and state health insurance for qualified low-income people.

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Medical Home

answer

Another name for Patient-Centered Medical Home.

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Medical Waste

answer

Any intervention that has no possible benefit for the patient, or in which the potential risk to the patient is greater than the potential benefit. Occurs if the provider is misinformed; if the patient is misinformed and the provider succumbs to patient demands; or if the provider behaves unethically.

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Medically Necessary and Appropriate

answer

The most cost-effective level or type of treatment, care, service, or supply that is consistent with the illness, injury, or other condition under treatment or care, based on the patient's overall medical history, condition, and prognosis, and current, generally accepted medical practice.

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Medicare

answer

The national program that provides medical care to the elderly, certain people with disabilities, and those who have End Stage Renal Disease (ESRD). This program was established by Title XVIII of the Social Security Act.

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Medicare Plus Choice ( Medicare Advantage Plans)

answer

The program of medical care benefits established by Title XVIII of the Social Security Act, providing an HMO option. Extra benefits and lower co-pays are typical.

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Medication Therapy Management

answer

A distinct service or group of services that optimize therapeutic outcomes for individual patients and that are independent of, but can occur in conjunction with, the provision of a drug product. A partnership of the pharmacist, the patient or the caregiver, and other health professionals that promotes the safe and effective use of medications and helps patients achieve the targeted outcomes from medication therapy.

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Member

answer

A participant in a health plan who makes up part of the plan's enrolled population. This term is used to describe both employees and dependents.

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Mental Disorder

answer

A psychotic, neurotic, personality, or other mental or emotional disease or disorder. For policy purposes, alcoholism and drug addiction are not mental disorders, but they are illnesses.

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MSA

answer

An acronym for "medical savings account". An MSA is used to pay for routine medical care, and unused funds may be rolled over for use in the following year.

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MTMP

answer

An acronym for Medication Therapy Management Program

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Multi-Source Brand Drug

answer

Prescription drugs available from more than one manufacturer and have at least one generic equivalent alternative available.

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National Transitions of Care Coalition

answer

A group of concerned organizations and individuals who have joined together to address problems associated with transitions of care. Founded in 2006 by the Case Management Society of America (CMSA) and sanofi-aventis US to define solutions addressing those gaps that impact safety and quality of care for transitioning patients.

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NAIC

answer

An acronym for National Association of Insurance Commissioners, which is an organization of state insurance regulators.

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NCQA

answer

An acronym for National Commission for Quality Assurance. The NCQA is an independent non-profit organization that assesses the quality of managed care plans, preferred provider organizations (PPOs), etc.

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Network

answer

A defined group of providers typically linked through contractual arrangements, which supply a full range of primary and acute health care services. A "closed" network is one in which beneficiaries are not allowed to access non-network providers, whereas an "open" network allows access to other providers at some cost to the beneficiary.

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Network Provider

answer

Any provider deemed to be a member of the network of providers under the policy with regard to a person at the time treatment, care, services, or supplies are provided to that person.

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Non-Network Provider

answer

Any provider not meeting the policy definition of a network provider at the time treatment, care, services, or supplies are provided

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Nonparticipating Provider ( also called a Non-par provider)

answer

A health care provider who has not contracted with the carrier or health plan to be a participating provider of health care within that particular plan or insurance.

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NTOCC

answer

An acronym for National Transitions of Care Coalition.

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Off-Label Use

answer

The use of a drug for clinical indications other than those stated in the product labeling approved by the Food and Drug Administration (FDA). For example, if there was a drug that received FDA approval for treating diabetes and it was being used to treat cancer, its use would be off-label in this particular case. This is often done with cancer drugs, where it is approved for certain cancers but not others.

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OOA( Out-Of Area)Charge

answer

A covered charge for treatment, care, services, or supplies provided by a non-network provider to a patient who resides outside the PPO area (whether or not the provider is located outside the PPO area). Covered charges are defined, with limits and exclusions, under major medical expense benefits and medical care benefit exclusions.

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OON ( Out of Network ) Charge

answer

A covered charge for treatment, care, services, or supplies provided by a non-network provider to a patient who resides inside the PPO area (whether or not the provider is located inside the PPO Area). Covered charges are defined, with limits and exclusions, under major medical expense benefits and medical care benefit exclusions.

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Open enrollment period

answer

The period during which an MCO allows people not currently enrolled in their plan to sign-up for plan membership

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OTC

answer

An acronym for over-the-counter, which usually refers to non-prescription drugs.

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Out -of Plan

answer

This refers to choosing a provider who is not a member of the preferred provider network.

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Out-Of -Pocket Costs

answer

The share of health services payment made by the enrollee, or the expenses that the enrollee must pay on his/her own

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Out-of-Service Area

answer

This refers to medical care received out of the geographic area that may or may not be covered, depending on the plan

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Outpatient

answer

A person who receives treatment, care, services, or supplies other than in an inpatient or partial hospitalization setting.

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Patient-Centered Medical Home

answer

An approach to providing comprehensive primary care that facilitates partnerships between individual patients, their personal providers, and when appropriate, the patient's family. May allow better access to health care, increased satisfaction with care, and improved health.

