subrogation

process of the third-party payer recovering health care expenses from liable party

Ambulatory Payment Classification (APC)

prospective payment system used to calculate reimbursement for outpatient  care according to similar clinical characteristics and in terms of resources required

APC

Ambulatory Payment Classification

Association Of Medical Care Plans

a national coordinating agency for physician-sponsored health insurance plans.

automobile insurance policy

contract between an individual and an insurance company whereby individual pays a premium and, in exchange, the insurance company agrees to pay for specific car-related financial losses during the term of the policy; typically includes medical payments coverage and personal injury protection (PIP) to reimburse health care expenses sustained as the result of injury from an automobile accident.

Balanced Budget Act Of 1997 (BBA)

addresses health care fraud and abuse issues, and provides for Departr of Health and Human Services (DHHS) Office of the Inspector General (OIG) investigative and audit services in health care fraud cases.

BBA

Balanced Budget Act Of 1997

base period

period of time that usually covers 12 months and is divided into four consecutive quarters.

ASCA

Administrative Simplification Compliance Act

Civilian Health and Medical Program—Uniformed Services(CHAMPUS)

originally designed as a benefit for dependents of personnel serving in the armed forces and uniformed branches of the Public Health Service and the National Oceanic and Atmospheric Administration; now called TRICARE.

CHAMPUS

Civilian Health and Medical Program—Uniformed Services

Civilian Health and Medical Program of the Department of Veterans

program that provides health benefits for dependents of veterans rated as 100 percent permanently and totally disabled as a result of service-connected conditions, veterans who died as a result of service-connected conditions, and veterans who died on duty with less than 30 days of active service.

CHAMPVA

Civilian Health and Medical Program of the Department of Veterans

Affairs

CHAMPUS Reform Initiative (CRI)

conducted in 1988; resulted in a new health program called TRICARE, which includes three options: TRICARE Prime, TRICARE Extra, and TRICARE Standard.

CRI

CHAMPUS Reform Initiative

BlueCross BlueShield Association (BCBSA)

an association of independent Blue Cross and Blue Shield plans.

BCBSA

BlueCross BlueShield Association

Blue Cross Association (BCA)

replaced the American Hospital Association (AHA) in 1972 as the approval agency for new Blue Cross health plans.

BCA

Blue Cross Association

Coinsurance 

also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

allows employees to continue health care coverage beyond the benefit termination date.

COBRA

Consolidated Omnibus Budget Reconciliation Act of 1985

form used to submit Medicare claims; previously called the HCFA-1500.

Clinical Laboratory Improvement Act (CLIA)

establised quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test was performed.

CLIA

Clinical Laboratory Improvement Act

HCFA-15QO

now called CMS-1500.

health care

expands the definition of medical care to include preventive services.

health insurance 

contract between a policyholder and a third-party payer or government program to reimburse the policyholder for all or a portion of the cost of medically necessary treatment or preventive care by health care professionals.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

mandates regulations that govern privacy, security, and electronic transactions standards for health care information.

health maintenance organization (HMO)

responsible for providing health care services to subscribers in a given geographical are for a fixed fee.

HMO

health maintenance organization

HIPAA

Health Insurance Portability and Accountability Act of 1996

Hill-Burton Act

provided federal grants for modernizing hospitals that had become obsolete because of a lack of capital investment during the Great Depression and WWII (1929-1945). In return for federal funds,facilities were required to provide services free, or at reduced rates, to patients unable to pay for care.

Health Plan Employer Data and Information Set (HEOIS)

created standards to assess managed care systems using data elements that are collected, evaluated, and published to compare the performance of managed health care plans.

HEOIS

Health Plan Employer Data and Information Set

Health Maintenance Organization Assistance Act of 1973

authorized grants and loans to develop HMOs under private sponsorship; defined a federally qualified HMO as one that has applied for, and met, federal standards established in the HMO Act of 1973; required most employers with more than 25 employees to offer HMO coverage if local plans were available.

COpayment (COpay)

provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received.

consumer-driven health plan

health care plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of hold­ing down costs; also called consumer-directed health plan

deductible

amount for which the patient is finan­cially responsible before an insurance policy provides coverage.

reimbursement for income lost as a result of a temporary or permanent illness or injury.

diagnosis-related group (DRG)  

prospective payment system that reimburses hospitals for inpatient stays.

DRG

diagnosis-related group

Dependents' Medical Care Act of 1956

provides health care to dependents of active military personnel.

Evaluation and Management (E/M)

services that describe patient encounters with health care professionals for evaluation and management of general health status.

Employee Retirement Income Security Act of 1974 (ERISA)

mandated reporting and disclosure requirements for group life and health plans (including managed care plans), permitted large employers to self-insure employee health care benefits, and exempted large employers from taxes on health insurance premiums.

ERISA

Employee Retirement Income Security Act of 1974

Federal Employees' Compensation Act (FECA)

replaced the 1908 workers' compensation legislation; civilian employees of the federal government are provided medical care, survivors' benefits, and compensation for lost wages.

FECA

Federal Employees' Compensation Act

group medical practices

three or more health care providers who share equipment, supplies, and personnel, and divide income by a prearranged formula.

 health care coverage available through employers and other organizations (e.g., labor unions, rural and consumer health cooperatives); employers usually pay part, or all, of premium costs.

World Health Organization (WHO)

developed the International Classification of Diseases (ICD).

WHO

World Health Organization

end-stage renal disease (ESRD)

chronic kidney disorder that requires long-term hemodialysis or kidney transplantation because the patient's filtration system in the kidneys has been destroyed.

