Comparative Health Information Management Chapters 1-6 Midterm Practice

a voluntary process in which facilities agree to follow a set of standards and receive recognition for having met those standards
administrative simplification
provisions of Health Insurance Portability and Accountability Act (HIPAA) that addressed standardization of electronic data interchange, privacy of health information, and security of health data
American College of Surgeons (ACS)
a professional organization founded in 1913 to “improve the quality of care for the surgical patient by setting high standards for surgical education and practice” (ACS, 2003, p.1); in the early twentieth century, the ACS established a hospital standardization program that was the forerunner of today’s accreditation organizations
American Recovery and Reinvestment Act (ARRA)
Also known as the “Stimulus Act” or the “Recovery Act”, ARRA was enacted in 2009; its main purpose was to create jobs and stimulate economic growth; however, it contains many provisions for health care, including billions of dollars for health information technology; Title XIII of ARRA is Health Information Technology for Economic and Clinical Health (HITECH) that addresses many of the health information and technology requirements, including privacy
business associate (BA)
partner or contractor performing a job or service on behalf of a covered entity; the original HIPAA legislation required covered entities to have a business associate
a method of payment for health care in which the health care provider receives a monthly payment based on the number of persons the provider has agreed to treat, regardless of the number of persons actually treated or the amount of service rendered
Centers for Medicare & Medicaid Services
a federal agency within the Department of Health and Human Services; its main focus is to administer the Medicare and Medicaid programs
Children’s Health Insurance Program (CHIP)
allows states to offer health insurance plans for children, up to age 19, who are not already insured; CHIP affords families who earn too much to qualify for Medicaid an opportunity to obtain health insurance for their children
clinical documentation improvement (CDI) program
a locally implemented program focused upon improving the quality of clinical documentation to “facilitate an accurate representation of health care services through complete and accurate reporting of diagnosis and procedures”; accurate clinical documentation can positively affect reimbursement, severity of illness and mortality risk assessment, and reporting of quality an pay-for-performance measures
covered entity (CE)
under HIPAA, a health plan, a health care clearinghouse, or any health care provider that transmits health information in electronic form
deemed status
the status of a health care provider that is deemed to meet federal Conditions of Participation by virtue of accreditation by a federally approved voluntary accrediting organization. the health care provider’s accreditation satisfies the COP & routine surveys by the state agency are unnecessary
electronic health record (EHR)
a system in which a health care provider maintains individual patient health records electronically; fully developed EHRs include capabilities such as generating clinical alerts and reminders and providing readily available decision support
a method of payment for health care in which the health care provider charges and is paid for each item of service provided
Flexner Report
a report published in 1910, examining the state of medical education in the US and Canada; the Flexnor Report resulted in sweeping changes in the way North American physicians were educated
health information exchange (HIE)
a process defined as “the electronic movement of health-related information among organizations according to nationally recognized standards (contrast with HIE organization)
health information technology (HIT)
electronic health records and related information systems to manage health care processes; the major focus of the HITECH Act of 2009 is to promote adoption of HIT in an effort to improve the quality, efficiency, and safety of health care delivery while reducing costs and minimizing medical errors
Health Information Technology for Economic and Clinical Health (HITECH)
The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology; amends HIPAA privacy and security rules by introducing additional privacy regulations, breach notification rules, and stiffer civil and criminal penalties for security violations
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
provisions include the portability of health care benefits, prevention of fraud and abuse in health care, and simplification of the electronic interchange of health care data, while improving the privacy and security of health information
health record banking
a concept analogous to online financial banking, where the patient controls access to the health record “account”; deposits and withdrawals may be made by authorized individuals; an alternative to a personal health record (PHR), while achieving similar goals
HIE organization
an entity that “oversees and governs the exchange of health-related information among organizations according to nationally recognized standards”; often used synonymously with regional health information organization (RHIO), which focuses more on HIE within a specific region; contrast with health information exchange, which is a process rather than an entity
Hill-Burton Act
the “Hospital Survey and Construction Act” enacted by Congress in 1946; this legislation provided federal money to determine the need for more hospitals and to pay for their construction
Hospital Inpatient Quality Reporting (IQR)
a national quality initiative implemented by CMS. requires hospitals to submit data for certain quality measures, which are made publicly available to consumers via the Hospital Compare Web site. program participation is voluntary. hospitals that do not participate receive a reduced Medicare Annual Payment Update.
