CMM Study Guide
Glossary of Terms & Acronyms
This page correlates with the CMM Study Guide, formally titled: Fundamentals of Health Care Management for Physician Practices and Ambulatory Health Service Organizations, 5th Edition
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Actual Charge
The amount a physician or supplier actually bills for a particular medical service or supply.
Adjudication
When a claim is submitted for payment, an employee of the healthcare payor determines the amount of reimbursement due the provider. Based on regulation, coverage exclusion, individual policy limits or other factors, an individual claim may be paid, reduced, or denied.
Adjustments Percentage
The amount not collected on fees for services due to contractual write-offs, charitable adjustments, free services and other discounts divided by gross charges. This measures the percentage of what a practice bills which is not collectible. A lower figure is better. Differs among specialties.
Admission Review
The examination of a case for medical necessity and appropriateness of admission, at the time of, or immediately following, admission, to an in-patient facility for treatment.
Advance Beneficiary Notices (ABN)
The CMS-R-131 form is the ABN approved by OMB (Office of Management and Budget) on June 18, 2002. Beginning Monday, March 1, 2009 providers (including independent laboratories), physicians, practitioners, and suppliers will use the revised ABN (Form CMS-R-131) for all situations where Medicare payment is expected to be denied. The revised ABN replaces the ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20002).
Note: Skilled nursing facilities (SNFs) must use the revised ABN for items/services expected to be denied under Medicare Part B only. An ABN will be presented to all patients when there is a likelihood that an ordered test or service will not be paid as a covered service by insurance. The person administering the ABN (clinical personnel) to the patient will explain what the ABN is, and what test/tests are being ordered, and that he or she will likely be responsible for paying for those tests out of pocket. The patient then has the right to receive the test(s) or service(s) and sign the ABN or agree not to receive the test(s) or service(s) ordered. If the patient refuses the test, it will be documented in the patient’s medical record and the provider will be notified. If tests are ordered after an ABN has been signed for a service performed on the same date, the patient must initial on the ABN by the services or tests that are being added. Each time the services proposed may not be covered by insurance, the patient must sign a new ABN. Under no circumstances will a patient sign a blank ABN, nor will a signed ABN be used repeatedly.
Agent
A person who is authorized by another to act for him. That person entrusted with another's business.
Appeal
This is the process by which a patient or provider may request a reconsideration of an adjudication decision.
Appointments and Providers’ Schedules
The provider schedules are checked on a regular basis to ensure that the patients are on the appropriate providers’ schedule. The time frame and the reason for the visits are reviewed. A search is conducted for over booking of appointments and confirmation of appointments with the daily sign-in sheets of patients’ names and actually seen by the designated provider. Corrections and adjustments are made accordingly.
Assignment
A process through which a physician or supplier agrees to accept the Medicare program's payment as payment in full except for specific coinsurance and deductible amounts required of the patient.
Bad Debt Percentage
Bad debts (amounts written off as not collectible, amounts turned over to collection agency, and other amounts that represent losses from receiving less than was billed) divided by the total adjusted charges (gross charges minus contractual, professional charity and other discounts). Differs among specialties. Ranges from .4 to 7.5 percent.
Beneficiary
The person receiving the benefits of the insurance policy, usually referring to the policy owner.
Bloodborne Pathogens
Pathogenic microorganisms that are present in human blood that can cause disease in humans. These include, but are not limited to, HBV and HIV.
Capitation
This method is used for HMO members but is being extended to EPO and POS plans. Although capitation payments can be based upon a number of criteria, the general structure is a flat rate, per member/per month—or pm/pm. Physicians and/or hospitals can then be paid this amount each month for each member that has chosen that provider for services at open enrollment. This means that the HMO enrollee selects a primary care physician who is responsible for all services and an associated hospital. These providers are then paid the flat rate for each member and are financially responsible for all services rendered, regardless of the actual cost of providing the services. Capitation demands accurate and efficient procedures throughout the organization so that appropriate and medically necessary services are provided in an efficient and cost-effective manner.
Case Management
The process of identifying and recommending appropriate and cost-effective professional health and mental health services for a given patient and family during the period of the patient's rehabilitation.
Claim
A request sent to any payer in order for the provider to be reimbursed for services or procedures rendered to a patient who has insurance including Medicare or Medicaid.
Claims Processing
This is the process that begins with the submission of a claim to Medicare, Medicaid, Managed Care Plan, or any third-party payor for services rendered to the insured patient and ends with the reimbursement from the healthcare payor.
Closed Panel
A healthcare program that requires participants to use providers or facilities from a list provided by the plan, with whom the plan has established a contractual relationship.
