AI in HC - Introduction to Healthcare Flashcards
Independent Facilities
Healthcare providers and facilities outside of traditional hospitals, including dental practices, optometry practices, independent labs, and diagnostic facilities.
Fee-for-Service (FFS)
A payment model where providers are paid for each individual service provided to a patient.
Charge Master
A comprehensive list of services and their corresponding charges maintained by hospitals for billing purposes.
Per Diem Payment
A hospital payment system where a fixed daily rate is paid for patient care, regardless of the services rendered.
Diagnosis-Related Group (DRG)
A system for categorizing hospital services into groups for payment purposes based on diagnoses and procedures.
Electronic Medical Record (EMR)
A digital version of a patient’s medical history maintained within a single provider’s facility.
Electronic Health Record (EHR)
A broader digital record of a patient’s medical history that can include data from multiple providers.
Physician-Hospital Organization (PHO)
An integrated organization combining hospitals and physicians to deliver coordinated care.
Integrated Delivery Network (IDN)
A healthcare system where a network of providers delivers a full spectrum of care within a unified system.
Global Budget
A payment model where a fixed total budget is allocated to a hospital or healthcare system for a defined period.
Outlier Payment
Additional payments made under DRG systems for cases that require significantly more resources than average.
Personal Health Record (PHR)
An electronic application enabling patients to manage and share their personal health data.
Shared Savings Model
A payment approach where providers are rewarded for reducing healthcare costs while maintaining quality.
Pay-for-Performance (P4P)
A payment model providing financial incentives to providers for meeting specific performance measures.
Teaching Hospital
A hospital that provides medical training in addition to patient care, often associated with a medical school.
Admitting Privileges
The rights granted to physicians to admit and treat patients in a specific hospital.
Intermediary
Entities such as insurance companies or health plans that facilitate payments between providers and patients.
Global Capitation
A payment system where providers are paid a fixed amount per patient for all services over a specific time period.
Health Maintenance Organization (HMO)
A healthcare system that provides care through a network of providers under a capitated payment system.
Hospital System
A network of hospitals operating under a single organization, often sharing resources and administration.
Independent Facilities
Healthcare providers and facilities outside of traditional hospitals, including dental practices, optometry practices, independent labs, and diagnostic facilities.
Fee-for-Service (FFS)
A payment model where providers are paid for each individual service provided to a patient.
Charge Master
A comprehensive list of services and their corresponding charges maintained by hospitals for billing purposes.
Per Diem Payment
A hospital payment system where a fixed daily rate is paid for patient care, regardless of the services rendered.
Diagnosis-Related Group (DRG)
A system for categorizing hospital services into groups for payment purposes based on diagnoses and procedures.
Electronic Medical Record (EMR)
A digital version of a patient’s medical history maintained within a single provider’s facility.
Electronic Health Record (EHR)
A broader digital record of a patient’s medical history that can include data from multiple providers.
Physician-Hospital Organization (PHO)
An integrated organization combining hospitals and physicians to deliver coordinated care.
Integrated Delivery Network (IDN)
A healthcare system where a network of providers delivers a full spectrum of care within a unified system.
Global Budget
A payment model where a fixed total budget is allocated to a hospital or healthcare system for a defined period.
Outlier Payment
Additional payments made under DRG systems for cases that require significantly more resources than average.
Personal Health Record (PHR)
An electronic application enabling patients to manage and share their personal health data.
Shared Savings Model
A payment approach where providers are rewarded for reducing healthcare costs while maintaining quality.
Pay-for-Performance (P4P)
A payment model providing financial incentives to providers for meeting specific performance measures.
Teaching Hospital
A hospital that provides medical training in addition to patient care, often associated with a medical school.
Admitting Privileges
The rights granted to physicians to admit and treat patients in a specific hospital.
Intermediary
Entities such as insurance companies or health plans that facilitate payments between providers and patients.
Global Capitation
A payment system where providers are paid a fixed amount per patient for all services over a specific time period.
Health Maintenance Organization (HMO)
A healthcare system that provides care through a network of providers under a capitated payment system.
Hospital System
A network of hospitals operating under a single organization, often sharing resources and administration.
Independent Facilities
Healthcare providers and facilities outside of traditional hospitals, including dental practices, optometry practices, independent labs, and diagnostic facilities.
Fee-for-Service (FFS)
A payment model where providers are paid for each individual service provided to a patient.
Charge Master
A comprehensive list of services and their corresponding charges maintained by hospitals for billing purposes.
Per Diem Payment
A hospital payment system where a fixed daily rate is paid for patient care, regardless of the services rendered.
Diagnosis-Related Group (DRG)
A system for categorizing hospital services into groups for payment purposes based on diagnoses and procedures.
Electronic Medical Record (EMR)
A digital version of a patient’s medical history maintained within a single provider’s facility.