Hospital Outpatient Quality Data Reporting Program (HQP QDRP)
a national quality program implemented by CMS that is modeled after the hospital IQR initiative; hospitals must report data for standardized quality measures for outpatient hospital services, which are made publically available to consumers via the Hospital Compare Web site; participation is required in order to receive the full annual update to the Outpatient Prospective Payment System (OPPS) payment rate
United States’ clinical modification of the World Health Organization’s diagnostic disease classification (International Classification of Diseases, 10th Revision, Clinical Modification); effective 10/1/13, ICD-10-CM is the diagnosis code set required by HIPAA
United States’ procedural coding system for inpatient, acute care settings (International classification of Diseases, 10th Revision, Procedural Coding System); effective 10/1/13
Institute of Medicine (IM)
health division of the National Academy of Sciences; it is an independent, nonprofit organization that serves as a national adviser on matters related to health improvement
a governmental process in which a facility must meet certain regulations, set by the state, in order to provide care
longitudinal patient record
a record documenting a patient’s health status, conditions, and treatments throughout their life and across multiple facilities, providers, and health care encounters
meaningful use
requirement in ARRA. providers must demonstrate this in relation to EHR in order to become eligible for reimbursement incentives for Medicare/Medicaid
Title XIX of the 1965 Amendments to the Social Security Act, Medicaid is jointly funded by federal and state governments and provides medical assistance to lower-income individuals and families
Medicaid Integrity Program (MIP)
a national strategy created as a result of the Deficit Reduction Act of 2005 to detect and prevent Medicaid fraud, waste, and abuse; it uses contracted reviewers to audit the accuracy of Medicaid payments made to health care providers
Title XVIII of the 1965 Amendments to the Social security Act, Medicare provides health benefits for Social Security recipients and other qualified individuals
Medicare certification
process in which a state agency determines that a health care organization meets the standards set forth in the relevant Conditions of Participation or Conditions of Coverage and is therefore eligible for participation in the Medicare program
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
made significant revisions to the Medicare program by calling for the creation of Part D, e-prescribing for prescription drug plans, revision of claims processing, and a Medicare payment recovery demonstration project that ultimately resulted int eh Recovery Audit Contractor (RAC) initiative
National Patient Safety Goals (NPSG)
program created by the Joint Commission in 2002 to help accredited health care institutions focus upon specific patient safety concerns. updated annually based upon review of literature and available databases
National Quality Forum (NQF)
a private, nonprofit, membership organizational focused upon improving the quality of care through national goal setting, development and endorsement of performance measurement standards, and educational initiatives; NQF collaborated with CMS to develop measures for the Physician Quality Reporting Initiative (PQRI); through a contact with the US Department of Health and Human Services, NQF continues to provide support for improved quality of health care services
Nationwide Health Information Network (NHIN)
a set of standards, services and policies that enable secure health information exchange over the Internet. provides a foundation for the exchange of health IT across diverse entities, within communities and across the country, helping to achieve the goals of the HITECH Act. enables health information to follow the consumer, be available for clinical decision making, and support appropriate use of health care information beyond direct patient care so as to improve population health
Office of the National Coordinator for Health Information Technology (ONC)
“the principal Federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information; the position of National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009”
patient-centered medical home model
a care model in which the primary care physician act as a “gatekeeper” to coordinate the patient’s care across providers; it addresses preventative, acute, and chronic care needs and also provides patients with access to electronic tools such as provider-patient e-mail, online appointment scheduling applications, and electronic health record data; the Patient Protection and Affordable Care Act (PPACA or Health Reform) calls for use of the medical home model to improve health outcomes
Patient Protection and Affordable Care Act (PPACA or Health Reform)
a federal statute that contains a number of health care provisions, most notably an expansion of Medicaid eligibility requirements; Health Reform Act also increases quality reporting requirements for health care providers
patient safety organizations (PSOs)
“organization that can work with clinicians and health care organizations to identify, analyze, and reduce the risks and hazards associated with patient care”; Patient Safety and Quality Improvement Act of 2005 called for development of PSOs to help determine the root causes, risks, and harms of health care safety issues
pay-for-performance (P4P)
emerging incentive-based reimbursement programs that reward or penalize providers based upon their ability to meet pre-established quality and performance targets for delivery of health care services
per diem
per day; a per diem payment is a payment rendered to an institution based on the number of days of service provided
personal health record (PHR)
“an Internet-based set of tools that allows people to access and coordinate their lifelong health information and make appropriate parts of it available to those who need it”
Physician Quality Reporting Initiative (PQRI)
