Vocabulary Flashcards
What is Primary Source Verification (PSV)?
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.
AAAHC
Accreditation Association for Ambulatory Health Care
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.
AANA
American Association of Nurse Anesthetists
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.
AAPCC
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.
ABMS
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.
Accessibility
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.
ACCME
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.
Accreditation Decision Process - JC:
Accreditation Decision, Preliminary accreditation, accreditation with follow-up survey, contingent accreditation, preliminary denial of accreditation, denial of accreditation
Accreditation
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.
Accreditation - Joint Commission
The Joint Commission (TJC) accredits subscriber hospitals, ambulatory care centers, surgery centers, rehab centers, long term care centers, etc.
Accreditation - HFAP
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.
Accreditation - NCQA
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.
Accreditation - URAC
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.
Accreditation - AAAHC
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.
Accreditation - AOA
American Osteopathic Association - the AOA accredits a number of different institutions and programs as well as approves osteopathic postdoctoral training programs.
Accreditation Appeal
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.
Accreditation Cycle
A period of accreditation at the conclusion of which accreditation expires unless a full survey is performed.
Accreditation Decisions
Categories of accreditation that an organization can achieve based on a full survey by the accrediting body.
Accreditation Organizations
JC, AOA, DNV, NCQA, URAC and AAAHC
Accreditation Report
A report of an organization’s survey findings; the report includes organization strengths, requirements for improvement and supplemental findings, as appropriate.
Accreditation Survey Findings
Findings from an on-site evaluation conducted by Joint Commission’s surveyors which result in an organization’s accreditation decision.
Accreditation Watch
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.
Accredited
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.
ACGME
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.
Actuarial Soundness
The requirement that the development of capitation rates meet common actuarial principles and rules.
AOA
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.
Adverse Action
1) An action taken against a practitioners clinical privileges or medical staff membership in a health care entity or 2) a licensure disciplinary action.
Adverse Action Codes
A list of adverse actions and the codes used to identify them when submitting reports to the NPDB.
AAR (Adverse Action Report)
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.
Adversely Affects
reduces, restricts, suspends, revokes or denies clinical privilege or membership in a health care entity.
Administration Costs
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.
Admissions 1000
The number of hospital admissions per 1,000 health plan members.
ADS (Alternative Delivery System)
A method of providing healthcare benefits that depart from the traditional indemnity methods. An HMO for example is considered an alternative delivery system.
Adverse Selection
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.
Affiliated Provider:
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.
Age/Sex Factor
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.
AHP (Allied Health Professional)
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.
Accountable Health Plans
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.
AHRQ
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.
Allergy & Immunology Cert
No subspecialties
Allowable Costs
Charges for services rendered or supplies furnished by a health provider that qualify as covered expenses.
ALOS
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.
Alternative Delivery Systems
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.
AMA Master file
AMA Master file organization has been recognized by the JC and NCQA to provide PSV of medical school and residency graduation for US graduates.
Ambulatory Care
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.
Americans with Disabilities
The ADA is a wide-ranging civil rights law that prohibits, under certain circumstances, discrimination based on a disability.
AMICUS
friend of the court - a brief filed by an interested party giving an opinion/information on a case.
ANCC
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.
Anesthesia and Sedation
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.
Anesthesiology Certification
Critical care medicine, hospice and palliative medicine, pain medicine, pediatric anesthesiology, sleep medicine
Antitrust
Unlawful restraints and monopolies or unfair business practices.
Any Willing Provider Laws
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.
AOA
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..
APG (Ambulatory Patient Group)
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.
APIC
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.
APN or NON LIP
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.
Appeal
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.
Application
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.
ASO Administrative Services Only
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.
ASR - age/sex rates
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.
Attestation
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.
Attrition rate
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.
Authorized submitter
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).
Authorized Agent
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.
Balance Billing
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).
Balloon Endometrial Ablation
balloon endometrial ablation is performed by an OB-GYN
Bare bones/health plans
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.
Base capitation
a stipulated dollar amount to cover the cost of healthcare per covered person less mental health/substance abuse services, pharmacy and administrative charges.
Basic health services
defined as benefits that all federally qualified HMOs must offer defined under subpart A 110.102 of the federal HMO regulations.
Bed days/1000
the # of inpatient days per 1000 health plan members. The formula is # of days/member months x 1000 members x # of months.
Benchmark
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.
Benefit package
services an insurer, government agency or health plan to offer to a group or individual under the terms of a contract.
Benefits
The payment for, or health care services provided under terms of a contract with a MCO.
Blacklisting
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.