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Patient Protection and Affordable Care Act

answer

Signed into law on March 23, 2010. Commonly referred to as "health care reform" when taken in conjunction with the Health Care and Education Reconciliation Act of 2010.

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P & T Committee

answer

An abbreviation for Pharmacy and Therapeutics Committee. The P&T committee is an advisory committee responsible for developing, managing, updating, and administering the drug formulary system. P&T committees are also usually charged with developing and/or approving drug-related guidelines or programs within the health-system. P&T Committees can be found in MCOs, PBMs, hospitals and other related health systems and are usually comprised of PCPs, specialty physicians, pharmacists, and other health care professionals. Committee members may also include nurses, legal experts, and administrators

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PA

answer

An abbreviation for physician assistant.

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PAC

answer

An abbreviation for pre-admission certification.

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Par Provider

answer

Shorthand for a provider who is participating in a health care plan.

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Partial Hospitalization

answer

A situation in which the patient only stays part of each day over a long period. Cardiac, rehabilitation, psychiatry, and chronic pain patients, for example, could use this service.

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PBM

answer

An acronym for a "pharmacy benefit management" company. PBMs are organizations that manage pharmaceutical benefits for managed care organizations, other medical providers or employers. PBMs contract with clients interested in optimizing the clinical and economic performance of their pharmacy benefit. PBM activities may include some or all of the following: benefit plan design, creation/administration of retail and mail service networks, claims processing and managed prescription drug care services such as drug utilization review, formulary management, generic dispensing, prior authorization and disease and health management. PBMs can be stand-alone companies, or a health plan can have its own "in-house" PBM that acts in the same capacity as a PBM company. PBM staff can be HMO staff who monitor the amount and use of prescribed drugs

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PCP

answer

An abbreviation for "primary care physician". As noted, this physician is sometimes referred to as the "gatekeeper." This is because the primary care physician is usually the first doctor a patient sees for an illness. The physician then directly treats the patient, refers the patient to a specialist (secondary care), or admits the patient to a hospital. Often, the primary care physician is a family doctor or internist, but can also be an internist, a family practitioner, a pediatrician, or an obstetrician/gynecologist.

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Peer Review

answer

Evaluation of a physician's performance by his/her peers.

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Per Diem Reimbursement

answer

Reimbursement to an institution based on a set rate per day rather than on a charge-by-charge basis.

question

answer

An acronym for "physician identification number

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PMPM

answer

An acronym for "per member per month". PMPM is often used in the context of pharmacy or medical costs; the cost of providing a particular medical service stated as the average cost to provide that service to one member for one month.

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POS

answer

An acronym for "point of service". This refers to a plan in which members do not have to choose services (HMO vs. traditional) until they need them. Benefits may differ by choice and members may be financially motivated to choose managed care plans. (This could also refer to Place of Service or Point of Sale.)

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POS

answer

An acronym for Place of Service/Point of Service/Point of Sale.

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Preadmission Certification

answer

The practice of reviewing claims for hospital admission before the patient actually enters the hospital. This cost-control mechanism is intended to eliminate unnecessary hospital expenses by denying medically unnecessary admissions.

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Pre-Certification ( also Known as Pre-Authorization or Pre-auth)

answer

In managed care it refers to the approval of care, such as a hospitalization, certain diagnostic tests, or even non-covered medications. Preauthorization may be required before admission takes place or care is given by non-managed care providers.

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Pre-Existing Condition

answer

Any medical condition that has been diagnosed or treated within a specified period before the member's effective date of coverage under the group contract. There is often a short delay in beginning coverage when a pre-existing condition is present.

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Preferred Providers

answer

Physicians, hospitals, and other health care providers who contract to provide health services to persons covered by a particular health plan.

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Prescription Drugs

answer

Medicines which can only be obtained by law with a qualified practitioner's written prescription. For the purposes of the policy, nitroglycerin, insulin, and insulin injection syringes are also often deemed to be prescription drugs.

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Preventive care

answer

Health care emphasizing priorities for prevention, early detection, and early treatment of conditions, generally including routine physical examination, immunization, and well-person care.

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Primary Diagnosis

answer

The code reflecting the current, most significant reason for the services or procedures provided. If the disease or condition has been successfully treated and no longer exists, it is not billable and should not be coded.

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Provider

answer

Any supplier of health care services; ie, physician, pharmacist, case management firm, etc.

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QualityAssurance(QA)

answer

Quality assurance or quality assessment is the activity that monitors the level of care being provided by physicians, medical institutions, or any health care vendor in order to ensure that health plan enrollees are receiving the best care possible. The level of care is measured against pre-established standards, some of which are mandated by law.

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Quality Managment( QM)

answer

The monitoring and maintenance of established standards of quality using techniques proposed by Crosby, Demming, and Juran

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Reasonable and Customary

answer

Usual, customary, and reasonable services or costs.

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Reinsurance

answer

Insurance purchased by a payer to protect from extremely high losses.

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Retrospective Review

answer

A process of judging medical necessity and appropriate billing practices for services which have already been rendered.

