Concepts Flashcards
QMB
Qualified Medicare Beneficiary
The Qualified Medicare Beneficiary (QMB) program provides Medicare coverage of Part A and Part B premiums and cost sharing to low-income Medicare beneficiaries. In 2017, 7.7 million people (more than one out of eight people with Medicare) were in the QMB program.
Balance Billing (Medicare)
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
PEBB/SEBB
Public Employees Benefits Board / School Employees Benefits Board
ETL
Extract/Transform/Load
PHI
Protected Health Information
VBP
Value-Based Purchasing
OnPoint
Contracted to develop the APCD for HCA
de minimis
No significance or not worthy of consideration
DAN
Disposition Authority Number (Retention Policy)
MOUD
Medications for Opioid Use Disorder
FFS
Fee for Service (highest reimbursement for providers)
FFP
Federal Financial Participation
SNF
Skilled Nursing Facilities
PMPY
Per-member-per-year
NCBPs
Non-Claims-Based Payments
NCPHI
Net Cost of Private Health Insurance
THCE
Total Health Care Expenditures
TME
Total Medical Expenditures / Total Medical Expense
APM
Alternative Payment Methods
PHE
Public Health Emergency
BRG
Business Resource Group
PCTM
Primary Care Transformation Model
HRSN
Health-related social needs
ADI
Area Deprivation Index
SDOH
Social Determinants of Health
RFA
Request for Application
PCPCM
Person-centered Primary Care Measure
FQFC
Federally Qualified Health Center (like Planned Parenthood?)
DRG
Disease-Related Groups
Basically aggregated cases by CPT, ICD
ICD
International Classification of Diseases
CPT
Current Procedural Terminology
TCOC
Total Cost of Care
DEX
Disease Expenditure
ACO
Accountable Care Organization
Dual-Eligible
Eligible for both Medicare and Medicaid
MMP
Medicare-Medicaid Plan
Capitation
Bulk payments to providers based on a “per head” calculation rather than a per service. Drives incentives toward whole health of the patient.
DSRIP
Delivery System Reform Incentive Payment program
DY
Demonstration Year
IGT
Intergovernmental Transfer
IMC
Integrated Managed Care
P4R
Pay-for-Reporting
P4P
Pay-for-Performance
LTSS
Long-term Services and Supports
[CMS program]
DoN
Determination of Need
Essentially a permitting system for providers to clear building projects through government agencies
MA Plans
Medicare Advantage Plans
IMC
Integrated Managed Care
DP
Decision Packages (changes in budgetary funding)
EHB
Essential Health Benefits
Services mandated to be included by a HC plan as a part of ACA
NPR
Net Patient Revenue
GME
Graduate Medical Education
Term for Workforce development
