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Vocabulary Flashcards

1
Q

What is Primary Source Verification (PSV)?

A

PSV means that the individuals credentials and qualifications are verified through the original orginization or governmental entity that issued the document or credential, or through a designated equivalent source. Methods of PSV include a documented telephone conversation or by facsimile, email or letter. Designated Equivalent Sources accepted by Joint Commission include:
AMA, ABMS, ECFMG, AOA or FSMB.

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2
Q

AAAHC

A

the governing body must meet at least annually; requires re-credentialing every 3 years except for when state regulations require less time; requires the Primary Source Verification (PSV) of the following elements upon initial application; experience, peer evaluation, liability insurance, NPDB, education, training, state license, DEA, work history with gap explanations; requirements: Experience reviewed for continuity and relevance.

The accreditation association for Ambulatory Health Care - also known as AAAHC or the Accreditation Association - is a private, nonprofit organization formed in 1979 to assist ambulatory health care organizations improve the quality of care provided to patients.

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3
Q

AANA

A

Founded in 1931, the American Association of Nurse Anesthetists (AANA) is the professional association for Certified Registered Nurse Anesthetists (CRNAs) and student nurse anesthetists. CRNAs are advanced practice nurses.

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4
Q

AAPCC

A

Adjusted Average per Capita Cost (AAPCC) the estimated average fee for service cost of Medicare benefits for an individual by county of residence. It is based on the following factors: age, sex, institutional status, Medicaid disability, and end-stage renal disease status. HCFA uses the AAPCCS as a basis for making monthly payments to TEFRA contractors.

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5
Q

ABMS

A

The American Board of Medical Specialties (ABMS), a not for profit organization, assists 24 approved medical specialty boards in the development and use of standards in the ongoing evaluation and certification of physicians.

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5
Q

Accessibility

A

the extent to which a member of a managed care organization (MCO) can obtain available services at the time they are needed. Such service refers to both telephone access and ease of scheduling an appointment.

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6
Q

ACCME

A

The ACCME (Accreditation council for Continuing Medical Education) is the organization whose mission is the identification, development, and promotion of standards for quality continuing medical education (CME) utilized by physicians in their maintenance of competence and incorporation of new knowledge to improve quality medical care for patients and their communities.

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7
Q

Accreditation Decision Process - JC:

A

Accreditation Decision, Preliminary accreditation, accreditation with follow-up survey, contingent accreditation, preliminary denial of accreditation, denial of accreditation

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8
Q

Accreditation

A

Accreditation= confirmation and recognition of technical competence. A determination by an accrediting body that an eligible healthcare organization complies with applicable Joint Commission standards. The process by which an organization recognizes an institution as meeting predetermined standards.

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9
Q

Accreditation - Joint Commission

A

The Joint Commission (TJC) accredits subscriber hospitals, ambulatory care centers, surgery centers, rehab centers, long term care centers, etc.

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10
Q

Accreditation - HFAP

A

Healthcare Facilities Accreditation Program (HFAP) provides accreditation programs for primarily osteopathic hospitals, clinical laboratories, ambulatory surgical centers, office based surgery (OBS) critical access hospitals, mental health and physical rehabilitation facilities.

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11
Q

Accreditation - NCQA

A

The National Committee for Quality Assurance (NCQA) manages voluntary accreditation programs for individual physicians health plans, medical groups, NCQA also manages certification programs for CVO’s.

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12
Q

Accreditation - URAC

A

URAC, formerly known as the Utilization Review Accreditation Commission promotes healthcare quality by accrediting healthcare organizations including medical management organizations (disease management, case management, health care centers, independent review organizations, etc. health plans (HMOs, PPOs, etc.) hospitals and health websites.

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13
Q

Accreditation - AAAHC

A

The Accreditation Association for Ambulatory Health Care (AAAHC), accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers, and college student health centers, as well as managed care organizations, such as health maintenance organizations and preferred provider organizations.

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14
Q

Accreditation - AOA

A

American Osteopathic Association - the AOA accredits a number of different institutions and programs as well as approves osteopathic postdoctoral training programs.

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15
Q

Accreditation Appeal

A

The process through which an organization that has been preliminarily denied Joint Commission accreditation exercises its right to a hearing by an appeals hearing panel, followed by a review of the panel’s report and recommendation by the joint commission’s board of commissioners.