Board Certification
According to NCQA standards, state licensing agency is an approved source for verification of board certification. If state agency conducts primary verification of board.
Board Certified Specialist
A doctor who has completed an accredited specialty program and who has passed the proper specialty board examination.
Board eligible
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.
Borrowed Servant Doctrine
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.
Board of medical examiners
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.
Break Even Point
The HMO membership level at which total revenues and total costs are equal and therefore produce neither a net gain nor loss from operations.
Brief
Document an attorney prepares on appeal cases-gives history, facts, legal action, opinion about case presented to an appeals judge.
Bring business before assembly:
(a main motion) I move that [ or “to ] - majority vote
Business Associates
Physicians with hospital privileges do not have to enter into HIPPA Business associate contracts with the hospital. the hospital and such physician participated in what the HIPPA privacy rule defines as an organized Health care arrangement (OHCA). Thus they may use and disclose protected health information for the joint health care activities of the OHCA without entering into a business associate agreement.
Business Associates (Cont).
Accreditation organizations (JC, AOA, DNV, NCQA, URAC and AAAHC) are business associates of the covered entities they accredit. Like other business associates, accreditation organizations provide a service to the covered entity which requires the sharing of protected health information.
Bylaws
Biannually bylaws should be reviewed. Organizational structure of the medical staff are delineated in the bylaws. Credentialing and privileging determine applicants eligibility for membership to ensure compliance with accreditation and regulatory standards. Bylaws are written to conform to generally accepted guidelines for broad content categories they ensure compliance with legal requirements and accreditation and regulatory agencies. Bylaws are reviewed and appropriate amendments are essential to keep up with changes in accreditation standards and regulatory requirements. The purpose of the bylaws committee is to review the bylaws and to make recommendations to the medical staff’s executive committee (MEC). Bylaw changes are adopted by majority vote of the medical staff. Bylaw changes are not effective until approved by the governing body. Bylaws should include all items necessary to provide a basic framework for the MSO and to fulfill requirements of the law, regulatory agencies, and accreditation bodies. Also some states have specific requirements for elements to be included in bylaws. A governance framework that establishes the roles and responsibilities of a body and it’s members. (JOINT COMMISSION)
JC bylaw requirements regarding medical staff membership. They require the hospital, based on recommendations by the organized medical staff and approval by the governing body to develop criteria to be used in making decisions to grant, limit or deny a requested privilege. Medical staff membership and professional privileges can not be dependent upon certification, fellowship or membership in a specialty body or society.
You should determine the basis for the bylaw requirement, if it is not required by accreditation standards, state of federal regulations, confer with your legal counsel as to whether or not to change the bylaws to reflect your current practice. What criteria must the bylaws include to meet COPs requirements, they must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges.
CAHPS (Consumer Assessment of Healthcare Providers and Systems)
A public-private initiative to develop standardized surveys of patient’s experiences with ambulatory and facility level care. Health care organizations, public and private purchasers, consumers, and researchers use CAHPS results to: Assess the patient centeredness of care, compare and report on performance and improve quality of care.
CAMH (Comprehensive Accreditation Manual for Hospitals)
Publishing by TJC, the Comprehensive Accreditation Manual for hospitals includes guidelines for obtaining, managing and using information to improve patient outcomes and individual and hospital performance in patient care, governance management and support process.
Canadian Style System
1) Commonly, a term used to describe a single payer system, nationalized healthcare or socialized medicine.
2) Canada’s healthcare system is actually none of the above. Canada’s national health insurance program is composed of 12 separate single payer systems with global budgets. Patients may choose their doctors who are mainly self-employed and reimbursed under a negotiated fee schedule. Hospitals, about half goverment owned and half publicly held nonprofits, are reimbursed in set lump sums. Each province approves technology and facility investments.
CAP (Capitation)
The process of flat rate prepayment for professional services for a given population of health plan (literally “per head”). In practice, a flat fee is paid per member per month (PMPM) to a contracting medical group IPA or primary call physician in return for the provider’s assumption of the financial risk required to provide certain professional services to a given population of health plan members. The provider is responsible for delivering or arranging for the delivery of all health services required by the covered person under the condition of the provider contract.
Capitation
A dollar amount established to cover the cost of health care services delivered for a person during a specified length of time. The term usually refers to a health care provider by a MCO. The provider is then responsible for delivering or arranging the delivery of all health services required by the covered person under the conditions of the provider contract. This term may also refer to the amount paid to a MCO by the HCFA or state.
Carrier
An entity which may underwrite or administer a range of health benefit programs. May refer to an insurer or a managed health plan.