voluntary, incentive-based quality reporting system for eligible professionals who report data on quality measures for covered professional services provided to Medicare beneficiaries; it was established as a requirement by the 2006 Tax Relief and Health Care Act (TRHCA) and is implemented yearly by CMS through an annual rule-making process; therefore, program requirements and measures may vary from year to year
prospective payment system (PPS)
a payment system in which payment levels for health care services are determined before the services are rendered; in a prospective payment system, the unit of payment is not based solely on the individual services provided, but on the payment units that represent general groupings of patient encounters, hospital stays, or episodes of care
protected health information (PHI)
individually identifiable health information
quality improvement organization (QIO)
“private, mostly not-for-profit organizations, which are staffed by professionals, mostly doctors and other health care professionals, who are trained to review medical care and help beneficiaries with complaints about he quality of care and to implement improvements in the quality of care available throughout the spectrum of care; QIO contracts are 3 years in length”
Recovery Audit Contractor (RAC)
a 3rd-party entity working under the direction of CMS to detect improper Medicare payments through review of providers’ medical records an Medicare claims data
Regional Extension Center (RECs)
nonprofit organizations called for by ARRA and initially funded by federal grants to provide health information technology support to providers; RECs offer technical assistance, guidance, and support to help providers become meaningful uses of certified electronic health record technology; an additional goal for the REC program is to create HIT jobs
regional health information organization (RHIO)
“health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community”; often uses synonymously with HIE organization, which is a broader term that encompasses the use of nationally recognized standards and is not limited by geographic boundaries
state agency
the agency of the state government responsible for administering the federal requirements for participation in Medicare and Medicaid programs; the state agency is ordinarily also charged with administering applicable licensure requirements for the state
“such technologies as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices which are used to collect and transmit patient data for monitoring and interpretation”
the practice of medicine in which electronic signals are utilized to transmit clinical information from one site to another; generally, the patient is in a remote location from the physician, and medical information, which may include images and video, is transmitted back and forth between with 2 locations electronically
the use of robotic technology to assist with or perform procedures remotely
Zone Program Integrity Contractor (ZPIC) program
program implemented by CMS to identify and investigate malicious fraudulent claims activity within Medicare’s 7 geographic regions (zones)
ambulatory surgery center (ASC)
a setting provided for surgery on an ambulatory basis; centers usually have at least one full-time operating room and provide surgical privileges to physicians in the community
scheduled time that a patient is to arrive at the health care facility
appointment system
a system by which appointments are scheduled for patients
ASC reimbursement system
a Medicare reimbursement system for ambulatory surgery in which the HCPCS codes are listed (ASC list) and reimbursed on a percentage of the outpatient prospective payment system rates
birth center
ambulatory setting that provides labor and delivery services in uncomplicated deliveries
block appointment method
an appointment scheduling method that assigns all patients in a large block for the same appointment time (e.g., 9 a.m. for all morning appointments), then patients are seen on a first-come, first-serves basis
a method of reimbursement in which the phshiucian or facility receives a fix amount each month for each patient enrolled in the plan, regardless of the amount of care that the patient receives
certified nurse midwife (CNM)
a nurse practitioner who handles pregnancy, labor, and delivery
color coding
a system that helps prevent the misfiling of records by assigning colors to numbers or letters and displaying those colors on the record folder so that misfiled records are easily spotted by their mismatched color patterns
community health center
an ambulatory setting developed in the 1960s to provide ambulatory care to the indigent of a particular neighborhood; subsequent legislation expanded the scope of these health centers to any medically underserved area or population
compliance plan
a plan for ensuring that a facility/practice is compliying with all laws and regulations, including those pertaining to reimbursement under Medicare and Medicaid
Current Procedural Terminology (CPT)
a coding system for procedures that is used extensively in ambulatory care and that forms a part of HCPCS
decision-support system
a computerized system that assists physicians in deciding on a diagnosis or treatment
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Service
a program of Medicaid for children younger than 21 that ensures that these services (screening, diagnostic, and treatment) are provided and paid for whether or not they are normally included under the state’s Medicaid program
face-to-face contact between the patient and the provider
encounter form
a form used for billing purposes that include the services the patient received, the charges, and the diagnosis and procedure codes
a method of entering prescriptions into an electronic system that also transmits the prescription to the pharmacy to be filed
family numbering system
a numbering system in which a family is given a number and each individual receives that number with a suffix indicating their position within family
family planning center
an ambulatory setting that provides family planning services
federally qualified health center (FQHC)