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Second Opinion

answer

Obtaining another professional's opinion to help determine the necessity of a medical procedure or drug treatment. This is often required by plans before a surgical procedure.

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Self-Insured or Self Funded plan

answer

A plan where the risk is assumed by the employer rather than the insurer.

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Service Date

answer

The date a charge is incurred for a service

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Single-Source Brand Name Drug

answer

A prescription drug which is known only by the single trade name under which it is advertised and sold, and with respect to which a generic drug with equivalent components is not marketed.

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Skilled Nursing Care

answer

Nursing care that requires the skills of, and can only be performed by, a nurse or health professional of equivalent or greater training to achieve the medically necessary and appropriate result.

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Skilled Nursing Facility ( SNF)

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An institution for convalescence or a nursing home; provides a high level of specialized care for long-term or acute illness. It is an alternative to extended hospital stays or difficult home care.

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State Insurance Commission

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The state group that approves insurance certificates for each state and regulates the industry based on statutes.

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Stop Loss

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A form of reinsurance that protects health insurance above a certain limit.

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Subrogation

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The recovery of monies or benefits from a third party who is liable for the patient.

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Surgicenter

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A separate, free-standing medical facility specializing in outpatient or same-day surgical procedures. Surgicenters drastically reduce the costs associated with hospitalizations for routine surgical procedures because extended inpatient care is not required for specific disorders.

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Technology Assessment

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This term is used to describe the evaluation process of new or existing diagnostic and therapeutic devices and procedures. Technology assessment evaluates the effect of a medical procedure, diagnostic tool, medical device, or pharmaceutical product. In the past, technology assessment primarily meant evaluating new equipment and focused on the clinical safety and efficacy of an intervention. In today's health care world, it includes both a broader view of clinical outcome, such as the effect on a patient's quality of life, and the effect on society, such as cost-benefit analysis. Committees within health plans that evaluate new technologies are sometimes called Technology and Bioethics Committees (TBC).

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Tertiary Care Facility

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A hospital providing specialty care to patients referred from other hospitals because of the severity of their injuries or illnesses

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Third-Party Administrator ( TA)

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An organization that is outside of the insuring organization that handles the administrative duties and sometimes provides utilization review. Third-party administrators are used by organizations that actually fund the health benefits but do not find it cost effective to administrate the plan themselves.

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TPL

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An acronym for "third-party payers"; they are liable for the cost of an illness or injury, such as auto or homeowner insurer.

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Transition of Care

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A series of actions that ensures continuity of health care delivery as patients navigate through the system. Refers to a patient moving from one level of care to another, such as from primary care to specialty physicians; from the emergency department to surgery or intensive care; or when patients are discharged from the hospital to home, to an assisted living arrangement, or to a skilled nursing facility.

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UB-92

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An abbreviation for Uniform Billing Code of 1992. It is the common claim form used by facilities to bill for services.

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UCR

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An acronym for "usual, customary, and reasonable

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Underwriting

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Evaluating and determining the financial risk a member or member group will have on an insurer.

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UPIN

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An acronym for "unique physician identification number".

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UR

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An abbreviation for Utilization Review. UR is performed by the HMO to discover if a particular physician-provider or other provider (eg, pharmacy) is spending as much of the HMO's money on treatment or any specific portion thereof (eg, specialty referral, drug prescribing, hospitalization, radiologic or laboratory services) as his or her peers.

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URAC

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An acronym for Utilization Review Accreditation Commission. One of the accrediting bodies of health plans.

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Urgent Care Center

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A medical facility in which ambulatory patients can be treated on a walk-in basis, without an appointment, and receive immediate, non-emergency care. The urgent care center may be open 24 hours a day. Patients calling an HMO after hours with urgent, but not emergent clinical problems, are often referred to these facilities.

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Usual, Customary and Reasonable (UCR)

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Usual, Customary, and Reasonable (UCR) Fee-for-service payment to physicians based on the usual and customary fee for the same service in the area where the practice is located or on some other judgment of reasonable payment

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Worker's Compensation

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Laws requiring employers to furnish care to employees injured on the job. Services performed under worker's compensation policies are usually excluded from commercial health plan coverage.

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Algorithms

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Also known as a Decision Tree: These are designed to reflect current standards of practice and aid in the decision-making process. Unlike pathways or guidelines, algorithms are considered to be precise interventions, often termed "cookbook medicine"

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Care maps

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these are also called care pathways. They embrace continuing care, instead of a timed episode of care. these are primrily used in the post-acute setting and have more detail than a clinical patheway in areas that cover function, therapies, discharge planning and psychosocial needs. They are not as specific and directed as clinical pathways, and the patients for which the care map is used do not fall eaily into treatment categories

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Clinical Pathway

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Time, activity and event are featured in a grid format that outlines categoreis of interventions on one axis( usally the vertical) and time ( or other indicators of clincial progression on the other axis. Time can be measured in minutes to years or in activities or specific task performed to arrrive at an expected outcome. the events shown on a pathway are observable milestones that reflect progress toward the expected outcomes.

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Patient Care Guidelines

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Practice guidelines that include times, tested methods of describing practice patterns. The guidelines are useful informing a basis for development of algorithms and clinical pathways. They can become a statement of unity between providers and disciplines in supporting a collaborative practice base.