Coinsurance
A cost-sharing requirement that a beneficiary will assume a portion or percentage of the cost of covered services.
Commercial Insurance Plans
Commercial insurance companies such as Guardian, Travelers, and New York Life are managed separately and can offer their clients any type of coverage to meet a particular group's needs as long as the coverage is within state and federal regulations. Some of the larger private insurance carriers also serve as Medicare carriers within a certain state(s).
Competitive Medical Plan (CMP)
An organization that provides a full range of healthcare coverage in exchange for a monthly, fixed fee. CMPs with Medicare contracts offer Medicare beneficiaries all services covered by fee-for-service Medicare. Medicare pays these plans on a monthly basis for each Medicare beneficiary. Medicare beneficiaries get all Medicare-covered hospital and medical insurance benefits through the plan. The CMP may also collect a premium from each Medicare member enrolled in the plan.
Computerized Provider Order Entry (CPOE)
A computer application that allows a physician’s orders for diagnostic and treatment services (such as medications, laboratory, and other tests) to be entered electronically instead of being recorded on order sheets or prescription pads. The computer compares the order against standards for dosing, checks for allergies or interactions with other medications, and warns the physician about potential problems.
Concurrent Review
The examination of cases for medical necessity and appropriateness of treatment during the time the service is being provided. A part of hospital utilization management and quality assurance programs where hospital admissions and length of stay are reviewed for medical necessity.
Consolidated Health Informatics (CHI) Initiative
One of the 24 Presidential eGovernment initiatives with the goal of adopting vocabulary and messaging standards to facilitate communication of clinical information across the federal health enterprise. CHI now falls under FHA.
Contaminated
Soiled by the presence or reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.
Contaminated Sharps
Any contaminated object that can puncture the skin.
Co-Payment
A fixed liability for the beneficiary. An amount paid by the beneficiary for specific levels of service to offset fee-for-service and capitation amounts.
Cost Ratio
Shows the average cost of performing procedures in the physician office. Total Operating Expenses/Total Procedures.
Covered Service
A service that any given payer (Medicare, Medicaid, private insurance…) lists as eligible for payment. Some services are only covered for specific conditions which are determined based on the diagnosis code or codes submitted. A non-covered service is never a benefit regardless of the condition being treated. For example, a steroid injection may be payable for certain diagnoses but not for others. An example of a non-covered service is cosmetic surgery.
CPT
Current Procedural Terminology, developed and published by the American Medical Association, lists numerical codes of 5 digits and numeric 2-digit modifiers for procedures performed by physicians.
Current Ratio
Current assets amount as shown on balance statement of practice divided by current liabilities. Measures how cash received by practice covers cash needs of practice. Current Assets/Current Liabilities.
Custodial Care
Treatment or services given safely and reasonably by a person not medically skilled, regardless of who recommends the treatment and/or services or where they are provided. The services are designed mainly to help the patient with daily living. Examples include helping the patient with walking, bathing, dressing, and using the toilet.
Customary Charge
The amount a physician or supplier most frequently charges for each separate service and supply furnished.
Decision-Support System (DSS)
Computer tools or applications to assist physicians in clinical decisions by providing evidence-based knowledge in the context of patient specific data. Examples include drug interaction alerts at the time medication is prescribed and reminders for specific guideline-based interventions during the care of patients with chronic disease. Information should be presented in a patient-centric view of individual care and also in a population or aggregate view to support population management and quality improvement.
Decontamination
The use of physical or chemical means to remove, deactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infection.
Deductible
The amount of any given expense a beneficiary must first meet before Medicare begins payment for covered services.
Defendant
The person defending or denying a legal action; the party against whom relief or recovery is sought in an action or suit.
Deliberate Ignorance
To act in deliberate ignorance means that the provider has deliberately chosen to ignore the truth or falsity of the information on a claim submitted for payment, even though the provider knows, or has notice, that information may be false. An example of a provider who submits a false claim with deliberate ignorance would be a physician who ignores provider update bulletins and thus does not inform his/her staff of changes in the Medicare billing guidelines or update his/her billing system in accordance with changes to the Medicare billing practices. When claims for non-reimbursable services are submitted as a result, the False Claims Act has been violated.
Demand Management
A program by provider organizations to process and monitor various requests of members for clinical information and services. This may involve operating an extended hours nursing telephone triage service for members, patient education materials or other services.
Disease Management
Disease management involves aspects of case and outcomes management with a focus on specific diseases, evaluating the reasons for the costs, what treatment plan works, educating patients and providers and coordinating all levels of care (hospital, physician, pharmacy, etc.).
