Module 4 Flashcards
Activity of Daily Living
Activity performed as part of a person’s daily routine of self-care, such as bathing, dressing, and eating
Acute Care
Level of health care, typically provided in hospitals or emergency departments, for sudden, serious illnesses or trauma
Advance Directive
Legal document stating a patient’s wishes regarding the type, the continuation, or the withdrawal of treatment to be used if the patient loses decision-making abilities
Ambulatory Care (or outpatient care)
Health care services provided on an outpatient basis with no overnight stay in a hospital
Assisted Living Facility (ALF)
Offers a broad range of residential care services, excluding nursing services, for individuals who are unable to live alone
Attending Physician
Physician in charge of the patient’s care
Behavioral Health Care
Treatment of mental health or substance abuse disorders
Case Management
Process in which a health care professional supervises the administration of health care services to a patient
Chronic Disease
Longstanding, persistent, noncurable disease or health condition that requires ongoing surveillance and care
Cosmetic Surgery
Surgery for the sole purpose of improving appearance
Durable Medical Equipment (DME)
Equipment used to serve a medical purpose that can withstand repeated use and is appropriate for use in the home (i.e. wheelchair, walker)
Employee Assistance Program (EAP)
Employer-sponsored counseling service for employees and their dependents to solve workplace and personal problems
Extended Care Facility (ECF)
Nursing home type setting that offers skilled, intermediate, or custodial care
Home Health Care
Medical Care administered at a patient’s residence by a health care professional or other health care workers
Hospice Care
Philosophy of care and full set of medical services available to terminally ill persons that focus on pain relief, counseling, and dying with dignity
Hospitalist
Physician who practices exclusively in hospitals, has no outpatient responsibilities, and usually cares for the admitted patients of other physicians
Inpatient Care
Admission to a hospital, for at least 24 hours, under the care of a physician
Long-Term Care (LTC)
Multilevel care system providing care to elderly, chronically ill, or disabled persons, typically in some type of inpatient facillity
Nurse Practitioner (NP)
Doctoral degree-prepared registered nurse, capable of independently providing basic medical services to patients
Palliative Care
Care focused on relieving pain and suffering caused by serious illness; pain and suffering management is offered to the patient at any time during active curative treatment or in the terminal stages of illness
Physician Assistant (PA)
Health care professional who provides basic health care services to patients under the supervision of a physician
Primary Care
Broad based comprehensive health care of patients provided by various general practitioners, such as family physicians, internists, and pediatricians; a physician who provides this care is called a primary care physician (PCP); opposite of specialist care
Preventative Care
Health care services that emphasize prevention, early detection, and early treatment of conditions
Provider
Any licensed or approved supplier of health care services
Skilled-Nursing Facility (SNF)
Nursing home that provides a high level of specialized care for long-term or acute episodes of illness
Specialist
Health care providers with advanced, concentrated training in a specific area
Urgent Care Center
Facility treating acute illness that can be managed without the patient visiting a hospital emergency department
Accreditation
Formal recognition that an organization conforms to a set of industry-specific, qualifying standards
Board Certified
Health care professional who passed an examination by a specialty board and are now certified by that board as a specialist
Board Eligible
Health care professional who is eligible to take a specialty board examination after having completed the required schooling, training, and practice
Center for Medicare and Medicaid Services (CMS)
Federal government agency responsible for administering the Medicare and Medicaid programs
Current Procedural Terminology (CPT)
Standardized system of terminology and coding developed by the American Medical Association and used for describing and reporting medical services and procedures
Electronic Medical Record (EMR)
Technology in which medical records are stored on computer rather than in paper files
Episode of Care
Treatment for a specific medical condition for a continuous, defined period of time
Evidence-Based Medicine (EBM)
Use of current best evidence available from clinical research in making decisions for the care of the individual patient; used in conjunction with the clinical experience and expertise of the treating provider while being sensitive to the values and wishes of the patient
Family Medical Leave Act (FMLA)
Federal law requiring employers to provide 12 weeks of unpaid sick leave per year to employees with qualifying medical circumstances
Health Care Power of Attorney (HCPA)
Type of advance directive in which a patient appoints another individual to make treatment decisions in the event the patient loses decision-making abilities
Health and Human Services (HHS)
Department of the federal government that is charged with protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Provides rights and protections for participants and beneficiaries in group health insurance plans
International Classification of Diseases, 10th Edition (ICD-10)
A listing of diagnoses and identifying codes used by health care providers, providing a uniform language for the submission of insurance claim forms
Living Will
Type of advance directive containing a patient’s wishes regarding initiation, continuation, or withdrawal of treatment if the patient loses decision-making abilities
Medicaid
Entitlement program run by both the state and federal governments designed to provide health care coverage to patients who cannot afford to pay for health insurance
Medically Necessary
Health care services that are appropriate and required to meet the person’s health needs and are consistent with established standards of care