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DSM IV

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4th Edition: Mental disorders are diagnosed according to a manual published by the American Psychiatric Association called the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). A DSM-IV diagnosis has five parts. Each part, called an axis, gives a different type of information about the diagnosis.

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DSM IV-AXIS I-Clinical Syndromes

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provides information about clinical disorders. Any mental health conditions, other than personality disorders or mental retardation, would be included here.

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DSM IV-AXIS II-Developmental and Personality disorders

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provides information about personality disorders and developmental disorders. Developmental disorders include autism and mental retardation, disorders which are typically first evident in childhood Personality disorders are clinical syndromes which have a more long lasting symptoms and encompass the individual's way of interacting with the world. They include Paranoid, Antisocial, and Borderline Personality Disorders.

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DSM IV-AXIS III-Physical conditions

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provides information about any medical conditions that are present. Physical conditions such as brain injury or HIV/AIDS that can result in symptoms of mental illness are included here.

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DSM IV-AXIS IV-Severity of stressors

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describe psychosocial and environmental factors affecting the person. Events in a persons life, such as death of a loved one, starting a new job, college, unemployment, and even marriage can impact the disorders listed in Axis I and II. These events are both listed and rated for this axis.

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DSM IV-AXIS V- Highest Level of Functioning

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a rating scale called the Global Assessment of Functioning; the GAF goes from 0 to 100 and provides a way to summarize in a single number just how well the person is functioning overall.

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Deliruim

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Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication, or medication side effect

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Mini Mental State Examination (MMSE)

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help diagnose and assess dementia, scores of 27 or above (out of 30) are considered normal score-10-23 mild to moderate dementia score , 10 severe dementia

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Geriatric Depression Scale

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30 items, answer yes or no on how felt in the past week, short form has 15 items. score of 0-4: normal, 5-8: mild depression, 9-11: moderate depression, 12-15: severe depression

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Factitious Behavior

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Intentional production or feigning of physical or psychological signs or symptoms. The motivation for the behavior is to assume the sick role. External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in Malingering) are absent.

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ECT

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- The most effective tx for depression (90% within 1 week); The most rapid onset; Very well tolerated - Protocol - pretx w/ atropine, methohexital, succinylcholine; 3x weekly x 2-4 wks - SE: HA, retrograde amnesia

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CAGE Questionnaire

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Substance Abuse Screening Tool used to determine if substance abuse exists and needs to be addressed.

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Borderline Personality Disorder

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characterized by grandiose and dramatic behavior, impulsive and disturbances of conduct, poor or absent interpersonal relationships, self mutilate or engage in suicidal threats, do not recognize the rights of others.

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SF-36 Questionnaire

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SF-36 is a multi-purpose, short-form health survey with only 36 questions. It yields an 8-scale profile of functional health and well-being scores as well as psychometrically-based physical and mental health summary. Summary Measures -Physical Health(physical function, role- physical, bodily pain, general health. Mental Health (Vitality, social function, role-emotional, mental health).

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Malingering

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individuals who intentionally pretend to have symptoms of mental or physical illness to achieve financial or other gain,

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Waddles Behavioral Signs

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An assessment for inconsistency related to objective and subjective factors, indicating a perhaps a secondary gain issue for the person.(Objective symptoms do not correlate with subjective complaints.

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Somatiform disorders

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there is no medical explanation for symptoms and psychological explanations should be explored.

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Job Accommodation Network

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Provides individuals information about the American Disabilities Act.

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Philosophy of Nursing Dept

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is congruent with mission statement of the college

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how Each Person evolves

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as a unique holistic being viewed in the context of family and community

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Health

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dynamic state of being in which psychological, physical, spiritual and cultural needs of individual, family or community are met

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Wellness-illness Continuum

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each individual moves through it and possesses various strengths and limitations that affect ability to meet needs

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what Failure to meet any needs creates

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health problems to individual, family or community that may require health care system

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Nursing's Unique Function

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to assist individuals during all stages of development and to achieve optimal health

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how Nursing Process is used

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in health promotion and maintenance, and diagnosing and treating human responses to actual or potential health problems

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where Nursing takes place

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in any setting in which a systemic approach to diagnosing and treating is applied

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Nursing Decisions

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based on critical thinking

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how Nurses perform

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independent, collaborative and dependent functions

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Faculty

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facilitators of the teaching/learning process

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Dynamic Teaching-learning Environment

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systematically evaluated by students, faculty, administration and community

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what Curriculum Changes reflect

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ongoing evaluation process and changes in education, technology and health care practice

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what Educational Program includes

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nursing, plus humanities and social sciences, to prepare student to participate in society as educated and responsible nurse

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Broad Academic Basis

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nurtures ability of student to respond to personal, communal and global relationships

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how Graduate Nurses practice

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practices with accountability, competency, integrity and caring; within the ethical and legal framework of nursing

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Assessment and Nursing Diagnoses

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form the basis for nursing interventions that are theory based, and outcomes can be measured

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how to Manage Multiple Patients