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16
Q

Accreditation Cycle

A

A period of accreditation at the conclusion of which accreditation expires unless a full survey is performed.

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17
Q

Accreditation Decisions

A

Categories of accreditation that an organization can achieve based on a full survey by the accrediting body.

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18
Q

Accreditation Organizations

A

JC, AOA, DNV, NCQA, URAC and AAAHC

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19
Q

Accreditation Report

A

A report of an organization’s survey findings; the report includes organization strengths, requirements for improvement and supplemental findings, as appropriate.

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20
Q

Accreditation Survey Findings

A

Findings from an on-site evaluation conducted by Joint Commission’s surveyors which result in an organization’s accreditation decision.

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21
Q

Accreditation Watch

A

An attribute of an organization’s Joint Commission accreditation status. A healthcare organization is placed on accreditation watch when a sentinel event has occurred and a thorough and credible root cause analysis of the sentinel event has not been completed within a specified time frame. Although accreditation watch status is not an official accreditation category, it can be publicly disclosed by the Joint Commission.

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22
Q

Accredited

A

Accreditation assists organizations in monitoring and improving quality of care. It can be used to meet certain Medicare certification requirements, organizations that are accredited are given “deemed status” meaning they meet the Medicare and Medicaid requirements for participation.

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23
Q

ACGME

A

The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the Accreditation of post-MD medical training programs within the United States Accreditation is accomplished through a peer review process and is based upon established standards and guidelines.

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24
Q

Actuarial Soundness

A

The requirement that the development of capitation rates meet common actuarial principles and rules.

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25
Q

AOA

A

Americans with Disabilities Act (ADA) 1990 federal law prohibits pre-employment medical examinations. Also prevents pre-employment inquiries regarding disabilities. This 1990 law requires that public places be generally accessible to individuals with disabilities.

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26
Q

Adverse Action

A

1) An action taken against a practitioners clinical privileges or medical staff membership in a health care entity or 2) a licensure disciplinary action.

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27
Q

Adverse Action Codes

A

A list of adverse actions and the codes used to identify them when submitting reports to the NPDB.

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28
Q

AAR (Adverse Action Report)

A

The format used by health care entities and state licensing boards to report an adverse action taken against a physician, dentist, or other health care practitioner.

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29
Q

Adversely Affects

A

reduces, restricts, suspends, revokes or denies clinical privilege or membership in a health care entity.

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30
Q

Administration Costs

A

Costs incurred by a carrier, such as an insurance company or HMO, for administrative services like claims processing and overhead expenses. Administration costs are usually expressed as part of premium.

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31
Q

Admissions 1000

A

The number of hospital admissions per 1,000 health plan members.

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32
Q

ADS (Alternative Delivery System)

A

A method of providing healthcare benefits that depart from the traditional indemnity methods. An HMO for example is considered an alternative delivery system.

33
Q

Adverse Selection

A

1) Describes a plan with a disproportionate share of enrollees who ar sicker than the general population, members who are sicker than anticipated when the medical costs budget was develped. 2) Occurs when a carrier enrolls a poorer risk than the average risk of the group. Fierce competition for the healthiest individuals leaves insurers such as BCBS with members who are more likely to use services because of their existing higher health risk conditions.

34
Q

Affiliated Provider:

A

a health care provider or facility that, is part of the Managed Care Organization’s network, usually having formal arrangements to provide services to the MCO’s Member.

35
Q

Age/Sex Factor

A

A measurement used in underwriting which represents the age and sex risk of medical costs of one population relative to another. An age/sex factor below 100 indicates a lower than average demographic risk of expected medical claims.

36
Q

AHP (Allied Health Professional)

A

AHP are specially trained and licensed when necessary healthcare workers other than physicians, dentists, optometrists, chiropractors, podiatrists and who are credentialed through certification, registration, and/or licensure. Allied health practitioners work with physicians and other members of the health care team to deliver high-quality patient care services for identifying, preventing, and treating disease and disabilities.

37
Q

Accountable Health Plans

A

Under the proposed managed competition plans, these would be insuring delivery systems that would offer a standard federally defined benefit plan set by the National Health board.

38
Q

AHRQ

A

Agency for Health Care Research and Quality: arm of the Department of Health and Human Services (DHHS) was established by congress in 1989 to improve the quality appropriateness and effectiveness of US health care. One of 12 agencies within DHHS.