Carve Out
one or more services excluded from those required to be provided under the capitation rates. These services may be paid on a fee for service or other basis.
Case Management
The process for identifying covered persons with specific healthcare needs in order to facilitate the development and implementation of a plan that efficiently uses healthcare resources to achieve optimum member outcome.
Case Manager
An experienced professional (e.g. nurse, doctor or social worker) who works with patients, practitioners, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate healthcare.
Catastrophic Health Insurance
Insurance beyond basic and major medical insurance for severe and prolonged illness that poses the threat of financial ruin to the family.
Catchment Area
the geographic area from which an HMO draws its patients.
CBA Cost Benefit Analysis
measures both costs and results of a treatment method in monetary terms, not in physical units.
CDC
Centers for Disease Control and Prevention an agency of the United States Department of Health and Human Services based near Atlanta Georgia. It works to protect public health and safety by providing information to enhance health decisions, and it promotes health through partnerships with state health departments and other organizations. The CDC focuses national attention on developing and applying disease prevention and control (especially infectious diseases) environmental health, occupational safety, and health, health promotion, prevention and education activities designed to improve the health of the people of the US.
CDS
Controlled Drugs and Substances
CE - Participation
It is not a JC standard requirement that an applicant’s participation in CE is evaluated and considered on initial appointment to the medical staff.
CEA (Cost effectiveness analysis)
Measures costs and consequences with costs measured in dollars and outcomes calculated in terms of their effectiveness in obtaining a specific objective measured in biological units. CEA is particularly useful for comparing alternative treatments which are very similar and affect similar clinical results or use similar methods.
CEO
One of the highest ranking corporate officer (executive) or administrator in charge of total management. An individual selected as president and CEO of a corporation, company, organization, or agency, reports to the board of directors.
Certification
Confirmation that prescribed requirements are met.
Charitable Immunity Doctrine
An immunity from civil liability and particularly as regards negligent torts that is granted to a charitable or nonprofit organization. The legal charitable immunity holds that a charitable organization is not liable under tort law.
Cherry Picking
It is the practice of selling policies only to people who don’t need medical care and dropping them once they do. Insurers argue it is an unavoidable practice. Also referred to as cream skimming.
Churning
The practice of a provider seeing a patient more often than is medically necessary, primarily to increase revenue through an increased number of services.
Claim experience
The claim cost associated with the utilization of healthcare services related to the contract between the account and the carrier.
Claims (Incurred)
It represents actual carrier liability and includes all claims with dates of service within a specified period, usually called the experience period. Because of the time period between dates of service and claim payments are actually processed adjustments must be made to a paid claims data to determine incurred claims.
Claims (Paid)
The amounts paid to providers to satisfy the contractual liability of the benefit plan. These amounts do not include member liability for ineligible charges, deductibles or copayments. If the carrier has preferred payment contracts with providers (e.g. fee schedules, capitation arrangements), lower paid claims liability will usually result. Without such contracts, the total of paid claims plus member liabilities should equal provider billed claims. NOTE: Paid claims for a specific time period do not necessarily reflect the actual liability for medical services delivered during the same period of time. See the definition of claims (incurred) for further information.
Clinic without walls
The concept of a clinic without walls focuses primarily on an organizational structure rather than a physical structure. In so doing, it sidesteps one of the primary barriers to the creation of medical group practices that has existed in the past. Instead of having to buy out the lease and pay to relocate the physicians into a single location, one simply leaves everyone in place while throwing a super PA (professional association) or other entity over the top of their existing PAs to create a combined organization.
Clinical Privilege
A clinical privilege is an authorization granted by the appropriate authority to a practitioner to provide specific care, treatment and services. Privileges, membership on the medical staff, and other circumstances (including panel memberships) in which a physician, dentist, or other licensed health care practitioner is permitted to furnish medical care by a health care entity. The main reason for periodically assessing appropriateness of clinical privileges for each specialty is to protect patient safety by ensuring current competency relevance to the facility and accepted standards of trade. TJC hospital standards require that clinical privileges are hospital specific and based on the individuals demonstrated current competence and the procedures the hospital can support: Congenital septal and vascular defect repair is performed by Cardiovascular or thoracic surgeon
According to JC hospital standards, professional criteria for the granting of clinical privileges must include at least relevant training or experience, ability to perform privileges requested current licensure and competence.
Cardiovascular surgeon is most likely to be granted privileges for surgical management of congenital septal and valvular defect.
Authorization granted by the appropriate authority (for example, a governing body) to a practitioner to provide specific care, treatment and services in an organization within well-defined limits, based on the following factors, as applicable: license, education, training, experience, competence, health status and judgement.