DRG (Diagnosis Related Group)
Actually, a form of per-case reimbursement, DRGs are riskier than most case rates because they are more specifically defined and prospectively determined. Thus, they demand sophisticated systems to determine and track the correct payment. Originally used by Medicare as a basis of payment, a number of third-party payers are also negotiating their rate structure based upon DRGs.
Electronic Health Record (EHR)
A real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decision making. The EHR can automate and streamline a clinician's workflow, ensuring that all clinical information is communicated. It can also prevent delays in response that result in gaps in care. The EHR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and public health disease surveillance and reporting.
Electronic Prescribing (eRx)
A type of computer technology whereby physicians use handheld or personal computer devices to review drug and formulary coverage and to transmit prescriptions to a printer or to a local pharmacy. E-prescribing software can be integrated into existing clinical information systems to allow physician access to patient specific information to screen for drug interactions and allergies.
Emancipation
Freedom from restraint, control, or power over another; release from paternal care and responsibility.
Engineering Controls
Controls that isolate or remove the bloodborne pathogens hazards from the workplace (e.g., sharps containers, self-sheathing needles).
Enterprise Architecture
A strategic resource that aligns business and technology, leverages shared assets, builds internal and external partnerships, and optimizes the value of information technology services.
Ethics
The moral sense that dictates the duties that a member of a profession owes to the public.
EPO (Exclusive Provider Organization)
A variation of the PPO, EPOs provide one level of benefits. The patient is still able to select a physician/hospital from network providers; however, no benefit is paid for going out-of-network. As a result of this restriction, EPO premiums can be priced to compete more closely with HMOs but maintain some of the freedom of choice of the PPO. Examples of EPOs include: PARTNERS EPO and SANUS WEST.
Exposure Incident
A specific eye, mouth, any mucous membrane, non-intact skin, or parenteral contact with blood or OPIM that results from the performance of an employee's duties.
False Claims
A false claim is a claim for payment for services or supplies that were not provided specifically as presented or for which the provider is otherwise not entitled to payment. Examples of false claims for services or supplies that were not provided specifically as presented include, but are not limited to:
§ A claim for a service or supply that was never provided.
§ A claim indicating the service was provided for some diagnosis code other than the true diagnosis code in order to obtain reimbursement for the service (which would not be covered if the true diagnosis code were submitted).
§ A claim indicating a higher level of service than was actually provided.
§ A claim for a service that the provider knows is not reasonable and necessary.
§ A claim for services provided by an unlicensed individual.
Fast Healthcare Interoperability Resources (FHIR)
A standard for exchanging healthcare information electronically and to support automated clinical decision support and other machine-based processing in a structured and standardized manner
Federal Health Architecture (FHA)
A collaborative body composed of several federal departments and agencies, including the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS), the Department of Veterans Affairs (VA), the Environmental Protection Agency (EPA), the United States Department of Agriculture (USDA), the Department of Defense (DoD), and the Department of Energy (DOE). FHA provides a framework for linking health business processes to technology solutions and standards and for demonstrating how these solutions achieve improved health performance outcomes.
Fraud
The intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment such as submitting claims for services not provided or supplies not used. Another example is falsifying claims or medical records.
FFS (Fee-for-Service, 90/10; 80/20 plans)
This is the traditional form of insurance. Under this coverage a patient self-selects a provider. The patient usually has a deductible of $250, $500, $1,000, or $1,500. The insurance carrier pays 80% of the bill after the patient has met the deductible and the patient is responsible for the remaining 20 percent. The 20 percent is termed the patient's coinsurance. Co-insurance is easily confused with co-payment, which is a fixed amount; say $5.00 per visit.
Gatekeeper
A gatekeeper is used by most HMO models and is a primary care physician pre-selected by each insured person and that person must go to the gatekeeper for referrals to any specialist. Some HMOs allow females to have a gatekeeper but also a gynecologist they may go to without a referral from the gatekeeper.
HBV
Hepatitis B Virus
HCPCS (Healthcare Common Procedure Coding System)
A coding system developed by CMS (formerly HCFA) in 1983 providing alphanumeric codes in addition to those defined in CPT. While some of these additional codes are also for physician services, most relate to Durable Medical Equipment and non-physician services covered by Medicare Part B and Medicaid. CPT is, however, included in its entirety within the HCPCS Codes as Level I of HCPCS then, Level II is referred to as National Codes.
Health Information Technology (HIT)
The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making.