a nonprofit or public organization that provides or arranges for comprehensive health care services to a medically underserved area or population
fee for service
a reimbursement system in which the payment is based on the type and amount of service provided
financial system
a compute system that maintains information on services billed, insurance determination, payment received, and collection efforts
freestanding ambulatory care
care provided to patients who do not stay overnight in a setting not located within a hospital
growth and development chart
a graphic recording of a child’s height and weight over time
Healthcare Common Procedural Coding System (HCPCS)
a system used by ambulatory care facilities to code procedures and services
immunization record
record that maintains a list of immunizations that a child has received and often indicates when additional immunizations will be required
incident report
internal documentation of an unusual event such as a fall, incorrect medications given or taken, or some other untoward occurrence (see also occurrence report)
incident to
services provided to patients by mid-level providers, such as nurse practitioners or physician assistants, when the physician is on site
industrial or occupational health center
an ambulatory setting where care is provided to employees at their place of work
integrated format
a record format in which the information is entered in chronological order
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
a classification system used by ambulatory care facilities for coding diagnoses through 9/30/13
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
a classification system used by ambulatory care facilities for coding diagnoses beginning 10/1/13
International Classification of Primary Care (ICPC)
a coding system developed by the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians (WONCA); it includes chapters arranged by body systems, with components that describe the reason why the patient is being seen for care at the primary care level
Local Coverage Determinations (LCDs)
guidance documents published by Medicare Administrative Contractors (MACs) that include information on codes that indicate medical necessity of services; these policies apply to services covered under Medicare in the region served by the contractor
locum tenens
an arrangement by which one physician temporary works in place of another physician
Medicaid Integrity Program (MIP)
a joint federal and state government initiative to identify fraud and abuse in the Medicaid system
medical home
a method of providing care in which the primary care provider works with a team of health care professionals to provide care to patients using a whole-person concept
Medicare physician fee schedule (MPFS or PFS)
a list of Medicare-covered services and their payment rates
mid-level provider (MLP)
a health care professional whose license permits a degree of independent judgment in treating patients, generally under the supervision of a physician (ex: NP, PA, CNM); scope of practice and requirements for supervision vary by type of provider and by state
National Coverage Determinations (NCDs)
guidance documents published by Medicare that include information on codes that indicate medical necessity of services; these policies apply to services covered under Medicare throughout the nation
nurse practitioner (NP)
a registered nurse who has additional training and credential that allow for limited independent practice
occurrence report
internal documentation of an unusual event such as a fall, incorrect medications given or taken, or some other untoward occurrence (see also incident report)
Office of the Inspector General (OIG)
the office in the Department of Health and Human Services responsible for motioning compliance with reimbursement laws and regulations
patient identifier
an item of data that identifies the patient in the health information management system, such as the patient’s name or medical record number
patient portal
a secure method of patient access to his or her own information through a facility’s electronic information system
patient registration system
a computer system that contains demographic and financial information for every patient
physician assistant
a professional who is not a nurse but has received training to use independent judgment in treating patients
physician private practice
a setting in which physicians practice in their own business rather than working for an organization such as a clinic or urgent care center owned or operated by others
physician quality reporting system
a system for physicians to report quality measures to CMS
problem list
a numbered list of the patient’s problems over time that serves as a table of contents for the problem-oriented medical record
problem-oriented medical record (PROM) format
a record format in which the parts of the record are keyed to the problem number listed on the problem list
program manuals for Medicare and Medicaid
basis instructions for the 2 programs, developed by the centers for Medicare & Medicaid Services
program transmittals
periodically issued by CMS to provide revision for a specific program manual
prospective review/precertification
1 of 2 basic approaches to utilization management, prospective review determines whether services are needed before they are provided
public health department
an organization that provides services to promote the health of the community as a whole, such as immunizations and disease screenings; usually an agency of state or local government
reason for visit
the reason provided by the patient for why care is required
the process by which basis demographic and financial information is obtained from the patient and entered into the health information system
resource-based relative value scale (RBRVS)
a reimbursement system used by Medicare Part B to reimburse physicians; it is based on the relative value of the services provided
retrospective review
1 of 2 basic approaches to utilization management, retrospective review examines care after it has been given, to identify inappropriate care and provide feedback to the caregiver