Clinical Service Group
Clinical service group is patients of services categorized into distinct populations for which data can be collected.
Close debate
I move the previous question = 2/3 vote
Close meeting
I move to adjourn - majority vote
Closed access
a type of health plan in which covered persons are required to select a primary care physician from the plan’s participating providers. The patient is required to see the selected PCP for care and referrals to other healthcare providers within the plan. Typically found in a staff, group or network model HMO. Also called close panel or gate keeper model.
Closed panel
1) A managed care plan that contracts with physicians on an exclusive basis for services and does not allows those physicians to see patients for another managed care organization. Examples include staff and group model HMO’s. It could apply to a large private medical group that contracts with a HMO.
2) Medical services are delivered in the HMO owned health center or satellite clinic by physicians who belong to a specially formed but legally separate medical group that only serves the HMO. This term usually refers to group and staff HMO models. See also closed access.
CMA
Cost minimization analysis measures and compares costs of alternative therapies that have identical clinical effectiveness including adverse reactions, complications and duration of therapy.
CME
Continuing medical education refers to a specific form of continuing education (CE) that helps those in the medical field maintain competence and learn about new and developing areas of their field. Content for these programs is developed, reviewed, and delivered by faculty who are experts in their individual clinical areas. Similar to the process used in academic journals, any potentially conflicting financial relationships for faculty members must be both disclosed and resolved in a meaningful way.
CMP
Competitive Medical Plan: A federal designation that allows a health plan to obtain eligibility to receive a Medicare risk contract without having to obtain qualification as an HMO. Requirements for eligibility are somewhat less restrictive than for an HMO.
CMS
Centers for Medicare & Medicaid Services, the federal agency of the Department of Health and Human Services that administers the Medicare program and oversees state’s administration of Medicaid.
CMS
or the centers for Medicare and Medicaid Services is the federal agency responsible for administering the Medicare, Medicaid, SCHIP (State Children’s Health Insurance), HIPAA (Health Insurance Portability and Accountability Act), CLIA (Clinical Laboratory Improvement Amendments)
CMS requirements
examination of experience and competence is required.
COBRA
Consolidated Omnibus Budget Reconciliation Act of 1985
1) A component of this act requires employees to offer the opportunity for terminated employees to purchase continuation of health care coverage under the group’s medical plan. Employees of companies with 20 or more workers are entitled to continue coverage under the group plan for 18 months after leaving.
2) The act also allows for a Medicare recipient to disenroll from an HMO or CMP with a Medicare risk contract.
Code of Ethics
A systematic set of rules or guidelines to direct appropriate and value-based conduct or behaviors.
Colon and Rectal Surgery
No subspecialties
Correction
A change intended to supersede a report in the NPDB
Committees
Medical Executive Committee (MEC) and also a governing body are committees required by TJC.
Common Law
A body of law based on judicial decisions and customs as distinct frm statute law.
Community Care Networks
Local groups of doctors and clinics, organized by hospitals, compete for contracts with group insurers and are responsible for providing care to enrolled individuals. Typically reimbursement is by capitation. Payment schedules are set by an independent regulatory board. Community Care Networks are the center piece of the American Hospital’s reform plan.
Competency
A determination of an individual’s capability to meet defined expectations.
Compliance
Participate in the development, implementation, and ongoing assessment of bylaws, rules and regulations, policy and procedure to ensure continuous compliance with accreditation regulatory standards.
Conditional Accreditation
Organization is not substantial compliance with standards and must submit an ESC (evidence of standard compliance report)
Confidentiality
restriction of access to data and information to individuals who have a need, a reason, and permission for such access. An individual’s right, within the law, to personal and informational privacy, including his/her healthcare records.
Conflict of Interest
The circumstance of a public official or corporate officer whose personal interests might benefit from his/her official position or actions, especially as it relates to confidential information.
Consent
A voluntary act by which the person allows someone else to do something.
Contract
An agreement that identifies rights and obligations
1) An agreement between two or more persons that creates an obligation to do or not do a particular thing.
2) An HMO agreement executed by a subscriber group. The term may be used in place of subscriber when referring to penetration within a given comment; subscriber group. Also used to designate an enrollee’s coverage.
Contract year
the period of time from the effective date of the contract to the expiration date of the contract.
Conversion
The conversion of a member covered under a group master contract to coverage under an individual contract. This is offered to subscribers who lose their group coverage (through job loss, death of a working spouse, etc.)