Health Maintenance Organization (HMO)
An organization that provides a full range of healthcare coverage in exchange for a monthly, fixed fee. HMOs with Medicare contracts offer Medicare beneficiaries all services covered by fee-for-service Medicare. Medicare pays the organizations on a monthly basis for each Medicare beneficiary. Medicare beneficiaries get all Medicare-covered hospital and medical insurance benefits through the organizations. The HMO may also collect a premium from each Medicare member enrolled in the plan.
HIPAA
Health Insurance Portability and Accountability Act of 1996. These are statutes designed to protect the confidentiality of patient information. All medical practices are covered by HIPAA which place specific requirements on how, when and what protected health information may be released to others.
HIV
Human Immunodeficiency Virus
Hold Harmless (in Managed Care Contracts)
A statement in a legal contract stating that the provider agrees to contractually assume the liability exposure of the other party – generally a managed care organization (MCO). These can be broadly or narrowly defined. Providers should not agree to a broad hold harmless clause such as assuming the liability for any lawsuits filed by a patient for malpractice, without contacting an attorney. A simple example of a common clause, though, is the provider agrees not to charge the patient for the fees in excess of the allowed amount of the MCO. This type of clause should not deter entering into a contract.
HMO (Health Maintenance Organization)
HMOs have been available for over 50 years (Ross, Loos, and Kaiser were the first). HMOs are typically less expensive in employer/employee premiums than PPOs and EPOs but have greater restrictions. They provide very comprehensive benefits (usually 100%) for service provided in-network but no benefits if the patient goes out-of-network (except for emergency care).
Staff Model HMOs receive premiums directly and hire their own physicians (usually with salary and incentive or bonus components). Patients (known as members or enrollees) then visit clinics for treatment, typically seeing different physicians on each visit (although these HMOs are moving away from this system for competitive reasons).
Hospice
A program operated by a public agency or private organization primarily providing pain relief, symptom management, and supportive services for terminally ill people and their families.
Hospital Insurance
The part of Medicare that helps pay for inpatient hospital care, some inpatient care in a skilled nursing facility, home healthcare, and hospice care.
ICD-9-CM
International Classification of Disease-9th Edition-Clinical Modification. This is a coding system that was used to describe the patient's medical condition using medical terminology and translating it into codes of 3 to 5 digits which includes specific diagnosis as well as symptoms, problems, reasons, and complaints for the encounter/ visit. This edition was used in the United States for all medical encounters with dates of service through September 30, 2015.
ICD-10-CM
International Classification of Diseases-10th Edition-Clinical Modification. This is the 10th revision of ICD-9-CM and was implemented, nationwide, in the United States effective with dates of service October 1, 2015 and subsequent. The codes can be between 3 to 7 alphanumeric characters and all codes start with a letter.
Intermediary
A private insurance organization under contract to the Federal government to handle Medicare payment for services by hospitals, skilled nursing facilities, hospices, outpatient rehabilitation providers, and home health agencies.
IPA (Independent Physician Associations)
An IPA is a corporation formed by physicians who each maintain independent practices but participate in the IPA to compete for business, primarily HMO business. IPAs accept financial risk for their members (e.g., capitation); the group is spread out geographically and is less formal than a medical group. IPAs were originally formed to allow independent, community-based physicians a vehicle to compete with Staff and Group Model HMOs. IPAs typically have a core of primary care physicians who self-monitor all medical services and authorize all referrals to specialists. IPAs have been a successful form of HMO for independent and group practices.
Joint ventures
A business arrangement between physicians, physicians and hospitals, physicians and non-physicians. For example, a few surgeons and the local hospital decide to build an ambulatory surgery center.
Kickback
A payment to a party, as an inducement to buy or influence that party’s behavior for their financial gain. For example, the hospital does not charge a physician for office space in the hospital because he refers so many patients to the hospital for care.
Knowingly
To knowingly present a false or fraudulent claim means that the provider: (1) has actual knowledge that the information on the claim is false; (2) acts in deliberate ignorance of the truth or falsity of the information on the claim; or (3) acts in reckless disregard of the truth or falsity of the information on the claim. It is important to note the provider does not have to deliberately intend to defraud the Federal Government in order to be found liable under this Act. The provider need only knowingly present a false or fraudulent claim in the manner described above.
Locum Tenens
Holding the place. A substitute or representative.
Malfeasance
The act of committing harm or evil: a harmful or evil act.
Malpractice
Wrong or injurious treatment.
Managed Care
The concept of managed healthcare has been around for several years and has dramatically affected medical practices in recent years. Two major alternative delivery systems that have emerged are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). These systems contain costs through financial incentives and utilization controls. Managed Care Plans are administered by Managed Care Organizations (MCOs).