Electronic Health Record (EHR)
A broader digital record of a patient’s medical history that can include data from multiple providers.
Physician-Hospital Organization (PHO)
An integrated organization combining hospitals and physicians to deliver coordinated care.
Integrated Delivery Network (IDN)
A healthcare system where a network of providers delivers a full spectrum of care within a unified system.
Global Budget
A payment model where a fixed total budget is allocated to a hospital or healthcare system for a defined period.
Traditional Indemnity Insurance
Classic health insurance model with open panel and fee-for-service payments.
HMO (Health Maintenance Organization)
Health plans focused on preventive care with a closed provider panel and capitation payment model.
PPO (Preferred Provider Organization)
Plans with semi-open networks allowing in-network and out-of-network care with differing cost-sharing.
High Deductible Health Plan
Plans with high deductibles, encouraging patients to manage care costs more directly.
Narrow Network Plan
Plans with a small, carefully chosen provider network to control costs and maintain quality.
Fee-for-Service (FFS)
Payment model where providers are paid for each individual service delivered.
Capitation
Payment model providing a fixed amount per patient per time period for care.
Utilization Review
A process to monitor and approve care usage, including pre-authorization, concurrent review, and retrospective review.
Gatekeeper Requirement
Requirement for a primary care physician to coordinate all care and provide specialist referrals.
Deductible
Amount a patient pays out-of-pocket before insurance begins covering costs.
Copayment
Fixed amount a patient pays for specific services, such as a doctor’s visit.
Coinsurance
Percentage of service costs a patient pays after meeting the deductible.
Out-of-Pocket Maximum
The maximum amount a patient pays for covered services in a year before insurance covers 100% of costs.
Selective Contracting
Process by which insurers create a provider network by contracting with specific providers.
Medicare Advantage
Private insurance plans contracted by Medicare to provide Part A and Part B benefits.
Managed Care
Health plan designs where intermediaries manage utilization through tools like networks and cost-sharing.
Episode-Based Payment
Payment model providing a single payment for all services related to a care episode.
Salary Payment Model
Physicians are paid a fixed salary regardless of the volume of care provided.
RVU (Relative Value Unit)
A measure used in fee schedules to value the work, expense, and risk of a service.
DRG (Diagnosis-Related Group)
A system for categorizing hospital cases for payment purposes.
Panel
The population of patients assigned to a provider or practice.
HCPCS (Healthcare Common Procedure Coding System)
Coding system used in the US for billing medical services and procedures.
ICD-10
International Classification of Diseases, used for coding diagnoses.
CPT (Current Procedural Terminology)
A standardized coding system for medical procedures and services.
IPA (Independent Practice Association)
An organization that contracts with physicians to provide care for insurers.
Medigap
Supplemental insurance for covering gaps in Medicare, like cost-sharing.
Global Capitation
Capitation payment covering all medical care for a population over a set time.
Tiered Networks
Network structure where providers are grouped by cost and quality, with differing patient cost-sharing.
Network Organizer
Entities that facilitate insurer-practice relationships, e.g., IPAs.
Primary Care Gatekeeper
Physician who manages a patient’s overall care within a plan.
Bundled Payment
Payment model for multiple services in a single episode of care.
PMPM (Per Member Per Month)
Payment metric in capitation models.
Patient Cost Sharing
Financial responsibility shared by patients through deductibles, copayments, or coinsurance.
Out-of-Network Care
Services received outside an insurer’s network, often with higher patient costs.
Medicaid Managed Care
Medicaid services provided through private plans under state contracts.
Risk Adjustment
Adjusting payments to insurers based on the health status of enrollees.
ACO (Accountable Care Organization)
Groups of providers that share responsibility for patient care to improve quality and reduce costs.
Shared Savings Program
Program rewarding providers for reducing healthcare costs while meeting quality benchmarks.
Tiered Cost Sharing
Cost-sharing model with different levels for various services or provider tiers.
Premium Subsidies
Government payments to reduce the cost of insurance premiums for individuals.
Integrated Care
Coordinated healthcare services to improve quality and efficiency.
Preventive Care
Services aimed at preventing illnesses or detecting them early.
Prior Authorization
Requirement for approval before certain services are covered by insurance.
Concurrent Review
Ongoing evaluation of care during treatment.
Retrospective Review
Evaluation of care after treatment has been delivered.
Practice Ownership Models
Structures of practice ownership, e.g., private, corporate, or governmental.
Self-Insured Plans
Employer-sponsored health plans where employers bear the financial risk.
Community Rating
Setting insurance premiums based on the community’s overall health risk.
Adverse Selection
When higher-risk individuals are more likely to enroll in health insurance, raising costs.
MCO (Managed Care Organization)
Entity that integrates the financing and delivery of healthcare services.