Conversion privilege
This gives an individual insured under a group plan the right to convert from a group health policy to an individual policy in the event the individual leaves the group.
COP: Conditions of Participation
Federal regulations issued by the Healthcare Financing Administration delineating standards. For Healthcare delivery, similar to standards of the Joint Commission. Hospitals receiving reimbursement for treatment of Medicare patients must meet the conditions. CMS officially recognizes that JC hospital accreditation requirements meet or exceed the Medicare Conditions of Participation. As a result, JC accredited hospitals have “deemed status” and are deemed eligible to participate in the Medicare program.
Copayment
a cost-sharing arrangement in which a member pays a specific charge for a specified service (eg $10 for an office visit). The member is usually responsible for payment at the time the service is rendered.
COPs
COPs require a mechanism be established to examine credentials of prospective member.
COPs cont.
Medicare Conditions of Participation: The COPs are contained in the code of federal regulations are intended to protect patient health and safety and to ensure quality of care for hospitalized patients.
Core Competencies
Knowledge, skills, values, and belief systems required for someone to be able to provide the services of a profession.
Corporate Liability Doctrine
Negligent credentialing holds a hospital liable when they knew or should have known a practitioner was not competent.
Cost Contract
A TEFRA contract payment methodology option by which HCFA pays for the delivery of health services to members based on the HMOs reasonable cost. The plan receives an interim amount derived from an estimated annual budget, which may be periodically adjusted during the course of the contract to reflect actual cost experience. The plan’s expenses are audited at the end of the contract to determine the final rate the plan should have been paid.
Cost effective
a term that refers to the allocation of resources in a manner so as to maximize outcome and minimize cost. There is a point at which more cost will not incrementally improve outcome to the extent of the increased cost.
Cost sharing
A general set of financing arrangements in which a covered member must pay a portion of the costs associated with receiving care. (See also copayment, coinsurance, and deductible).
Cost shifting
It is the expression that describes the primary method of paying for indigent care in the United States. The “high” cost of private insurance premiums are perceived as the hidden tax to pay for uncompensated medical care and medical treatment of the poor. It is viewed as the primary cause of health insurance inflation.
Cost of illness analysis
Examines all the costs of a specific disease in a defined population. A macro economic analysis, often used to evaluate preventive programs for diseases.
Covered Entities
Health plans, clearinghouses, and providers that conduct health care transactions electronically are referred to as covered entities.
CPM - Competitive Medical Plan
A status, established by TEFRA and granted by the Federal government, to an organization that meets specific requirements enabling that organization to obtain a Medicare risk or cost based contract.
CPMSM
Certified Professional Medical Services Management: a medical staff services management practitioner who has successfully completed the examination for certification by the National Association Medical Staff Services.
CPR
Customary Prevailing and Reasonable: a payment process developed by Medicare. CPR describes the rate physicians charge based on what they have charged in the pact (customary) and what other physicians are charging (prevailing) The 4reasonable charge can be adjusted to the prevailing charge, the customary charge or the physician’s present charge.
CPT
Current Procedural Terminology: a list of medical services and procedures performed by physicians and other providers. Each service and/or procedure is identified by its own unique five digit code CPT has become the healthcare industry’s standard for reporting of physician procedures and services, thereby providing an effective method of nationwide communication.
Credentialed
who do not need credentialed. practice exclusively within an inpatient setting, free-standing facilities, dentists, pharmacists, locum tenens, (unless longer than 90 days), those who do not provide care to members in a treatment setting. (Eg. Board certified consultant)
Must be credentialed
psychiatrists or other physicians (MD/DO), Dentists, Podiatrists, Chiropractors, other behavioral health specialists, practitioners with independent relationship with organization - defined as when organization selects and direct members to individual or group practitioners members can select as PCP.
Credentialing
JC: the process of obtaining, verifying and assessing the qualifications of a health care practitioner who seeks to provide patient care in or for a hospital. PATIENT SAFETY: is the # 1 reason for credentialing.
The basic “or core” criteria are usually reflective of education, training, and current competence, health status and licensure. Outlined in bylaws. Credentialing and privileging determine applicants eligibility for membership to ensure compliance with accreditation and regulatory standards. 3 Reasons: Patient Safety, Risk Management Concerns, and Required by accrediting and regulatory agencies. Credentialing standards apply to all licensed practitioners or groups of practitioners who provide care to the organizations members. Credentialing and privileging: determine applicant’s eligibility for membership/participation to ensure compliance with accreditation and regulatory standards.
Criteria
what is the minimum criteria for appointment? applicant’s character, competence, training, experience and judgement.