Managed Care Encounters Per Member
Measures the average number of visits per member in a managed care plan. Total Visits of Managed Care Plan Patients / Average Number of Members Per Month.
Marketing
The compliance program will require honest, straight forward, fully informative, and non-deceptive marketing devices for their laboratory and for the medical practice as a whole. It must be consistent with and within the limits of the state laws regarding physician advertisements.
Medicaid
The Medicaid Program is funded jointly by the state and federal governments. Medicaid beneficiaries are state residents who are medically and/or financially needy. Each state determines the eligibility of its residents, the benefits it renders, the scope of its care, the providers it deals with, and the amount that it reimburses to each provider.
Medical Group Practice
A medical group is a formalized group of physicians who practice under a common corporate structure (combined assets and liabilities). The member physicians are generally employees of the corporation. They receive a salary, and the group practice bills for all services. Medical Groups may be multi-specialty, specialty only (e.g., cardiology, orthopedics, etc.), or primary care. Medical Groups usually have one physician who acts as managing physician. The physicians in the Group Practice make business decisions for the practice (i.e., whether or not to participate with Medicare and Managed Care Plans).
Medical Insurance
The part of Medicare that helps pay for medically necessary physician services, outpatient hospital services, and a number of other medical services and supplies not covered by the hospital insurance part of Medicare, as well as some home health services.
Medical Risk Contract
A contract between HCFA and a particular HMO where the HMO is capitalized at 95% of projected fee-for-service costs for Part A and Part B. In essence, the HMO is at risk for Parts A and B services.
Medicare
The Medicare Program is a federal health insurance program for people 65 years or older and for certain disabled people. It is run by the Centers for Medicare & Medicaid Services, of the U.S. Department of Health and Human Services.
There are four parts to Medicare: Part A, B, C, and D.
Medicare Part A
Covers inpatient hospital care, some inpatient care in a skilled nursing facility, home healthcare, and hospice care.
Medicare Part B
Helps pay for physician's services, outpatient hospital services, some durable medical equipment, and a number of other medical services and supplies.
Medicare Part C
Medicare Advantage (Part C) plans are run by private insurance companies and combine Medicare Parts A (hospital coverage) and B (doctor coverage) plus additional benefits all in one plan. Many plans also include prescription drug coverage and are known as MA-PD or Medicare Advantage with Prescription Drug plans.
Medicare Part D
Drug plans that patients may sign up for coverage of prescription drugs.
Medicare Participating Physician or Supplier
A physician or supplier who agrees to accept assignment on all Medicare claims.
Medigap Policy
Private health insurance designed to supplement Medicare.
Minor
A person who has not attained legal age as defined in the state.
Negligence
Failure to exercise the care that a prudent person would exercise. An act or instance of negligence.
NIOSH
National Institute for Occupational Safety and Health.
Nursing/Clinical Staff Duties Regarding ABNs
§ Understand the purpose of an ABN and become familiar with those tests/services routinely not covered by insurance carriers.
§ Appropriately inform the patient of the purpose of an ABN and fill out ABNs accordingly. When requested, assist with clarification to the patient why the test was ordered.
§ Verify the appropriate diagnosis per the medical record or the provider. Document pertinent information (e.g., verification of orders for tests, refusal of patient to sign the ABNs, etc.).
§ Notify the appropriate provider immediately when a patient refuses to have lab tests or services performed.
§ When questioned by the patient regarding billing/insurance, direct patient to appropriate personnel for assistance.
§ Oversee the staff when lab services are ordered to confirm the use of only current and pertinent diagnoses.
§ If a test is ordered after the patient has already signed the ABN, it is the responsibility of the clinical staff to make sure that the patient initials by any test that is added to the ABN.
Occupational Exposure
Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or OPIM that may result from the performance of an employee's duties.
Open Panel
A healthcare program that permits participants to purchase services from the provider or facility of his or her choice.
OPIM
Other potentially infectious materials.
OSHA
Occupational Safety and Health Administration.
Other Potentially Infectious Materials (OPIM)
The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, saliva in dental procedures, body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;
Any unfixed tissue or organ from a human (living or dead);
HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions.
Outcomes Management
This is a program to determine the clinical end-results according to defined various categories (by provider, by procedure, by clinical guidelines, etc.) and then encourage use of those categories to show improved patient outcomes.
Outpatient Facility
A facility designed to provide health and medical services to individuals who are not inpatients.
Over the Counter Collection Percentage
Measures the percentage of practice receipts collected at the time of service (cash, check, credit card). Over the Counter Collections / Total Receipts..