39
Q

Allergy & Immunology Cert

A

No subspecialties

40
Q

Allowable Costs

A

Charges for services rendered or supplies furnished by a health provider that qualify as covered expenses.

41
Q

ALOS

A

Average Length of Stay: ALOS - the average # of days in the hospital for each admission. The formula for this measure: total patient days incurred divided by the # of admissions and discharges during the period.

42
Q

Alternative Delivery Systems

A

A phrase used to describe all forms of health care delivery except traditional fee for service, private practice. The term includes HMOs, PPOs, IPAs and other systems of providing health care.

43
Q

AMA Master file

A

AMA Master file organization has been recognized by the JC and NCQA to provide PSV of medical school and residency graduation for US graduates.

44
Q

Ambulatory Care

A

All types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are hospital inpatients.

45
Q

Americans with Disabilities

A

The ADA is a wide-ranging civil rights law that prohibits, under certain circumstances, discrimination based on a disability.

46
Q

AMICUS

A

friend of the court - a brief filed by an interested party giving an opinion/information on a case.

47
Q

ANCC

A

The American Nursed Credentialing Center internationally renowned credentialing programs certify nurses in specialty practice areas, recognize healthcare organizations for nursing excellence through the magnet recognition program and accredit providers of continuing nursing education.

48
Q

Anesthesia and Sedation

A

The administration to an individual in any setting for any purpose by any route, medication to induce a partial or total loss of sensation for the purpose of conducting an operative or other procedure. Definitions of our levels of sedation and anesthesia include the following:
1) Minimal sedation: anxiolysis - a drug induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired.
2.) Moderate sedation/analgesia (“conscious sedation”) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patient airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained and are unaffected.
3.) Deep sedation/analgesia - a drug induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patient airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
4) Anesthesia: Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug -induced loss of consciousness during which patients are no arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

49
Q

Anesthesiology Certification

A

Critical care medicine, hospice and palliative medicine, pain medicine, pediatric anesthesiology, sleep medicine

50
Q

Antitrust

A

Unlawful restraints and monopolies or unfair business practices.

51
Q

Any Willing Provider Laws

A

Statutes requiring that managed care networks accept any willing physician who meets a managed care network’s established selection criteria. The insurer’s viewpoint is that these laws reduce competition and increase administrative costs. Physician’s position is that these laws protect them from being shut out of networks. Without these laws, the livelihoods of many physicians may be in jeopardy.

52
Q

AOA

A

American Osteopathic Association - the accrediting body for osteopathic hospitals. The AOA is a member association representing osteopathic physicians (DO’s). The AOA serves as the primary certifying body for DO’s and is the accrediting agency for all osteopathic medical colleges and health care facilities..

53
Q

APG (Ambulatory Patient Group)

A

A reimbursement methodology developed by 3M Health information systems for the HCFA/CMS. APGs are to outpatient visits/services what DRGs are to inpatient hospital days. APGs (ambulatory patient group) provide for a fixed reimbursement to an institution for outpatient procedures & visits and incorporate data regarding the reason for the visit and other patient data. APGs prevent unbundling of ancillary services.

54
Q

APIC

A

Association of professionals in infection control and epidemiology, a multi-disciplinary, voluntary, international organization promoting wellness and prevention of infection world-wide by advancing health care epidemiology.

55
Q

APN or NON LIP

A

JC: If APN (advance practice nurses) or PA (physician assistants) function as LIP, they must be credentialed through organized medical staff. If non-LIP APN or PA, may be credentialed through medical staff standards or equivalent process. Equivalent process must be approved by governing body and must include communication and input from MEC.

56
Q

Appeal

A

A formal request by a practitioner or member for reconsideration of a decision, such as a utilization review recommendation, a benefit payment, an administrative action or a quality of care or service issue, with the goal of finding a mutually acceptable solution.

57
Q

Application

A

A form on which the prospective insured states facts requested by the carrier and on the basis of which the carrier decide s whether or not to accept the risk, modify the coverage offered or decline the risk. Endless in non-insurance health benefit plans also complete enrollment applications.

58
Q

ASO Administrative Services Only

A

A service requiring a third party to deliver administrative services to an employer group and requiring the employer to be at risk for the cost of healthcare services provided. This is a common arrangement when an employer sponsors a self-funded healthcare program.