Criteria for appointment to a medical staff or provider panel the basic or “core” criteria are usually reflective of education, training, current competence, health status, and licensure. These criteria should be outlined in bylaws, policies, and or rules and regulations. Expected level(s) of achievement or specifications against which performance or quality may be compared.
Criteria for medical staff?
What are the CMS COP criteria for selection the medical staff? (HINT: CCJET) - Competency, Character, Judgement, Experience and Training.
CUA: Cost Utility Analysis
Measures costs of alternative treatments in dollars, but evaluates outcomes in terms of the patient’s ability to lead a normal satisfying life, their “quality of life”. The outcome may be measured in terms of discomfort and pain, changes in functioning or preference for one intervention over another.
CVO
Credentialing Verification Organization
Cynical Privileges
when developing clinical privileges the following are important to evaluate. Established standards of practice such as, specialty board recommendations.
DAW
Dispense As Written: the instruction from a physician to a pharmacist to dispense a brand name pharmaceutical rather than a generic substitution.
DBID: Data bank Identification Number
A unique 15 digit identification # assigned to eligible entities and authorized agents when they register with the NPDB. Entities and agents need this number to query and report to the NPDB using the IQRS. The DBID must be included on all correspondence to the NPDB.
DEA
The government agency that registers practitioners to dispense controlled substance and issues certificates to medical providers authorizing them to prescribe controlled substances (ie: narcotics) and other medications. The DEA registration expires every three years.
DEA, DPH
Schedules: I, II, III, IV, V routine schedules: 2, 2N, 3, 3N, 4, 5 - Note: drugs listed in schedule I have no currenlty accepted medical use in treatment in the United States and therefore may not be prescribed, administered, or dispensed for medical use. Schedule 1 drugs subject to criminal prosecution.
Decision analysis
A systematic approach to decision-making under uncertain conditions, explicitly analyzing all of the factors in a decision (in a specified order), assessing the probability of the possible outcomes, and selecting the best possible choice.
Deductible
A specified amount of money a member must pay before insurance benefits begin. Usually expressed in terms of an “annual” amount.
Deemed status
After CMS approves an accreditor they are given deemed status, name the accreditors that have deemed status. JC, AOA-HFAP, DNV, NCQA, URAC, AAAHC; Status conferred by the centers for Medicare and Medicaid services (CMS) on a healthcare provider when that provider is judged or determined to be in compliance with relevant Medicare Conditions of Participation because it has been accredited by a voluntary organization whose standards and survey process are determined by CMS to be equivalent to those of the Medicare program or other federal laws. Successful completion of a JC hospital survey can result in deemed status recognition. In order for a healthcare organization to participate in and receive payment from the Medicare or Medicaid programs, it must be certified as complying with the Conditions of Participation (COP), or standards, however if a national accrediting organization such as the Joint Commission, has and enforces standards that meet the federal conditions of participation (COP), CMS may grant the accrediting organization “deeming” authority and “deem” each accredited health care organization as meeting the Medicare and Medicaid certification requirements. The healthcare organization with “deemed status” would not be subject to the Medicare survey and certification process.
Defendant
Party against whom legal action is brought.
Delegated Credentialing
One organization grants by mutual agreement, responsibility to another organization to perform a specified scope of credentialing activities.
Delegated Credentialing - JC
Organizations that use information from a CVO should have confidence in the completeness, accuracy and timeliness of that information and outlines nine principles to evaluate such an agency. Among the necessary aspects are disclosure of data and information available, processes utilized limitations of information available, identification of primary source information versus information obtained from a secondary source, overview of quality control measure related to data integrity, security, transmission accuracy.
Delegation
A formal process by which an MCO gives another entity the authority to perform certain functions on its behalf, such as credentialing utilization management and quality improvement. Although, an MCO can delegate the responsibility for ensuring that the function is performed appropriately.
Delineation of Clinical Privileges
The listing of the specific clinical privileges an organization’s staff member is permitted to perform in the organization.
Denial
Non-authorization of a request for care or services. NCQA considers non-authorization decision that are based on either medical appropriateness or benefit coverage to be denials. Partial approvals and care terminations are also considered to be denials.
Deposition
written sworn testimony made before a public officer for a court action, often as answers to questions posed by a lawyer, used for discovery of information or evidence for a trial.
Dermatology Certification
Dermatopathology, pediatric dermatology
Differential
The out of pocket difference that an eligible individual may pay when opting for indemnity insurance versus a managed care plan.
Discounting
Method used to convert future benefits and costs into equivalent current monetary units, taking into account the general preference for current dollars over future dollars.