return-to-work physical
a physical done before an employee may return to the job after an injury or illness
rural health clinic (RHC)
health care clinic that, in addition to physician services, utilizes mid-level providers such as PAs and NPs, and that is located in an underserved rural area
source-oriented format
a record format in which the information is organized according to the source of the information, such as laboratory, nursing, etc
standard scheduling
a method in which appointments are scheduled continuously throughout the day, with appointment times at specific intervals (e.g: every 15 minutes)
a form used for billing purposes that includes the services the patient received, the charges, and diagnosis and procedure codes
terminal digit filing
a filing system in which records are filed first by the last 2 digits of their numbers, allowing files to expand evenly
university health center
an ambulatory setting in which care is provided to university staff and students
urgent care center
an ambulatory care setting in which patients are seen on a walk-in basis without appointments; these centers provide service for longer hours than do must private physician practices
patients who arrive without an appointment or who receive an appointment at the last minute
ambulatory payment classifications (APCs)
groupings of outpatient services (based on the HCPCS code assigned) that determine the payment the hospital receives under the Hospital Outpatient Prospective Payment Systems (HOPPS)
ambulatory surgery
(also called “same-day” surgery) surgery in which it is planned that the patient will arrive at the facility, have surgery, recover from any anesthesia, and be ready for discharge in a single day, thus avoiding an overnight stay in the health care facility
American Recovery and Reinvestment Act (ARRA)
a federal law that, among other things, created an incentive program for health care providers to utilize EHRs for improved patient care
chargemaster or charge description master (CDM)
a computer file that contains a list of the Healthcare Common Procedural Coding System codes and associated charges for services provided to hospital patients
clinic outpatient
an outpatient treated in an organized clinic of the hospital, in which hospital staff evaluate the patient and manage the patient’s care
common working file
a file maintained on each Medicare beneficiary in one of the 9 regional databases; this file contains claims history information from both Part A and Part B claims and data on utilization patterns of Medicare beneficiaries
reducing the payment for additional procedures or ambulatory patient groups so that these other items are not paid at the full rate, as they would be if they had been the only services performed in a given encounter
Emergency Medical Treatment and Active Labor Act (EMTALA)
a federal law that imposes a legal duty on hospitals to screen and stabilize, if necessary, any patient who arrives int eh emergency department; the purpose of EMTALA is to prevent the “dumping” of patients who may not be able to pay for emergency department services
emergency outpatient
an outpatient evaluated and treated in the emergency department of the hospital
fiscal intermediary (FI)
before the implementation of MACs, an organization with a contract with CMS to process and pay Part A Medicare claims
hospital inpatient
an individual receiving health care services as well as room and board and continuous nursing care in a hospital and where patients generally stay overnight
hospital outpatient
a hospital patient who receives care at the hospital but who is not admitted as a patient
Hospital Inpatient Prospective Payment System (HIPPS or IPPS)
Medicare’s payment system for hospital inpatient services; the basic unit of payment in the IPPS is the Medicare Severity Diagnosis Related Group (MS-DRG)
Hospital Outpatient Prospective Payment System (HOPPS or OPPS)
Medicare’s payment system for hospital outpatient services; the basic unit of payment is the ambulatory payment classification (APC) of each service provided
“a physician who specializes in inpatient medicine”
Medicare Administrative Contractor (MAC)
an organization that has contracted with CMS to process Medicare claims. they replaced fiscal intermediaries and Medicare carriers
Medicare carrier
before the implementation of MACs, an organization having a contract with the CMS to process and pay Part B Medicare claims
Medicare Severity Diagnosis Related Groups (MS-DRGs)
groupings of inpatient services (based on the diagnosis, expected resource consumption, and other characteristics) that determine the payment the hospital receives under the Hospital Inpatient Prospective Payment System (HIPPS)
observation services
“services furnished by a hospital on the hospital’s premises, including use of a bed and periodic monitoring by a hospital’s nursing or other staff, which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for a possible admission to the hospital as an inpatient
partial hospitalization program (PHP)
an intensive treatment program in which patients receive services for part of each day; these patients would otherwise require inpatient psychiatric care
potentially compensable event (PCE)
an occurrence that may result in litigation against the health care provider or that may require health care provider to financially compensate an injured party
referred hospital outpatient
an outpatient who is referred to the hospital for specific services, such as laboratory or radiology examinations; the hospital is responsible only for providing the diagnostic or therapeutic services requested, while the referring physician is responsible for evaluating and managing the patient’s care
primarily a licensed physician, dentist, or podiatrist who participates in an approved graduate medical education program
revenue codes
used on the UB-04 to indicate the general nature of the services provided
status indicator
an alphabetic character that indicates the type of each APC and whether or how that APC is paid under the Hospital Outpatient Prospective Payment System (OPPS)