Parenteral
Piercing the mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.
Patient Referrals
The patient’s best interest will always be taken into account when choosing providers for patient referrals and services utilized by reference laboratories. The practice will recommend the most appropriate provider for the patient’s problem.
At no time shall the practice or any of its employees make any prohibited self-referrals. The practice will comply with any disclosures of financial interests, if necessary, to be in accordance with federal or state regulations. The practice will not participate in any referrals of reference lab testing that would result in a violation of any anti-kickback laws. The patient’s provider in our practice will recommend that provider. Keep in mind that the patient’s health insurance and patient choice may also play a role in this decision.
Peer Review
The examination, with the provider, of cases for medical necessity and appropriateness of treatment by a clinician of the same specialty.
Peer Review Organizations (PROs)
Groups of practicing doctors and other healthcare professionals under contract to the federal government to review the care provided to Medicare patients.
Per Case
This is an all-inclusive rate based upon the type of admission. This type of rate is commonly negotiated for obstetrics and cardiovascular surgery because there is some agreement in the industry about typical lengths of stay for these services.
Per Diem
This per-day payment is a flat rate paid to a hospital for each day of inpatient hospitalization. Per Diems can be structured as all inclusive—one rate no matter what type of service the patient receives—or, unbundled—various rates depending on where the patient is located in the hospital (e.g., Med/Surg, ICU, CCU, Telemetry, etc.).
Personal Health Record (PHR)
An electronic application through which individuals can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment.
Personal Protective Equipment
Specialized clothing or equipment worn by an employee for protection against a hazard. Examples are gloves, gowns, masks, etc.
Plaintiff
The person who brings an action. A person who complains or brings an action and is named in the record.
Physician-Hospital Organization (PHO)
Organizations that bond hospitals and their attending medical staff – usually for the purpose of contracting with a managed care plan. The PHO may be open to any member of the medical staff who applies or, it may be closed if there are too many physicians of the same specialty and subspecialty.
Point of Service Plans (Open HMO or Swing Plan)
Point of Service Plans are a variation in the managed care continuum. Based upon an HMO format, they demand the selection of a primary care physician but allow for opting out of the network (called self-referring) at a substantially reduced benefit. POSs have been predicted by some experts to be the predominate plan design of the future. POS premiums are generally priced to be competitive with an HMO. They have the associated utilization management mechanisms but also provide out-of-network flexibility, although generally at a significant financial expense to the member. Examples of Point of Service plans include: Metropolitan's Managed Care Network and Partners Managed Choice (MC).
Post-Payment Audit
An investigation of payments that have been processed to a practice. The practice would be notified of the investigation.
Pre-Admission Review
The examination of a case for medical necessity and appropriateness of admission at the time of or, in case of emergency, immediately following admission to treatment.
Pre-Certification
A requirement imposed by the payor or review organization for the examination of cases to determine the medical necessity and appropriateness for admission within a specified time frame prior to the actual admission.
Preferred Provider Organization (PPO)
This type of managed care plan contracts with providers who are considered network providers. A patient may go to any provider they choose and don’t need to see a gatekeeper first as they would in an HMO but the patient’s out of pocket expenses are less when they see a network physician than when they see a non-network physician.
Prepayment Healthcare Plans
Healthcare providers such as Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) are examples of prepayment healthcare plans. Medicare pays these plans on a monthly basis for each Medicare beneficiary. Medicare beneficiaries get all Medicare-covered hospital and medical insurance benefits through the plan.
Procedure Revenue Ratio
Measures the average revenue generated per procedure. Total Revenue / Total Procedures
Prohibited Self-referrals
Physician self-referrals are prohibited by the complicated Stark regulations. The legislators are concerned that if a physician would financially profit by referring the patient to a medical supply company he owns, that physician would have financial incentive to refer to his own company and thus may make medically unnecessary referrals to patients for that service or product. There are many exceptions to this regulation. Any questions regarding self-referral should be directed to your health lawyer.
PPO (Preferred Provider Organizations)
This form of insurance typically contains two levels of benefits. The patient has the ability to choose his/her provider at the time services are needed/ provided. The first level—within the PPO network of providers—provides the highest coverage, typically 90 percent to 100 percent of covered services. The second level—for services outside of the PPO network still provides benefits, but, typically, at a minimum of 20 percent lower than the in-network benefit. This difference provides a financial incentive to the patient to utilize contracted providers, thus enabling the insurance company to demonstrate channeled (or directed) business to a provider in exchange for a discount. This channeling effect is the basis for all managed care discounts.