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with understanding of communication, collaboration and delegation

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CCM Organizing Framework

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based on Human Needs Theory, using holistic approach

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PERSON acronym

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Human Needs Theory applied - most basic to nursing process, problem exists when ability to meet needs is interrupted

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3 Components of CCM Organizing Framework

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Holistic Approach, Human Needs Theory, Recognition of Unmet Needs

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Holistic Approach

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supports the assessment, diagnosis, planning, intervention and evaluation of care of total person

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Patient

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may be an individual, family group or community

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Holistic considerations

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physical, emotional, social, spiritual, intellectual and cultural stresses that impact whole patient

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Assessment

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info is gathered to recognize unmet needs

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Unmet Need

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constitutes a problem (usually physical and/or emotional)

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Nursing Diagnoses

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problems are formulated and listed in order of priority

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P

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Psychological

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E

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Elimination

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R

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Rest and Activity

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S

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Safe Environment

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O

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Oxygen

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N

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Nutrition

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Illness

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develops when on or more need is unmet

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Nursing Process

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addresses health problems created by unmet needs

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Workers Compensation- State

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State laws designed to ensure workers receive wage replacement and medical care for a work-related injury and provides benefits for dependents who are killed d/t work related illness or injury protecting employers from lawsuits for wages and injury related cost..

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Workers Compensation-Federal

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Federal statutes are limited to Federal employees or those working in interstate commerce.

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Federal Employment Compensation Act

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provides compensation for non-military federal employees.

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Federal Employment Liability Act (FELA)

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not a workers compensation law, holds railroads engaged in interstate commerce liable for work-related injuries if they have been negligent.

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The Jones Act

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provides compensation for seaman - same protection that FELA provides railroad workers. Davey Jones' Locker

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The Longshore and Harbor Act

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provides compensation for private maritime workders

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The Black Lung Benefit Act

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provides compensation for miners suffering black lung

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Benefits Under Workers Compensation

answer

Medical-requires all "reasonable customary services" be covered. There can be disagreement to resolve. Indemnity = wage replacement(2/3 of weekly salary, based on salary history with the employer) & permanency awards such as loss of function and scarring. Expense- covers fees ie; police report, defense council, expert witness

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three-point -contact

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the parties involved in a workman's comp file: Injured Worker (IW) Employer (ER) Medical Providers (MP) Initial contact:introductory and inquiry, set tone of trust.

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Occupational Health

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a medical specialty focusing on workplace injury, pre-employment testing, health education, ergonomics, and therapies.

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Managed Care Organization (MCO)

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a company that employers can use to structure arrangements for care to injured employees at a reduced premium. Often will use a PPO.

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Preferred Provider Organization (PPO)

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The medical network used by the MCO to coordinate the medical aspects of the workers claim.

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First Report of Injury (FROI)

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Generated by the employer, it gives details of the injury-date-time-place-type-and medical provider. Necessary to begin workman's comp claim. Filed with the State jurisdiction, sent to worker's compensation carrier or TPA.

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Date of Hire (DOH)

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provided by the employer, the date when employment began.

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FULL TIME (FT)

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the amount of time an employee can work.

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FULL DUTY (FD)

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The worker has recovered sufficiently to perform all tasks required for the position.

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LIGHT DUTY (LD) MODIFICATIONS, RESTRICTIONS

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Description of the work capacity a worker can perform. It is defined in terms of lifting, climbing, twisting, and standing.

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RETURN TO WORK (RTW)

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Physician approval for the injured worker to return to some level of work.

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FUNCTIONAL CAPACITY EXAM (FCE)

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Assessment of residual physical abilities and evaluation of ability to handle activities of daily living. Determines return to work capabilities, job placement, accomodation.

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INDEPENDENT MEDICAL EXAM

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A physical exam to make a medical determination regaurding causation, current physical impairment, and the need for present and future treatment. arranged by the insurer to confirm, rebut, or supplement medical findings offered by the IW chosen physician

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MAXIMUM MEDICAL IMPROVEMENT

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Indication that the injured worker has recovered sufficiently from injuries to a level that the MD states further treatment will not change the medical outcome.

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PERMANENT IMPAIRMENT (PI)

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Disability Classification used to indicate a deviation from normal form or function as a result of injury, disease, or condition that has become stabilized over a sufficient period of time for optimal healing to have occurred.

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PERMANENT PARTIAL DISABILITY

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Disability Classification used to indicate there is a permanent loss of function that is partial in nature but does not preclude work

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PERMANENT TOTAL DISABILITY

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Disability Classification used to indicate the injured worker is precluded by the extent of his injury from gainful employment.

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TEMPORARY PARTIAL DISABILITY

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Disability Classification used to indicate an Injury prevents worker from returning to his usual job, but the worker can be employed. There are restrictions to work activities.

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TEMPORARY TOTAL DISABILITY

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Disability Classification used to indicate an Injury prevents work in any capacity while treatment continues with expectation of recovery and return to work. Majority of claims fall into this category.

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VOCATIONAL REHABILITATION

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Case management provided by a certified counselor who is knowledgeable about implications of medical status/functional ability and vocational service necessary to facilitate an injured workers return to gainful employment.