Uniform Ambulatory Care Data Set (UACDS)
a 16-item data set approved by the National Committee on Vital and Health Statistics (NCVHS); one of the first attempts to standardize ambulatory data collection efforts
Uniform Hospital Discharge Data Set (UHDDS)
standard data elements to be collected from individual inpatient records; the UHDDS data definitions are important for correct reporting of inpatient data
American Correctional Association
a professionals association of correctional administrators, wardens, superintendents, and other individuals and institutions that promotes improved correctional standards and studies causes of crime and juvenile delinquents as well as methods of crime control and prevention, offering voluntary accreditation for all components of adult and juvenile corrections
American Correctional Health Services Association (ACHSA)
a professional association of health care providers, individuals, and organizations interested in improving the quality of correctional health services
American Public Health Association (APHA)
a professional association of health care workers, administrators, epidemiologists, planners, community and mental health specialists, and interested individuals who seek to protect and promote personal, mental, and environmental health through promulgation of standards, establishment of uniform practices and procedures, and research
Bureau of Citizenship and Immigration Services (USCIS)
a division of the Department of Homeland Security responsible for the immigration service functions that were formerly performed by the Immigration and Naturalization Service (INS)
Bureau of Immigration and customs Enforcement (ICE)
a division of the Department of Homeland Security responsible for the border and security functions of the former Immigration and Naturalization Service (INS)
Certified Correctional Health Professional Program (CCHP)
a certification program for health care professionals working in corrections, administered by the National Commission on Correctional Health Care
Correctional Cer6tification Program (CCP)
a certification program offered by the American Correctional Association to correctional officers, correctional staff, staff nurses, and nurse managers working in corrections
Department of Corrections (DOC)
a division of state government responsible fro the operation of prisons
a person held in custody awaiting trial or disposition
Division of Immigration Health Services (DIHS)
an organizational component of ICE responsible for providing health care services to individuals placed in ICE custody
Federal Bureau of Prisons (FBP)
a division of the US Department of Justice responsible for the administrator and operation of federal correctional facilities, including penitentiaries, prison camps, and metropolitan correctional centers
grievance process
a formal, administrative process whereby inmates may file complaints against a correctional facility for review by a panel; institutional policies, and sometimes state statutes, determine time frames for the review process, decisions, and appeals
health services director (HSD)
an individual responsible for the administration and operations of health services within a prison system or DOC
hybrid covered entity
an organization whose activities include both covered and noncovered functions under HIPAA
a person confined to a correctional institution such as a prison
inmate self-pay or copayment
the practice of requiring inmates to pay a (small) feel for predetermined, nonemergency medical treatments
an institution administered by local units of government (i.e., cities or counties) with the authority to detain adults for a period of 48 hours or longer and to confine adults convicted of misdemeanors whose sentence does not exceed 1 year
juvenile detention facility
a facility operated by a unit of government for the confinement of individuals under 18 years of age
National Commission on Correctional Health Care (NCCHC)
a national association that offers voluntary accreditation of the health services in correctional facilities
facilities operated by a unit of the state or federal government for the confinement of adults convicted of a felony whose sentence exceeds 1 year
the application of technology where a video camera, a high-speed line, and monitoring and imaging equipment are installed at both a correctional facility and a medical facility; the telehealth equipment is linked either by high-speed communication lines, computer networks, or satellite hookups, thus allowing videoconferencing and digital images to be transmitted and received by either site
chronic kidney disease (CKD)
a gradual loss of kidney function classified into 5 stages, with mild loss of kidney function in the early stages and severe or total loss in the later stages; in the final stage (stage 5) the individual’s kidneys are no longer able to perform the job of excreting the body’s wastes or promoting homeostasis, and the patient requires dialysis or kidney transplant
Clinical Performance Measures (CPM) Project
an ongoing project of CMS, implemented through the ESRD networks, to measure and report the quality of renal dialysis services provided under the Medicare program
Consolidated Renal Operations in a Web-enabled Network (CROWNWeb)
CMS Internet-based software application that is the required method by which dialysis facilities submit data about patients and facility operations
continuous ambulatory peritoneal dialysis (CAPD)
a form of peritoneal dialysis in which the patient is able to dialyze him/herself 3 to 4 times per day without special assistance and with a minimum amount of equipment
continuous cycling peritoneal dialysis (CCPD)
a form of peritoneal dialysis in which the patient uses a cycler machine to dialyze once a day for 9 to 10 hours, generally while sleeping
a solution used to filter products across a semipermeable membrane by the process of diffusion; waste products filter into the dialysate from the blood, while certain other products, such as bicarbonates, filter into the blood from the dialysate
