Term
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Definition
| "Diagnosis Related Group" based on LOS for hospital; 1983, 1st PPS |
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Term
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Definition
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Term
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Definition
| Health Maintenance Organizations; 1973 |
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Term
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Definition
| Preferred Provider Organizations |
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Term
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Definition
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Term
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Definition
| Entities that offer a HMO, PPO, or POS plan or any combo of these. |
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Term
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Definition
| Individuals responsible for following cases, approving or denying requests, & assuring timely attn: to detail. (work for 3rd party payer or hospital; often nurses in hospitals) |
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Term
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Definition
| A flat rate is received by practitioner and all services must be provided for that rate. |
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Term
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Definition
| A flat rate per visit regardless of services provided |
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Term
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Definition
| Flat rate per case based on level of symptoms, regardless of services provided. |
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Term
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Definition
| "Resource Based Relative Value System"- reimbursement based on amt of resources consumed by providing the care. |
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Term
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Definition
| a continuum of care provided through the same organization therefore removing any duplication of services by controlling all aspects of care |
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Term
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Definition
| Resource Utilization Group (used in SNFs; based on diagnosis & amt of resources; linked to per diem for prescribed amt of therapies) |
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Term
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Definition
| "Skilled Nursing Facilities" Reimbursement based on RUGS (Med A), services/resources |
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Term
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Definition
| "Minimal Data Set" records functional level of beneficiary & amt. of assistance needed per ADL index. Used in SNFs |
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Term
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Definition
| Calculated from MDS (min. data set); Key scale 1= independent, 5= assist 2+; Eating scale 1= independent, 3= total dependence. Composite score of 4 key scales determines RUGs category |
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Term
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Definition
| time/week, units/day, # of disciplines, frequency/wk. Ultra high, very high, high, medium, low |
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Term
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Definition
| Common Procedural Terminology (anything Med B)represent procedures & services; used in outpatient facilities |
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Term
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Definition
| use CPT codes (common procedural terminology), services |
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Term
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Definition
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Term
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Definition
| "Comprehensive Outpatient Rehab Facility" based on CPT codes |
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Term
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Definition
| "Functional Independence Measure" acute rehab; 0-6 scale, 0=total dep, 6= independent; used in acute rehab |
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Term
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Definition
| (Med A)uses PPS based on FIM scores |
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Term
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Definition
| Prospective Payment System (vs. fee for service & fee schedule) |
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Term
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Definition
| (Med A) reimb based on OASIS. Beneficiaries must meet def. of homebound |
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Term
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Definition
| "Outcome & Assessment Information Set" records functional level & # of home care visits |
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Term
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Definition
| non-acute, outpatient, pay for it |
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Term
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Definition
| hospital, acute, everybody gets it, DRGs, LOS |
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Term
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Definition
| benefits provided by an HMO/Managed Care Co. |
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Term
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Definition
| "Program of All-Inclusive Care for the Elderly." Medicaid Financing |
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Term
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Definition
| Dept. of Health & Human Services |
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Term
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Definition
| "Medicare Savings Programs" for dual eligables, who also are eligable for Medicaid |
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Term
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Definition
| Qualified Medicare Beneficiaries |
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Term
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Definition
| Supplemental Security Income |
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Term
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Definition
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Term
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Definition
| Specified Low-Income Medicare Beneficiaries |
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Term
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Definition
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Term
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Definition
| Qualified Disabled and Working Individuals |
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Term
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Definition
| Civilian Health & Medical Program of the Uniformed Services= Tricare |
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Term
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Definition
| Health Care Financing Administration; formed in 1977 to oversee Medicare & Medicaid; now called CMS |
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Term
First Party
Second Party
Third Party |
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Definition
1. Patient
2. Health Care provider
3. Insurance Co. |
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Term
| Commercial Insurance/ Indemnity Plans |
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Definition
ie. Blue Cross
Catastrophic care, limited preventaive;
choice of physician |
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Term
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Definition
ie. Kaiser
low co-pay, preventative care covered
Requires PCP referral, coverage dictated; keeps everything "in house" |
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Term
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Definition
ie. Mutual of Omaha
usu. commercial option
choice of doctors, but more expensive, limited preventative care |
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Term
| Principles of Bioethical Decision Making |
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Definition
Autonomy-informed consent
Veracity- tell truth
Nonmaleficence- do no harm
Beneficience- Contribute
Confidentiality- info
Justice- |
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