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REASONABLE ACCOMMODATIONS

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Any change in the work environment or the way the job is performed that enables a person with a disability to enjoy equal employment opportunities.

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7 DOMAINS OF HEALTH

answer

Physical, Social Cultural, Intellectual, Emotional, Spiritual, Occupational, Environmental.

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RTW HIERARCHY

answer

-same employer, same job -same employer, same job modified -same employer, transitional job -same employer, permanent light duty job -same employer, different job -new employer, same job -new employer, same job modified -new employer, alternate job based on transferable skills -new employer, on the job training -training/education tailored for job placement which leads to new job, new employer

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structured settlement

answer

an alternative to a lump sum cash payment in the resolution of a workers comp case. Two parts: up front payment for imm. needs and future periodic payments funded by defendant's purchase of annuity to pay directly to plaintiff.

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workers comp: different from SSDI how?

answer

Workers' compensation pays for medical care for work-related injuries immediately; it pays temporary disability benefits after a waiting period of three to seven days; and it pays permanent partial and permanent total disability benefits to workers who have lasting consequences of disabilities caused on the job.

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SSDI: different from WC how?

answer

Social Security Disability Insurance payments, which begin five months after the onset of the injury or condition that makes the individual unable to work. Medicare coverage begins 29 months after the onset of the injury or with a settlement > $250,000.

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SSDI vs Workers comp. The main difference....

answer

Workers' compensation benefits cover only those disabilities arising out of and in the course of employment, whereas Social Security disability benefits are provided whether the disability arises on or off the job.

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SSDI vs Workers comp: eligibility

answer

Workers are eligible for workers' compensation benefits from their first day of employment, while eligibility for SSDI requires workers to have a substantial work history.

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SSDI vs Workers comp: type of disability covered

answer

Workers' compensation provides benefits for both short-term and long-term disabilities, and for partial as well as total disabilities. Social Security disability benefits are paid only to workers who have long-term impairments that preclude any gainful work.

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SSDI vs workers comp: waiting period

answer

Workers' compensation cash benefits begin after a few days' work absence, and medical benefits are available immediately. Social Security disability benefits begin after a five month waiting period.

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Waiting period long term injury

answer

Medicare coverage begins for those on SSDI after a further 24-month waiting period, or 29 months after the onset of disability. Medicare covers all medical conditions, not just work-related injuries or illnesses. As a result of the Medicare Secondary Payer Act, when a worker receiving workers' compensation is a Medicare beneficiary, workers' compensation is the primary payer and Medicare is the secondary payer for care related to the occupational injury.

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If a worker becomes eligible for both workers' compensation and Social Security disability insurance benefits...

answer

...one or both of the programs will limit benefits to avoid making excessive payments relative to the worker's past earnings. The Social Security amendments of 1965 require that Social Security disability benefits be reduced (or "offset") so that the combined totals of workers' compensation and Social Security disability benefits do not exceed 80 percent of the workers' prior earnings. Some states, however, had established reverse offset laws prior to the 1965 legislation, whereby workers' compensation payments are reduced if the worker receives Social Security disability benefits.

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work hardening

answer

Work Hardening is an interdisciplinary, individualized, job specific program of activity with the goal of return to work. Work Hardening programs use real or simulated work tasks and progressively graded conditioning exercises that are based on the individual's measured tolerances. Work hardening provides a transition between acute care and successful return to work and is designed to improve the biomechanical, neuromuscular, cardiovascular and psychosocial functioning of the worker.

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Work hardening structure

answer

Can be on or off site 3-8 hours/day, 3-5 days/week Not long term Goal oriented Very structured Defined admission and discharge criteria

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FCE

answer

functional capacity evaluation: compares the individual's health status, and body functions and structures to the demands of the job and the work environment. In essence, an FCE's primary purpose is to evaluate a person's ability to participate in work, although other instrumental activities of daily living that support work performance may also be evaluated. May also be called a functional capacity assessment (FCA), physical capacity assessment or evaluation (PCA or PCE), or work capacity assessment or evaluation (WCA or WCE).Consist of a battery of standardized assessments that offers results in performance-based measures and demonstrates predictive value about the individual's return to work. SHOULD NOT BE EVALUATED BY A TREATING CLINICIAN.

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RTW

answer

Return to work

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vocational case management/voc rehab

answer

Vocational rehabilitation services are those vocational services provided directly to a client, the goal of which is to return a client to suitable gainful employment. However, there remain broad services standards that should be applied regardless of this uniqueness. These standards of practice and competencies include vocational assessment/testing, plan development, job development and placement, transferable skills analysis, job coaching, labor market surveys, training, and self-employment.

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managing secondary gain

answer

engage in participation/goals of management advocate acknowledge symptoms empower to progress

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PL 94-142

answer

IDEA

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Section 504 of the Rehabilitation Act

answer

Section 504 has provided opportunities for children and adults with disabilities in education, employment and various other settings. It allows for reasonable accommodations such as special study area and assistance as necessary for each student

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The Hill-Burton Act, or the Hospital Survey and Construction Act

answer

a federal law passed in 1946, that gave grants and loans to hospitals to grow and modernize. In exchange for those grants, hospitals were required to provide services (a "reasonable volume" of care) to all people living in the area, regardless of race or creed, and to help patients who couldn't pay by providing free or reduced-cost care. Hill-Burton hospitals must also participate in Medicare and Medicaid programs, post information about their community service obligations in English and Spanish, provide emergency services and maintain unbiased patient admissions policies.