“the process of artificially removing metabolic end products and water across a semipermeable membrane by diffusion” (McAfee, 1987); the 2 most common types of dialysis are hemodialysis and peritoneal dialysis
dialysis facility
“an entity that provides (1) outpatient maintenance dialysis services, or (2) home dialysis training and support services, or (3) both; a dialysis facility may be an independent or hospital-based unit…or a self-care dialysis unit that furnishes only self-dialysis services”(Conditions for Coverage, 2008, 20476)
end-stage renal disease (ESRD)
is stage 5 of chronic kidney disease; at this stage the patient has irreversible renal failure with little or no kidney function; when a patient is in end-stage renal disease, he/she requires either dialysis or a kidney transplant to maintain life
erythropoietin stimulating agent (ESA)
stimulates the bone marrow to make red blood cells and is used to treat and prevent anemia, a common complication of chronic kidney disease in patients on dialysis
ESRD networks
18 organizations that have contracted with the centers for Medicare & Medicaid Services (CMS) to assess the quality of care rendered to ESRD patients and to collect and analyze ESRD data
hemodialysis (HD)
cleansing of the blood as it circulates through an artificial kidney machine outside the patient’s body
a means of measuring the adequacy of dialysis (i.e., a way to determine whether the patient is dialyzing long enough or often enough to remove sufficient waste and excess fluid from the body); target Kt/V values in the Conditions for Coverage are 1.2 for hemodialysis and a weekly Kt/V of at least 1.7 for peritoneal dialysis
peritoneal dialysis (PD)
filling of the patient’s abdominal cavity with a solution (dialysate); the semipermeable membrane across which the products diffuse is the patient’s own peritoneal membrane; the fluid containing the wastes is later withdrawn from the peritoneal cavity
quality assessment and performance improvement (QAPI)
The Conditions for Coverage require each dialysis facility to adopt a data-driven performance improvement program that utilizes indicators of performance measures associated with improved health outcomes and with the identification and reduction of medical errors
Renal Management Information system (REMIS)
a system that determines Medicare coverage periods for ESRD patients and serves as the primary mechanism to store and access information in the ESRD Program Management and Medical Information System (PMMIS) Database; REMIS tracks the ESRD patient population for both Medicare and non-Medicare patients
renal replacement therapy (RRT)
a treatment that replaces kidney function; the treatment may be some type of dialysis or it may be kidney transplantation
validation survey
a survey conducted by a regional office of the CMS to determine whether the surveys being conducted by state agencies (or other groups) are appropriately assessing the facility’s operations
Accountable Care Organizations (ACOs)
“a local entity and a related set of providers, including at least primary care physicians, specialists, and hospitals, that can be held accountable for the cost and quality of care delivered to a defined subset of traditional Medicare program beneficiaries or other defined populations, such as commercial health plan subscribers. The primary ways the entity would be held accountable for its performance are through changes in traditional Medicare provider payment featuring financial rewards for good performance based on comprehensive quality and spending measurement and monitoring” (Devers and Berenson, 2009, pp. 1-2)
bed day
an inpatient service received by one member for one 24-hour period
payment of a fixed dollar amount to a provider for each patient assigned to that provider, regardless of the amount of care the patient receives
Clinical Laboratory Improvement Amendments of 1988 (CLIA)
federal legislation that provides for regulation of all clinical laboratories, including those operated in HMOs and physician practices within managed care networks
the amount of expense that is the responsibility of the insured under an indemnity insurance policy, usually 20%
concurrent review
verifying medical necessity of tests and procedures ordered during an inpatient hospitalization
coordination of benefits (COB)
determining which insurance is the primary payer and ensuring that no more than 100% of the charges are paid to the provider and/or reimbursed to the patient
a flat-rate payment, such as $10 per visit, made by the covered individual for a specific service at the time of the service
a process of review to approve a provider who applies to participate in a health plan
credentials verification organization (CVO)
an organization that contracts with a managed care organization or other health care organization to provide credential verification services for physicians and other clinicians seeking clinical privileges
the amount of expenses the insureds must pay each year from their own pockets before the plan will reimburse them
the spouse or child of the primary insurance recipient
Diagnosis Related Groups (DRGs)
basis of the inpatient prospective payment system used by Medicare to reimburse acute care facilities; also used in some MCO contracts
discharge planning
arranging post-discharge services for patients prior to discharge to provide continuity of care and aid in recuperation
whether a person is able to receive benefits under an insurance policy
contact between a patient and a provider who is responsible for the assessment and evaluation of the patient at a specific contact, exercising independent judgment
Flexible Spending Account (FSA)
tax-free money an employee sets aside to use during a specified period for health care expenses
the primary care provider who coordinates all of the patient’s health care and decides what, if any, additional care is required
group model HMO
a model in which the HMO has an exclusive contract with a multispecialty medical group that provides all physician services and contracts with other facilities as necessary to provide comprehensive services; Kaiser Permanente is a successful example of this model; in general, the group model is uncommon.