Discovery
Pretrial activities to determine what evidence the opposing side will present if the case comes to trial.
Dispute
A formal, written objection of the accuracy of a report of the fact that a specific event was reported to the NPDB. Disputed may be made only by the subject of a report.
DCN
Data bank control number: number assigned by the NPDB that is used to identify each query and report. Used when submitting a correction or a void to the bank.
Draft
A report that is temporarily stored without being submitted to the NPDB - HIPDB for processing. Can store for 30 days. Drafts are not considered valid submissions to the bank.
Divide and dump
describes separating low-risk workers from the high-risk workers and dumping the latter.
DME
Durable medical equipment (DME): equipment which can stand repeated use, in primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury and is appropriate for use at home. Examples of durable medical equipment include hospital beds, wheelchairs and oxygen equipment.
DNV
Det Norske Veritas - another type of accreditation
Doctrine of respondant superior:
latin, let the master answer. a common law doctrine that makes an employer liable for the actions of an employee when the action takes place within the scope of employment.
doctrine of corporate negligence:
cases are based on a nondelegable duty that a hospital owes directly to its patients. (A non-delegable duty is a legal obligation that cannot be delegated to a third party. The original party is still liable for any harm that results from a non-delegable duty, even if they entrust the task to someone else)
doctrine of ostensible agency
is a form of implied agency relationship created by the actions of the parties involved rather than by written contractual agreement. Example: hospital/doctors, doctors/allied health professionals. Shared liability is often proved because the parties are perceived to be partners, it is apparent that they are partners even if they are not.
DRG
Diagnostic Related Groups - a classification system for inpatient hospital services based on principal and secondary diagnosis, surgical procedures, age, sex and presence of complications used to determine reimbursement. A system of classification for inpatient hospital services based on diagnosis, age, sex, and the presence of complications. It is used as a means of identifying costs for providing services associated with a diagnosis and as a mechanism to reimburse hospital and selected other providers for services rendered.
Drug formulary
a listing of prescription medications which are approved for use and/or coverage by the plan and which will be dispensed through participating pharmacies to a covered person. The list is subject to periodic review and modification by the health plan.
Dual choice
1) a health benefit offered by an employment group that permits those eligible to voluntarily choose among health plans usually the employers primary insurer and an HMO.
2) the portion of the federal HMO regulations that requires any employer with 25 or more employers residing in an HMO’s service area paying minimum wage, and offering health coverage to offer a federally qualified HMO as well. Sometimes referred to as mandating, the HMO must request it. This provision was “unsettled” in 1995.
3) Another definition, unrelated to the previous one, pertains to point of service.
ECFMG
Educational Commission for Foreign Medical Graduates; the purpose of ECFMG certification is to assess whether international medical graduates (IMG) are ready to enter US residency and fellowship programs that are accredited by the ACGME. Must be certified by ECFMG to enter US residency and fellowship programs. Must be certified by ECFMG prior to applying to take Step 3 of the United States Medical Licensing Examination (USMLE). To obtain for a US Medical License. The US require that International Medical Graduates (IMG) apply for unrestricted licensure certified by ECFMG. Certification includes passing Step 1 and Step 2 of the USMLE exam. Step 2 exam has two seperately components Steps: Graduate Medical School. Obtain a USMLE/ECFMG identification number. Complete application for ECFMG certificate. Apply for exam. No time limited on certification, but there is a time limit on the exams for the certification. Must be certified by ECFMG before your training programs start date, although one can apply for the training program before being certified. The GME directory published by the AMA is recognized as the official list of ACGME accredited graduate medical education programs. Training programs require applicants to submit their applications using the Electronic Residency Application Service (ERAs)
International Medical Graduates (IMGs)
who are not citizens or lawful permanent residents, must obtain an appropriate visa to participate in US graduate medical education programs ECFMG, through its process of certification, assesses the readiness of graduates of foreign medical schools to enter residency or fellowship training programs in the United States. ECFMG administers an examination on knowledge of basic medical sciences and ability to understand the English language.
Economic credentialing
A process that measures and traces cost-effective physician practices used for appointment and reappointment of physicians to medical staff positions.
Education: JC
JC Accreditation standards requirements regarding verification of education. verification or medical school, AMA, CVO, ECFMG, AOA, AAPA.
EFT
Electronic Funds Transfer: a method of electronic payment for NPDB queries.
Eligible Entity
An entity that is entitled to query and/or report to the NPDB.
Entity Primary Function Code
NPDB’s two digit code that best describes the primary function your entity performs.