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Job Accommodation Network 2

answer

JAN's mission is to facilitate the employment and retention of workers with disabilities by providing employers, employment providers, people with disabilities, their family members, and other interested parties with information on job accommodations, entrepreneurship, and related subjects. JAN's efforts are in support of the employment, including self-employment and small business ownership, of people with disabilities.

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ADA exceptions

answer

Employers with fewer than 15 employees are not covered by the Act. Employers are not required to provide accommodation where doing so would impose an undue hardship on the business.

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NCQA

answer

Accreditation body for payer organizations

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critical access hospital

answer

Be located in a rural area Furnish 24-hour emergency care services 7 days a week, using either on-site or on-call staff; Provide no more than 25 inpatient beds that can be used for either inpatient or swing bed services; however, it may also operate a distinct part rehabilitation or psychiatric unit, each with up to 10 beds; Have an average annual length of stay of 96 hours or less per patient for acute care

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CAH payment info

answer

that CAH-owned and operated entity can be paid 101 percent of reasonable costs for its ambulance services as long as it is the closest provider or supplier of ambulance services to the CAH. CAHs are not subject to the Inpatient Prospective Payment System (IPPS) and the Hospital Outpatient Prospective Payment System (OPPS). CAH services are subject to Medicare Part A and Part B deductible and coinsurance amounts. Medicare pays CAHs for most inpatient and outpatient services to Medicare patients at 101 percent of reasonable costs.

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Life care plan collateral sources

answer

Items within a life care plan reflect the needs of the individual and the recommendations necessary to fulfill those needs. Needs and associated recommendations cannot be restricted to those items allowed either by collateral funding sources or by covered insurance. Funding issues are not considered when developing a life care plan. Rather, needs are identified and the costs associated with necessary care and/or rehabilitation are cited according to the prevailing charges in the community within which an individual resides

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daubert challenge

answer

A Daubert challenge is a hearing conducted before the judge where the validity and admissibility of expert testimony is challenged by opposing counsel. The expert is required to demonstrate that his/her methodology and reasoning are scientifically valid and can be applied to the facts of the case.

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Inclusions in the Life Care Plan

answer

the items themselves, each associated cost, replacement schedule, dates of implementation and suspension, and the name of the professional making the recommendation are clearly identified. Depending upon the specific needs of the patient, the following areas may be addressed within the life care plan: Projected evaluations Projected therapeutic modalities Medication Diagnostic testing and educational assessments Supply needs Wheelchair needs Wheelchair accessories and maintenance Home care or facility-based care needs Projected routine future medical care Orthopedic equipment needs Projected surgical treatment or other aggressive medical care Orthotic or prosthetic requirements Transportation needs Home furnishings and accessories Architectural renovations Aids for independent function Leisure or recreational equipment

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Age limits for IDEA programs

answer

Infants and toddlers with disabilities (birth-2) and their families receive early intervention services under IDEA Part C. Children and youth (ages 3-21) receive special education and related services under IDEA Part B.

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The Katie Beckett Program

answer

a special eligibility process that allows certain children with long-term disabilities, mental illness, or complex medical needs, living at home with their families, to obtain a Medicaid card. Children who are not eligible for other Medicaid programs because the income or assets of their parents are too high may be eligible for Medicaid through the Katie Beckett Program. A child may be eligible for this source of Medicaid even if they are currently covered under a private health insurance policy.

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PPS

answer

The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups for inpatient hospital services). CMS uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities

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Medicare benefit period

answer

A benefit period begins on the day you're admitted to the hospital and ends when you've been out of the hospital for 60 days in a row.

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Medicare "lifetime reserve" days

answer

This means that for the rest of your life you can draw on any of these 60 days—but no more—to extend Medicare coverage in any benefit period. In 2010, your share of the cost is $550 a day. But if you have any type of Medicare supplemental insurance (also known as medigap), your policy covers an additional 365 life-time reserve days, with no copays.

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Coverage with each benefit period -Medicare

answer

Once you've been out of the hospital for 60 days, you start a new benefit period if you need to be admitted again, even if it's for the same illness or injury that took you there before. And with each new period, you get the same benefits and pay the same set of charges as above, according to how long you need hospital care. This includes paying the Part A deductible again, unless you have a medigap policy that covers it.

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Medicare eligible:

answer

age 65 or older under age 65 with certain disabilities with end stage renal disease with Lou Gehrig's disease

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Medicare A and B

answer

Medicare Part A is premium-free hospital insurance. Medicare Part B is medical insurance, and you must pay Medicare Part B premiums to keep Medicare Part B coverage. The Centers for Medicare & Medicaid Services manages Medicare.

