CCM Glossary of Terms Flashcards
What does AAPM&R stand for?
American Academy of Physical Medicine and Rehabilitation
A set of healthcare providers, including primary care physicians, specialists, and hospitals, that work together collaboratively and accept collective accountability for the cost and quality of care delivered to a population of patients. These organizations became popular in the Medicare fee-for-service benefit system as a result of the Affordable Care Act and are formed around a variety of existing types of provider organizations such as multispecialty medical groups, physician-hospital organizations (PHO), and organized or integrated delivery systems.
Accountable Care Organization (ACO)
A legal duty, imposed by statute or otherwise, owing by defendant to the one injured
Actionable Tort
Statistical analysis of a population based on its utilization of healthcare services and demographic trends of the population. Results used to estimate healthcare plan premiums or costs.
Actuarial Study
A trained insurance professional who specializes in determining policy rates,
calculating premiums, and conducting statistical studies.
Actuary
What does ADA stand for?
Americans with Disabilities Act of 1990
What does ADAAA stand for?
Americans with Disabilities Act Amendments Act of 2008
The effectiveness and degree to which an individual meets standards of self-sufficiency and social responsibility for his/her age-related cultural group.
Adaptive Behavior
“The extent to which a person’s behaviour–taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations
[e.g., health regimen] from a health care provider” (Sabate, 2003).
Adherence
A contract between two parties where one party with stronger bargaining power
sets the terms and conditions and the other party, which is the weaker of the two
with little to no ability to negotiate, must adhere to the contract and is placed in
a “take it or leave it” position
Adhesive Contract
Developed by the School of Public Health at Johns Hopkins University, this system clusters clients into homogenous groups (102 discrete groups) based on a unique approach to measuring morbidity to ultimately improve accuracy and fairness in evaluating healthcare provider performance, identifying clients at high risk, forecasting healthcare utilization, and setting equitable payment structure and rates for the providers of care. The System accounts for the burden of morbidity in a client population based on disease patterns, age, and gender and relies on the diagnostic and/or pharmaceutical code information found in insurance claims or other computerized client health records.
Adjusted Clinical Group (ACG) System
That branch of public law that deals with the various organizations of federal, state, and local governments which prescribe in detail the manner of their activities
Administrative Law
A form of utilization review in which an assessment is made of the medical
necessity of a client’s admission to a hospital or other inpatient facility; ensures that clients requiring a hospital-based level of care and
length of stay appropriate for the admission diagnosis are usually assigned and
certified and payment for the services are approved.
Admission Certification
A grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence in a client’s health condition over time. This system was developed by the Bloomberg School of Public Health at Johns Hopkins University. An individual client can suffer more than one health condition and therefore may have for than one of these groupings of diagnosis codes (there are a total of 32 of these clusters). Individual diseases or conditions are placed into a single grouping based on a set of criteria including likely persistence of diagnosis, severity of illness, etiology, diagnostic certainty and need for specialty care interventions.
Aggregated Diagnosis Groups (ADGS)
An evaluation conducted by a provider who is selected by agreement between an injured workers’ attorney and the insurance claims administrator and/or attorney. The parties agree to conduct a medical examination and prepare a medical- legal report to help resolve an existing dispute. The evaluation also serves to determine
what portions of the work-related injury have contributed to the disability and what portions have resulted from other sources or causation.
Agreed Medical Examination
What does AHRQ stand for?
Agency for Healthcare Research and Quality
AMA
American Medical Association
A level of care that can safely be used in place of the current level and
determined based on the acuity and complexity of the client’s condition and the
type of needed services and resources.
Alternate Level Of Care
An encounter-based classification system for outpatient reimbursement, including
hospital-based clinics, emergency departments, observation, and ambulatory
surgery. Payment rates are based on categories of services that are similar in cost
and resource utilization.
Ambulatory Payment Classification (APC) System
A physical, manmade environment or arrangement of structures that is safe and
accessible to persons with disabilities.
Barrier-Free
Factors in a person’s environment that, if absent or present, limit one’s functioning
and create disability. Examples are a physical environment that is inaccessible,
lack of relevant assistive technology, and negative attitudes of people toward
disability. These also include services, systems, and policies that are either
nonexistent or that hinder the involvement of people with a health condition in
any area of life.
Barriers
An act of comparing a work process with that of the best competitor. Through
this process one is able to identify what performance measure levels must be
surpassed. This practice assists an organization in assessing its strengths and
weaknesses and in finding and implementing best practices.
Benchmarking
Principal Term: The type of health and human services covered by an insurance
company/health plan and as agreed upon between the plan/insurance company
and the individual enrollee or participant; the amount
payable by an insurance company to a claimant or beneficiary under the
claimant’s specific coverage as stipulated in the agreed upon health plan.
Benefits
BAS
Burden Assessment Scale
Models where healthcare resources, services and case managers are based
externally to an acute care/hospital setting, that is in the community.