ESRD

end-stage renal disease

Home Health Prospective Payment System (HH PPS)

reimbursement methodology for home health agencies that uses a classification system called home health resource groups (HHRGs), which establishes a predetermined rate for health care services provided to patients for each 60-day episode of home health care.

HH PPS

Home Health Prospective Payment System

Financial Services Modernization Act

prohibits sharing of medical information among health insurers and other financial institutions for use in making credit decisions; also allows banks to merge with investment and insurance houses, which allows them to make a profit no matter what the status of the economy, because people usually house their money in one of the options; also called Gmmm-Leach-Bliley Act.

fee schedule

 list of predetermined payments for health care services provided to patients (e.g., a fee is assigned to each CPT code).

HCFA-15QO

now called CMS-1500.

inpatient

admitted to the hospital for treatment with the expectation that the patient will remain in the hospital for a period of 24 hours or more.

Inpatient Psychiatric Facility Prospective Payment System

(IPF PPS)

system in which Medicare reimburses inpatient psychiatric facilities according to a patient classification system that reflects differences in patient resource use and costs; it replaces the cost-based payment system with a per diem IPF PPS.

IPF PPS

Inpatient Psychiatric Facility Prospective Payment System

Inpatient Rehabilitation Facilities Prospective Payment System

(IRF PPS)

implemented as a result of the BBA of 1997; utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs.

IRF PPS

Inpatient Rehabilitation Facilities Prospective Payment System

insurance

contract that protects the insured from loss.

International Classification of Diseases (ICD)

classification system used to collect data for statistical purposes.

ICD

International Classification of Diseases

major medical insurance

coverage for catastrophic or prolonged illnesses and injuries.

managed care

allows patients to receive care from a group of participating providers to whom a copayment is paid for each service

liability insurance

policy that covers losses to a third party caused by the insured, by an object owned by the insured, or on the premises owned by the insured.

lien

lifetime maximum amount

Medicare

Minimum Data Set (MDS)

 data elements collected by long-term care facilities.

MDS

Minimum Data Set

Protection Act Of 2003 (BIPA)

requires implementation of a $400 billion prescription drug benefit, improved Medicare Advantage (formerly called Medicare+Choice) benefits, faster Medicare appeals decisions, and more.

BIPA

Protection Act Of 2003

National Association of Blue Shield Plans

name of the former Associated Medical Care Plans

National Correct Coding Initiative (NCCI)

developed by CMS to promote national correct coding methodologies and to eliminate improper coding practices.

NCCI

National Correct Coding Initiative

Occupational Safety and Health Administration Act of 1970(OSHA)

legislation designed to protect all employees against injuries from occupational hazards in the workplace

OSHA

Occupational Safety and Health Administration Act of 1970 

Omnibus Budget Reconciliation Act of 1981 (OBRA)

federal law that requires physicians to keep copies of any government insurance claims and copies of all attachments filed by the provider for a period of five years; also expanded Medicare and Medicaid programs.

OBRA

Omnibus Budget Reconciliation Act of 1981

Outcomes and Assessment Information Set (OASIS)

group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement.

OASIS

Outcomes and Assessment Information Set

Outpatient Prospective Payment System (OPPS)

uses ambulatory payment classifications (APCs) to calculate reimbursement; was implemented for billing of hospital-based Medicare outpatient claims.

OPPS

Outpatient Prospective Payment System

peer review organization (PRO)

replaced Professional Standards Review Organizations (PSROs) as part of the Tax Equity and Fiscal Responsibility Act of 1983; now called quality improvements organizations (QIOs).

PRO

peer review organization

per diem

Latin term meaning "for each day," which is how retrospective cost-based rates were determined; payments were issued based on daily rates.

prepaid health plan

contract between employer and health care facility (or physician) where specified medical services were performed for a predetermined fee that was paid on either a monthly or yearly basis.

preventive services

designed to help individuals avoid health and injury problems.

Professional Standards Review Organizations (PSROs)

physician-controlled nonprofit organizations that contracted with HCFA (now called CMS) to provide review of hospital inpatient resource utilization, quality of care, and medical necessity; PSROs were replaced by peer review organizations, or PROs, as a result of the Tax Equity and Fiscal Responsibility Act of 1982, or TEFRA; PROs were replaced by quality improvement organizations (QIOs).

 PSROs

Professional Standards Review Organizations

prospective payment system (PPS)

PPS

prospective payment system

quality improvement organization (QIO)

previously called a peer review organization (PRO); performs utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries.

QIO

quality improvement organization

Resource Utilization Groups (RUGs)

based on data collected from resident assessments (using data elements called the Minimum Data Set, or MDS) and relative weights developed from staff time data.

RUGs

Resource Utilization Groups

Resource-Based Relative Value Scale (RBRVS) system

payment system that reimburses physicians' practice expenses based on relative values for three components of each physician's services: physician work, practice expense, and malpractice insurance expense.

RBRVS

Resource-Based Relative Value Scale

　Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

created Medicare risk programs, which allowed federally qualified HMOs and competitive medical plans that met specified Medicare requirements to provide Medicare-covered services under a risk contract.

TEFRA

　Tax Equity and Fiscal Responsibility Act of 1982

third-party administrator (TPA)

company that provides health benefits claims administration and other outsourcing services for self-insured companies; provides administrative services to health care plans; specializes in mental health case management; and processes claims, serving as a system of "checks and balances" for labor-management.

TPA

third-party administrator

usual and reasonable payments

based on fees typically charged by providers in a particular region of the country

medicaid

cost-sharing program between the federal and state governments to provide health care services to low-income Americans; originally adminstered by the Social and Rehabilitation Service (SRS). (indigent person- has nothing)