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TRICARE ineligible if:

answer

still on active duty

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What Medigap doesn't cover

answer

Medigap policies generally don't cover long-term care , vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

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SS Ticket to Work program eligible

answer

Social Security's Ticket to Work Program is a free and voluntary program available to people ages 18 through 64 who are blind or have a disability and who receive Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits.

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Benefit of Ticket to Work program

answer

beneficiaries can get the help they need to safely explore their work options without immediately losing their benefits and find the job that is right for them. Beneficiaries also can use a combination of work incentives to maximize their income until they begin to earn enough to support themselves.

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Specifics of Ticket to Work program

answer

Go to work without automatically losing disability benefits; Return to benefits if he or she has to stop working; Continue to receive healthcare benefits; and Be protected from receiving a medical continuing disability review while using the Ticket and making the expected progress with work or educational goals.

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Medicare Hospice Benefits:

answer

■ Doctor services ■ Nursing care ■ Medical equipment (such as wheelchairs or walkers) ■ Medical supplies (such as bandages and catheters) ■ Drugs for symptom control or pain relief (may need to pay a small copayment) ■ Hospice aide and homemaker services ■ Physical and occupational therapy ■ Speech-language pathology services ■ Social worker services ■ Dietary counseling ■ Grief and loss counseling for you and your family ■ Short-term inpatient care (for pain and symptom management) ■ Short-term respite care (may need to pay a small copayment) ■ Any other Medicare-covered services needed to manage your pain and other symptoms related to your terminal illness, as recommended by your hospice team

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Medicare Hospice DOESN'T cover:

answer

■Treatment intended to cure your terminal illness ■ Prescription drugs to cure your illness (rather than for symptom control or pain relief) ■ Care from any hospice provider that wasn't set up by the hospice medical team. However, you can still see your regular doctor if you've chosen him or her to be the attending medical professional who helps supervise your hospice care. ■ Room and board Medicare doesn't cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. However, if the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay. ■ Care in an emergency room, inpatient facility care, or ambulance transportation, unless it's either arranged by your hospice team or is unrelated to your terminal illness

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EPO Health Plan

answer

you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care. There are no out-of-network benefits.

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Viatical Settlements

answer

the sale of a policy owner's existing life insurance policy to a third party for more than its cash surrender value, but less than its net death benefit. Such a sale provides the policy owner with an lump sum. The third party becomes the new owner of the policy, pays the monthly premiums, and receives the full benefit of the policy when the insured dies -a settlement involving an insured who is terminally or chronically ill

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Capitation

answer

a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.

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Stages for Readiness to change Behavior

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*precontemplation *contemplation *preparation *action *maintenance

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5 principles of motivational interviewing

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*roll with resistance *express empathy *avoid argumentation *develop discrepancy *support self-efficacy

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HINN

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Hospitals provide Hospital-Issued Notices of Noncoverage (HINNs) to beneficiaries prior to admission, at admission, or at any point during an inpatient stay if the hospital determines that the services the patient is receiving, or is about to receive, is not covered because it is: - Not medically necessary; - Not delivered in the most appropriate setting; or - Is custodial in nature.

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IRF 75% rule

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The 75% Rule limits the number and types of IRF patients who are not within the 13 categories, including cardiac, pulmonary, cancer, pain, and joint replacement patients.

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LTAC characteristics

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Hospitals specialize in caring for patients with: - an average length of stay of 25-30 days - three to six concurrent active diagnoses and an acute episode on top of several chronic illnesses and co-morbidities that cannot be treated effectively at an alternative level of care - multiple acute complexities as determined by a physician assessment and subsequent documentation requiring daily physician intervention

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Stark safe harbor law

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disallows ownership/stake in referred services

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EMTALA

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ED care mandate - anti dumping law

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HIPAA is not applicable to:

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disability, auto, liability, workers comp

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Wilson v BCBS

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a financial decision = a medical decision in re: payer decisions

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mental health benefit 'carve outs'

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managed care behavioral health companies - separate benefits from medical

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COBRA

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18 months access to health benefits after termination of employment...29 months if disabled (medicare transition time)

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SSI Supplemental Security Income

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financial need 'unable to engage in substantial gainful activity'

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SSDI Social Security Disability Insurance

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Must have worked to earn level of credits became disabled before 22 - based on parent's SS earning record 'unable to engage in substantial gainful activity'

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Home & Community-Based Services

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Medicaid beneficiaries to receive services in their own home or community. These programs serve a variety of targeted populations groups, such as people with mental illnesses, intellectual disabilities, and/or physical disabilities

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ERISA

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allows employers to self-insure their health plans protected from malpractice liability, recovery limited to benefits denied violations filed in federal court exempt from state mandates

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ADA does not apply to:

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Native Americans federal employees religious organizations private membership clubs (unless sponsoring public event) employers with <15 employees

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FMLA

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employers with >50 employees in 75 mile radius 12 months of employment to qualify (at least 1250 hours) 12 weeks unpaid leave in 12 months birth, adoption or foster child serious health condition of self care of spouse, child or parent

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Wheelchair passage width

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32" at a point and 36" continuously

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mimimum wheelchair passing width

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60"

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Wheelchair turning space

answer

60"

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