health maintenance organization (HMO)
a business entity that either provides or arranges for health services for a covered population after prepayment of a fixed premium
Health Reimbursement Arrangement (HRA)
is a mechanism by which an employer funds an account for its employees to pay for otherwise unreimbursed health care expenses
Health Savings Account (HSA)
an account set up by an employee with pretax income that is also not taxed when the employee withdraws from the account at the end of the benefit year roll over to the next year, withdrawals for nonmedical expenses are subject to income tax and a 10% penalty
Hierarchical Condition Categories (HCGs)
disease groupings based on ICD codes from both inpatient admissions and outpatient visits in Medicare Advantage organizations, HCCs are used to risk-adjust Medicare payments to MCOs
indemnity insurance
traditional health insurance in which the insured is reimbursed for expenses after the care has been given
independent practice association (IPA) model
an HMO model that was developed primarily as a way for the solo practice physician to participate in the managed care market
integrated delivery systems/network (IDS/N)
a group of facilities contracted together to provide the comprehensive set of services that any patient may need; they are owned, leased, or grouped together by long-term contracts and are recognized by the public as a combined operating entity
managed care organization (MCO)
an organization that provides comprehensive health services, coordinated through a primary care provider who acts as a gatekeeper, after the patient formally enrolls in the organization
managed indemnity plans
indemnity insurance plans that do not limit the insured’s choice of health care providers but do include cost-control measures such as preauthorization of expensive tests, surgical procedures, and inpatient hospitalization
Medicare Advantage
a program by which eligible Medicare beneficiaries may choose to receive their health care through a qualified managed care plan, which in turn receives capitation payments from Medicare for each enrollee
mixed model HMO
an HMO that operates within 2 or more different types of organizational structures to provide flexibility to members
an individual who is enrolled in a managed care organization
National Committee for Quality Assurance (NCQA)
an accreditation association that accredits managed care organizations and related services; their accreditation programs include health plan accreditation, wellness and health promotion, managed behavioral health care organizations, new health plans, and disease management
network model HMO
an HMO that contracts with multiple physician groups, hospitals, and other facilities to provide a comprehensive health care package
the group of patients who have chosen a particular provider as their primary care provider
per diem
a reimbursement methodology where the payment is based on the number of days of care
preadmission certification
review and approval of the medical necessity of inpatient care prior to the patient’s admission
review and prior approval for payment of a health care service
preferred provider organization (PPO)
an insurance entity that contracts with providers to create a preferred network; the insured population is allowed to use any provider, but using network providers results in a lesser cost to the patient
Principal In-Patient Diagnostic Cost Groups (PIP-DCGs)
the first risk adjustment model that Medicare used to adjust capitation payments made to Part C plans, based largely on the principal diagnoses of hospitalized enrollees; PIP-DCGs were replaced by HCCs in 2004
an authorization to receive from a specific health provider a specific health services that will be paid for by the HMO
staff model HMO
the most tightly organized HMO structure; the HMO entity owns the facilities and arranges for health care through employed physicians, who are allowed to see only the particular HMO’s patients
primary recipient of the insurance benefit
an independent, nonprofit organization offering accreditation, education, and measurement programs; URAC’s Health Plan standards are appropriate for HMOs and other integrated health plans; its Health Network accreditation does not include utilization management and is better suited for PPO accreditation
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