Beyond (Outside)-The-Walls Case Management
Widely recognized information, standards, methods, tools, and practices about
a specific field; usually includes a comprehensive set of concepts,
terms, tools, and activities that make up a profession, as defined by a relevant
professional society. A prescribed
aggregation of essential knowledge in a particular field or specialty an individual
within the field is expected to have mastered to effectively practice and be
considered a practitioner within the specialty
Body of Knowledge (BOK)
A fixed amount of money per-member-per-month (PMPM) paid to a care provider
for covered services rather than based on specific services provided. The typical
reimbursement method used by HMOs. Whether a member uses the health
service once or more than once, the provider receives the same
payment.
Capitation
An insurance company formed by an employer to assume its workers’
compensation and other risks, and provide services.
Captive
Previously known as the Disease Management Association of America (DMAA).
Care Continuum Alliance
CARF
Commission on Accreditation of Rehabilitation Facilities. A private, non-profit
organization that establishes standards of quality for services to people with
disabilities and offers voluntary accreditation for rehabilitation facilities based on
a set of nationally recognized standards.
The insurance company or the one who agrees to pay the losses; may be organized as a company, either stock, mutual, or reciprocal, or as an association or Underwriters
Carrier
Services excluded from a provider contract that may be covered through arrangements with other providers. Provides are not financially responsible for services carved out of their contract.
Carve out
The process of evaluating the quality and appropriateness of care based on the review of individual medical records to determine whether the care delivered is acceptable. It is performed by healthcare professionals assigned by the hospital or an outside agency (e.g., Peer Review Organization [PRO]).
Case-based review
A multidisciplinary healthcare team meeting that is held to discuss a client or client’s support system situation such as conflict in decision making between the
client and client’s support system, clarification of plan of care and prognosis, end of life issues, or an ethical dilemma. Depending on the purpose of the conference,
the client and client’s support system may or may not participate in the meeting. Other participants are the case manager, social worker, physician of record or primary care provider, specialty care provider, registered nurse, registered dietitian, physical therapist, occupational therapist, ethicist (if the purpose is an ethical dilemma) and others as necessary.
Case Conference
The aggregate of reported cases forming a body of jurisprudence, or the law of a particular subject as evidenced or formed by the adjudged cases, in distinction to statutes and other sources of law.
Case Law
Case Management
A dynamic process that assesses, plans, implements,
coordinates, monitors, and evaluates to improve outcomes, experiences, and value; professional and collaborative, occurring in a variety of settings where medical care, mental health care, and social supports are
delivered. Services are facilitated by diverse disciplines in conjunction with the care recipient and their support system.
In pursuit of health equity, priorities include identifying needs, ensuring appropriate access to resources/services, addressing social determinants of health and facilitating safe care transitions. Professional case managers help
navigate complex systems to achieve mutual goals, advocate for those they serve, and recognize personal dignity, autonomy, and the right to self-determination.
A comprehensive resource of essential knowledge in the field of case management that a case manager is expected to master and become knowledgeable, skilled, as well as experienced in, to effectively care for clients
and their support systems and be considered a competent case management practitioner.
Case Management Body of Knowledge (CMBOK)
A conceptual or graphic representation of the practice of case management in an organization. It usually depicts the relationships among the key functions and stakeholders of case management, and the roles and responsibilities of case managers.
Case Management Model
The context in which case managers provide health and human services to clients and their support systems; consists of several steps or sub-processes that are iterative, cyclical and recursive rather than linear and applied until the client’s needs/interests are met. Steps include screening, assessing, stratifying risk, planning, implementing, following-up, transitioning, post-transitioning, communication, and evaluating outcomes
Case management process
Each of these groups has a relative weight that determines the base payment rate for inpatient rehab facilities under the Medicare system.
Case Mix Group (CMG)
An indication of the severity of illness, prognosis, treatment difficulty, need for intervention, or resource intensity of a group of clients
Case mix complexity
The sum of DRG-relative weights of all patients/cases seen during a 1-year period in an organization, divided by the number of cases hospitalized and treated during the same year
Case Mix Index (CMI)
The dollar amount stated in a claim file which represents the estimate of the amount unpaid.
Case reserve
A general class of insurance and workers’ compensation insurance
Casualty Insurance
Any medical condition or illness that has heightened medical,social and financial consequences that responds positively to the control offered through a systematic effort of case management.
Catastrophic Case
The approval of client care services, admission, or length of stay by a health benefit plan (e.g., HMO, PPO) based on information provided by the healthcare provider.
Certification
This health professional develops a client-specific lifetime plan of care, while applying the nursing process. The plan
employs a comprehensive and evidence-based approach in the estimation of current and future healthcare needs of the client. Also included are the associated costs and frequencies of items and services.
Certified Nurse Life Care Planner (CNLCP)
A professional specialized in vocational assessment and rehabilitation who has the met the minimum requirements for nationally recognized voluntary certification.
Certified Vocational Evaluator (CVE)