Provider Enrollment, Chain and Ownership System (PECOS)
Mandatory Internet-based Provider Enrollment System for Medicare Reimbursement.
Peer Review
The examination, with the provider, of cases for medical necessity and appropriateness of treatment by a clinician of the same specialty.
Quality Assessment
Activities intended to determine whether standards of care are being adhered to.
Quality Assurance
Activities intended to determine adherence to standards of care and to eliminate any identified deficiencies.
Quality Care
The greatest achievable health benefit with minimal, unnecessary risk and use of resources provided in a manner that is satisfactory to the patient.
Quality Review Organization (QROs)
Groups of practicing physicians and other healthcare professionals under contract to the Federal government to review the care provided to Medicare patients enrolled in HMOs and CMPs.
Reasonable Charges
Amounts approved by the Medicare carrier which will be either the customary charge, the prevailing charge, or the actual charge, whichever is the lowest.
Rebates
A monetary or material return for doing something. For example, the laboratory offers you an additional discount for higher volume of patient referrals.
Reckless Disregard
To act in reckless disregard means that the provider pays no regard to whether the information on a claim submitted for payment is true or false. An example of a provider who submits a false claim with reckless disregard would be a physician who assigns the billing function to an untrained office person without inquiring whether the employee has the requisite knowledge and training to accurately file such claims.
Referral Source
This term is part of the self-referral and anti-kickback situation referring to the original individual who made a referral to a prohibited entity. For example, a physician while seeing a patient in the hospital refers that patient to a nursing home upon discharge in which he has ownership interest. Even though many other providers and even the hospital may want to refer that patient to the nursing home, if the owner physician is the referral source, it may be a tainted referral. There are exceptions to this situation as well.
Reflex Testing
Consistent with Medicare coverage rules and compliance policies reflex testing (testing that occurs when initial test results are positive or outside normal parameters and indicate that a second related test is medically appropriate) will not be performed unless the reflex test to be performed is clearly indicated on the procedure checklist, tracking form or by other written order.
Regulated Waste
Liquid or semi-liquid blood or OPIM; contaminated items that would release blood or OPIM in a liquid or semi-liquid state if compressed; items caked with dried blood or OPIM that are capable of releasing these materials during handling; contaminated sharps; pathological and microbiological wastes containing blood or OPIM.
Reliance on Standing Orders
Consistent with Medicare coverage and compliance policies standing orders will be accepted when the standing order is executed in connection with an extended course of treatment. The compliance officer will require laboratory personnel and physicians to periodically monitor standing orders.
Standing orders will have a fixed term of validity and must be renewed by the authorized provider at their expiration. All standing orders will have proper documentation as to the diagnosis and duration of treatment for the standing order based on the patient’s medical record.
Remuneration
The reward of getting something in return as a favor or an inducement to do something. For example, the lab where you send your tests gives you free vials and testing supplies in return for the patient testing business.
Resource Based Relative Value Scale (RBRVS) Abbreviations
CF Conversion Factor
CMS Centers for Medicare & Medicaid Services (formerly HCFA)
CPR Customary, Prevailing, and Reasonable
CY Calendar Year
DRG Diagnosis Related Groups
GAF Geographic Adjustment Factor
GPCI Geographic Practice Cost Indices
HCFA Healthcare Financing Administration (now CMS)
HPB Historical Payment Basis
MEI Medicare Economic Index
MFS Medicare Fee Schedule
MVPS Medicare Volume Performance Standard
OBRA Omnibus Budget Reconciliation Act
PPR Physician Payment Reform
PPRC Physician Payment Reform Commission
RBRVS Resource Based Relative Value Scale
RVU Relative Value Unit
Respondeat Superior
Let the master answer. This maxim means that a master is liable, in certain cases, for the wrongful acts of his servants and that the master is a principal for those of his agency. A physician is responsible for the actions of his/her employees.
Retrospective Denial
The denial of payment to facility or clinician based on breach of contract or lack of solid documentation of medical necessity.
Retrospective Review
The examination of cases for medical necessity and appropriateness of treatment after the termination of treatment.
Retention of Compliance Records
The compliance program will require that all records required either by federal or state law or by the compliance officer are maintained in the appropriate section of the compliance guide. Adequate documentation of any compliance efforts should be maintained as well.
Risk Withhold/Risk Pool/Risk Sharing
A percentage of the capitation or fee-for-service payment from each service that is retained by the managed care plan to fund the risk pool and to finance potential deficits. Withhold funds may be distributed to physicians as bonuses if they have not been expended on specialty, hospital or other costly healthcare during a given year. The Risk Pool is the group of physicians that agree to a given managed care plan with the understanding that the withheld amount may be used by the managed care plan to pay for extra costs incurred by patients served in that group but that if there is money left at the end of each year, it will be distributed as bonuses. This is also known as risk sharing.