Artificial Intelligence (AI)
Technology that simulates human intelligence to assist in decision-making, predictions, and problem-solving in healthcare.
Risk Pooling
A method used in healthcare systems to combine financial risks across a group to make costs more predictable.
Intermediaries
Organizations like insurance companies that collect funds, pool risks, and pay for healthcare services.
Electronic Health Records (EHRs)
Digital versions of patients’ paper charts, containing medical history, treatment plans, and test results.
Branded Drugs
Drugs marketed under a specific brand name, often patented and sold at higher prices.
Generic Drugs
Chemically equivalent to branded drugs but sold without branding after patent expiration.
Formulary
A list of prescription drugs covered by a health insurance plan.
Prescription Drug Pricing
The cost structure of prescription drugs, often negotiated by intermediaries and pharmacy benefit managers.
Quality Measures
Metrics used to evaluate the quality of healthcare services, including structural, process, and outcome measures.
Outcomes Measurement
Assessing the results of medical care, such as patient health improvements and complication rates.
Pay-for-Performance
Payment model that rewards healthcare providers for meeting specific quality and efficiency benchmarks.
Health Disparities
Differences in healthcare access and outcomes among different populations, often due to socioeconomic factors.
Medicare
A U.S. government program providing health insurance for individuals aged 65 and older or with certain disabilities.
Medicaid
A U.S. government program providing health coverage for low-income individuals and families.
Preventive Care
Healthcare services aimed at preventing illnesses or detecting issues early.
Patient-Centered Care
Healthcare approach focused on respecting and addressing individual patient preferences, needs, and values.
Structural Measures
Metrics evaluating the infrastructure of healthcare systems, such as availability of qualified personnel and up-to-date equipment.
Process Measures
Metrics assessing the specific actions or steps taken to deliver healthcare, such as adherence to clinical guidelines.
Health Maintenance Organization (HMO)
A health insurance plan that provides care through a network of physicians and hospitals.
Preferred Provider Organization (PPO)
A health insurance plan offering more flexibility in choosing healthcare providers, both in-network and out-of-network.
Telemedicine
The use of telecommunications technology to deliver healthcare services remotely.
Patient Advocacy
Efforts by individuals or organizations to support and promote patient rights and access to care.
Pharmacy Benefit Manager (PBM)
Companies that manage prescription drug benefits on behalf of health insurers, negotiating prices and coverage.
Cost Sharing
The division of healthcare costs between insurance and patients, including copayments and deductibles.
Healthcare Access
The ability of individuals to obtain needed medical services.
Healthcare Equity
Ensuring that all individuals have access to necessary healthcare services regardless of socioeconomic status.
Regulatory Approval
The process by which healthcare products, including drugs and devices, are reviewed for safety and efficacy before use.
FDA (Food and Drug Administration)
U.S. agency responsible for regulating food, drugs, medical devices, and other health-related products.
Clinical Trials
Research studies performed on humans to evaluate the safety and effectiveness of medical treatments.
Health Insurance Premium
The amount paid, often monthly, to maintain health insurance coverage.
Health Information Privacy
Protecting patients’ medical information from unauthorized access or disclosure.
Bias in AI
Systematic errors in AI models that lead to unfair outcomes, often due to unrepresentative training data.
Accountable Care Organization (ACO)
A group of healthcare providers who voluntarily coordinate care to improve quality and reduce costs.
Managed Care
Healthcare delivery system designed to manage costs, utilization, and quality of care.
Patient Safety
Preventing harm to patients during the delivery of healthcare.
Social Determinants of Health
Conditions in which people are born, live, work, and age that affect health outcomes.
AI Transparency
The ability to understand and interpret how AI models make decisions.
Out-of-Pocket Expenses
Healthcare costs directly paid by patients that are not covered by insurance.
Health Technology Assessment (HTA)
Evaluation of medical technologies for their effectiveness and cost-efficiency.
Health Literacy
The ability of individuals to understand health information and make informed decisions.
Digital Health Tools
Technologies such as mobile apps and wearables used to monitor and improve health.
Healthcare Innovation
The development of new methods, technologies, or processes to improve healthcare delivery.
Ethical AI
Developing and using AI in a way that is fair, just, and prioritizes patient welfare.
Financial Risk in Healthcare
The potential for economic losses associated with healthcare costs.
Public Health
Efforts to prevent disease and promote health at a population level.
Utilization Review
Process of evaluating the necessity, efficiency, and appropriateness of healthcare services.
Evidence-Based Medicine
Healthcare practices based on scientific research to achieve the best outcomes.
Healthcare Sustainability
Creating systems that deliver quality care efficiently and can be maintained over time.
Healthcare Workforce
All individuals engaged in providing healthcare services, including physicians, nurses, and support staff.