Medicare
Entitlement program run by the federal government that provides people age 65+ and who are long-term disabled with health insurance
Medicare A
Covers hospitalization
Medicare B
Covers ambulatory care
Medicare D
Covers prescription medications
Medicare Advantage Plan
Private Insurance company contracts with Medicare to provide the insured person with Medicare Part A and B benefits
Medicare Supplement
Private insurance plan available to Medicare-eligible persons to cover the cost of medical care not covered by Medicare
Protected Health Information (PHI)
Any health information identifiable to a patient (i.e. name, address, phone #, birth date, ssn, diagnosis)
Privacy Notice
Notice to patients describing practices by the health provider to safeguard protected health information
Standard of Care
What other medical professionals would consider appropriate care in similar circumstances
The Joint Commission (TJC)
Private, non-profit organization that evaluates and accredits hospitals and other health care organizations using established standards of practice
Utilization Management (UM)
Process for measuring the optimal use of medical resources, based on medical necessity and cost-effective care
Utilization Review (UR)
Systematic, retrospective review designed to determine the medical necessity and economic appropriateness of medical services performed
Actual Charge
Amount a health care provider actually bills a patient for a particular medical service or procedure
Allowable Charge
Charges for services rendered or supplies furnished by a health care provider that qualify as covered expenses under a health plan and are reimbursable under their payment formula
Appeal Process
Mechanism by which patients or providers may request reconsideration of a decision by an insurance company or medical review board regarding medical services
Benefits
Health care services provided under the terms of a contract with an insurance company
Benefit Period
Time period when a person is eligible for covered benefits under a health insurance policy
Benefit Schedule
Summary of covered services, limitations and applicable copayments provided to a group of individuals
Bundled Payment
A single fixed compensation paid to a health care provider for a patient’s care, rather than paying providers for each service provided; the aim is to motivate providers to reduce amount of care provided
Carve out
Health benefit that is removed from a larger benefit package and is contracted for separately from another insurance company
Claim
Request for payment/reimbursement from a provider or a covered person made to a health insurance company
Claims Review
Method by which the health care services received by an insurance individual are reviewed and verified before payment is made
Coordination of Benefits (COB)
Provisions and procedures used to determine the amount payable when an individual is covered by more than one insurance plan
Copayment (Copay)
Dollar amount the patient is required to pay for each health care service received
Deductible
Fixed amount of health care dollars a person must pay before payment from the insurance company begins
Explanation of Benefits (EOB)
Statement issues to members by their health care plan listing services provided, dollars covered by benefits, and amounts not covered by insurance that members must pay
Fee for Service (FFS)
Traditional provider reimbursement by which a patient receives a bill from the provider than includes all professional services performed
Gatekeeper
Physician in an insurance plan who is the initial provider of health care and controls/authorized referrals to all other health care providers
Medical Underwriting
Process of evaluating an applicant’s medical history to determine insurability and the cost for coverage
Medical Savings Accounts
Health care savings accounts in which individuals can accumulate contributions to pay for unreimbursed medical expenses
Nonparticipation Provider
Health care provider who has not contracted with an insurance company to provide health care
Open Access
Arrangement that allows members to see participating providers, usually specialist, without referral from a gatekeeper
Open Enrollment
Period during which a health plan allows persons not previously enrolled to apply for plan membership
Out of Network
Receiving medical care, usually at a higher out of pocket cost, from providers who do not participate in the insurance company’s provider network
Out-of-Pocket Costs
The share of health care costs paid by the covered individual (includes the deductibles and copayments)
Participating Provider
Provider who has entered into an agreement with a health insurance plan to provide care to its members, often at a discounts rate
Pay for Performance
Program of structured incentives for providers and hospitals to encourage the achievement of performance benchmarks; in short, the better the provider’s outcomes, the better the reimbursement from the insurance company
Preauthorization (preauth)
Approval of specific serviced by a health insurance before a member can receive the services
Preexisting Condition
Illness or medical problem present before an individual obtains an insurance policy
Premium
Amount of money paid to a health plan to provide services over a specific period of time; This amount often is taking out of an employee’s paycheck
Reimbursement
Payment to a medical provider in exchange for the provided medical services
Third-Party Payer
Insurer, US government, or any other organization that pays for health care expenses on behalf of an individual
Usual, Customary, and Reasonable (UCR)
Amount an insurance company will pay for a given procedure or service calculated on the most frequent charge for the service in a given area
Waiting Period
Period between the start of employment and enrollment in a health insurance program and the date when an individual becomes eligible for insurance coverage and the payment for services
Write-off Amount
Difference between billed charged and the amount the provider has agreed to accept as payment in full for services rendered; cannot be billed to the patient