59
Q

ASR - age/sex rates

A

Also called table rates: a set of rates for a given group product in which there is a separate rate for each grouping of age and sex categories one overall table serves a defined group of product. These rates are used to calculate premiums for group billing purposes. This type of premium structure is often preferred over single and family rating in small groups because it automatically adjusts to demographic charges in the group. Also called table rates.

60
Q

Attestation

A

A signed statement indicating that a practitioner personally confirmed the validity, correctness, and completeness of his/her credentialing application as the time that he or she applied to the MCO for participation.

61
Q

Attrition rate

A

disenrollment expressed as a percentage of total membership. To be meaningful, one must distinguish between open enrollment and off open enrollment terminations. Off-open enrollment terminations are usually due to subscriber’s employment or relocation outside of the HMO’s/PPO’s service management. Open enrollment terminations may be due to subscriber dissatisfaction and thus may be controllable.

62
Q

Authorized submitter

A

an individual empowered by an eligible entity to submit repports or queries to the NPDB. The authorized submitter certifies the legitimacy of information in a query or report submitted to the NPDB. In most cases, the authorized submitted is an employee of the eligible entity (such as an administrator or Medical staff director).

63
Q

Authorized Agent

A

An individual or organization that an eligible entity designated to query the NPDB on its behalf. In most cases, an authorized agent is an independent contractor to the requesting entity for instance, a county medical society or state hospital association used for centralized credentialing. An authorized agent cannot query the NPDB without designation from an eligible entity.

64
Q

Balance Billing

A

The practice of a provider billing a patient for all charges not paid for by the insurance plan, even if those charges are above the plan’s UCR (Usual, Customary, or reasonable) or are considered medically unnecessary. Managed care plans and service plans generally prohibit providers from balance billing except for allowed co-pays, coinsurance and deductibles. Such prohibition against balance billing may even extend to the plan’s failure to pay at all (eg. because of bankruptcy).

65
Q

Balloon Endometrial Ablation

A

balloon endometrial ablation is performed by an OB-GYN

66
Q

Bare bones/health plans

A

these plans have high deductibles, copayments, low policy limits and may include only several stays of hospitalization. Over half of the states have waived mandated health benefits to allow sales of these plans. Although these no-frills, low cost policies are geared toward small businesses, they are not popular.

67
Q

Base capitation

A

a stipulated dollar amount to cover the cost of healthcare per covered person less mental health/substance abuse services, pharmacy and administrative charges.

68
Q

Basic health services

A

defined as benefits that all federally qualified HMOs must offer defined under subpart A 110.102 of the federal HMO regulations.

69
Q

Bed days/1000

A

the # of inpatient days per 1000 health plan members. The formula is # of days/member months x 1000 members x # of months.

70
Q

Benchmark

A

for a particular indicator or performance goal, the industry measure of best performance. The benchmarking process identifies the best performance in the industry/healthcare or nonhealthcare for a particular process or outcome, determines how that performance is achieved and applies the lessons learned to improve performance.

71
Q

Benefit package

A

services an insurer, government agency or health plan to offer to a group or individual under the terms of a contract.

72
Q

Benefits

A

The payment for, or health care services provided under terms of a contract with a MCO.

73
Q

Blacklisting

A

Refusal by insurers to cover high risk individuals especially those who could inherit diseases and these in high risk industries professions. The latter is also called red lining or industry screening.

74
Q

Board Certification

A

According to NCQA standards, state licensing agency is an approved source for verification of board certification. If state agency conducts primary verification of board.

75
Q

Board Certified Specialist

A

A doctor who has completed an accredited specialty program and who has passed the proper specialty board examination.

76
Q

Board eligible

A

a term used to describe a physician who is eligible to take the specialty board examination by virtue of having graduated from an approved medical school, completed a specific type and length of training and practiced for a specified amount of time.

77
Q

Borrowed Servant Doctrine

A

A principle under which the party usually liable for a person’s action. As in, a hospital which has employed a particular nurse is absolved of responsibility when that borrowed servant is asked to do something by a surgeon, which is outside of the bounds of hospital policy.

78
Q

Board of medical examiners

A

A body or subdivision of such body that is designated by a state for licensing, monitoring and disciplining physicians or dentists. This them includes boards of allopathic or osteopathic examiners, a composite board, a subdivision, or an equivalent body as determined by the state.

79
Q
A

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