Risk Management
The process whereby risk to the organization and all who are served by it and associated with it is evaluated and controlled in order to prevent or reduce loss.
Routine Physical Examinations
Physician checkups, x-rays, laboratory, or other tests made in the absence of definite symptoms of disease or injury.
Rural Exception
This term applies to a medical practice that may be excepted from the restricting Stark and other health care regulations if the practice is considered as a rural practice by the federal government. The government intermittently publishes a list of the areas that are designated as cities regardless of their location or size.
Rural Health Clinic
A specially qualified outpatient facility located in an area designated as rural, where there is a shortage of healthcare services or medical professionals.
Safe Harbor
This term refers to a designated legally safe situation that is not prohibited by the Stark or anti-kickback regulations. For example, a physician is permitted to refer patients for outpatient surgery at his own surgical center, as long as he performs the surgery at the surgical center.
Skilled Nursing Facility
A specially qualified facility with the staff and equipment to provide skilled nursing care or rehabilitation services and other related health services.
Source Individual
Any individual, living or dead, whose blood or OPIM may be a source of occupational exposure to the employee.
Subpoena
A writ or order directed to an individual requiring his attendance at a particular time and place to testify. It may require that the person bring books, documents or other things under his control which he is bound by law to produce in evidence. Subpoena Duces Tecum.
Supplemental Health Insurance
Also called Medigap, is private health insurance that fills some of the gaps in Medicare coverage.
Suspension
Suspension is the routing of a claim into an off-line evaluation process during claims processing. In the absence of suspension, the claim meeting all adjudication criteria is rapidly processed without development or further consideration. Suspension initiates a more detailed review and may result in further investigation prior to final adjudication.
Tests/Services Covered by Claims for Reimbursement
Only those tests/services that are ordered by an authorized individual or provider are performed and meet Medicare’s conditions of coverage are reimbursable by Medicare. If the lab receives a specimen without a valid test order or with a test order that is ambiguous, the lab will verify the tests that the provider wants and perform them before submitting a claim for reimbursement to Medicare. Similarly, if a lab did not perform an ordered test due to, for example, a lab accident or insufficient quantities of specimen, the lab will not submit a claim to Medicare. Medicare payments are made for tests that are ordered, performed and covered. If the above is encountered, the recollected specimen will be performed and recollected at no charge to the patient nor will it be resubmitted to Medicare or the patient’s insurance carrier.
Tort
A private or civil wrong or injury.
Treatment Authorization
A system of authorizing payment and payment levels for medical services provided for a patient and covered by a third-party payor organization.
TRICARE and Triple Option Plans
TRICARE is a Triple Option Plan. It was formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). It is a health insurance plan that covers members of the military services and their dependents for any care not available through the military medical systems. For example, if an active duty military person on leave had to have emergency surgery and the closest hospital was not military, the expense would be covered under TRICARE. The Triple Option aspect is true of any triple option plan and is so named because it provides the insured with three options: HMO, PPO or Indemnity.
Universal Precautions
Treating all human blood and body fluids as if known to be infectious for HIV, HBV, and other bloodborne pathogens.
Unlawful Conduct
It is a crime to knowingly and willfully execute (or attempt to execute) a scheme to defraud any health care benefit program, or to obtain money or property from a health care benefit program through false representations. Note that this law applies not only to federal health care programs, but to most other types of health care benefit programs as well.
Utilization Management
Utilization management consists of coordinating the volume and length of care given for each patient, including the level of care. The objective is to deliver care cost-effectively, at the appropriate level, and without unnecessary resources. Ways to accomplish this include authorization requirements to approve services before they occur, concurrent review for continuing cases, and profiling of cases after they occur for analysis. The planning, organizing, directing, and controlling of the healthcare product in a cost-effective manner while maintaining high-quality care and contributing to the overall goals of the institution.
Utilization Review
The process of evaluating the use of professional medical care, mental health treatment, services procedures, and facilities against pre-established criteria for individual patient and family members.
V
Workers' Compensation
Workers' Compensation programs represent a pervasive system of state regulation of care and payment for workers who are injured on the job or become ill in the course of their employment. Each state develops and administers its own program, usually through its Department of Labor. The amount of insurance to be carried by an employer is determined by the risk involved in the employee's job.
Work Practice Controls
Controls that reduce the likelihood of exposure by altering the way a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).
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