EP Element of Performance
is a specific performance expectations and/or structures or processes that must be in place in order for a hospital to provide safe, high-quality care, treatment, and services. EPs are scored and determine a hospital’s overall compliance with a standard. EPs are evaluated on a 3-point scale (with the option of scoring an EP “not applicable”) whereby 0= insufficient compliance, 1=partial compliance, 2=satisfactory compliance
Elements of Performance: JC
1) The organized medical staff provides leadership for measuring, assessing and improving processes that primarily depend on the activities of one or more licensed independent practitioners, and other practitioners credentialed and privileged through the medical staff process.
2) The medical staff is actively involved in the measurement, assessment, and improvement of the following: medical assessment and treatment of patients.
3) The medical staff is actively involved in the measurement, assessment, and improvement of the following: use of information about adverse privileging decisions for any practitioner privileged through the medical staff process.
4) The medical staff is actively involved in the measurement, assessment, and improvement of the following: use of medications.
5) The medical staff is actively involved in the measurement, assessment, and improvement of the following: use of blood and blood components.
6) the medical staff is actively involved in the measurement, assessment and improvement of the following: operative and other procedure (s) of the following: appropriateness of clinical practice patterns.
7) the medical staff is actively involved in the measurement, assessment, and improvement.
8) the medical staff is actively involved in the measurement, assessment, and improvement of the following: significant departures from established patterns of clinical practice.
9) the medical staff is actively involved in the measurement, assessment and improvement of the following: the use of developed criteria for autopsies.
10) information used as part of the performance improvement mechanisms, measurement or assessment includes the following: sentinel event data
11) information used as part of the performance improvement mechanisms, measure mentor assessment includes the following: patient safety data. (see also p1. 03.01.01. EPs 1-4)
12) for hospitals that use joint commission accredittaion for deemed status purposes: the hospital attempts to secure autopsies in all cases of unusual deaths and cases of medical, legal and educational interest, and informs the medical staff (specifically the attending physician or clinical psychologist) of autopsies that the hospital intends to perform. Note: the definition of “physician” is the same as that used by the centers for Medicare and Medicaid Services (CMS).
Emergency Medicine Certification
anesthesiology, critical care medicine, emergency medical services, hospice and palliative medicine, internal medicine - critical care medicine, medical toxicology, pediatric emergency medicine, sports medicine, undersea and hyperbaric medicine
Employer Mandate
under the federal HMO act, federally qualified HMOs can mandate or require an employer to offer at least one federally qualified HMO plan of each type (IPA network or group staff) Some state laws have similar provisions. Under the federal HMO act, describes conditions when federally qualified HMOs can mandate or require an employer to offer at least one federally qualified HMO plan of each type (IPA network or group/staff) Sun-setted in 1995.
EMTALA
Emergency Medical Treatment and active labor act: the federal program prohibits hospitals from turning away patients who present for emergency treatment based on their ability to pay. EMTALA violation penalties include: Hospital and physician fines up to $50,000 per violation, IRS investigations relating to the hospital tax exempt status, and loss of hospital and physician participation in the medicare program. “Anti-dumping” law was enacted as part of the COBRA act (consolidated omnibus budget reconciliation act) of 1985, designed to prevent hospital from refusing to treat patients or transferring them because of their source of payment. The Emergency Medical Treatment and Active Labor Act is a statute which governs when and how a patient may be 1) refused treatment or 2) transferred from one hospital to another when he is in an unstable medical conditon. EMTALA was passed as part of the consolidated omnibus budget reconciliation act of 1986, and it is sometimes referred to as “the cobra law”.
Encounter
A contract provided to a patient by a healthcare practitioner or provider. Generally, if the member receives more than one treatment within the same or related department at the same time, it is counted as a single encounter. Encounter claims from primary care providers (PCP) are generally capitated services and do not generate a claim to be paid to the physician.
Enrollee
An individual who is enrolled for coverage under a health plan contract and who is eligible on his/her own behalf (not by virtue of being an eligible dependent) to receive the health services provided under the contract.
EPO (Exclusive Provider Organization)
An EPO is similar to an HMO in that it often uses primary care physicians as gatekeepers may have capitated providers, has a limited provider panel, and uses an authorization system. An EPO differs from an HMO in that EPO physicians in most cases do not receive capitation but instead are reimbursed only for actual services provided. It is referred to as exclusive because the member must remain within the network to receive benefits. EPOS are generally regulated under insurance statuses rather than HMO regulations. Many states do not allow EPOs because they maintain that EPOs are really HMOs. If the patient goes outside the EPO network for care, they are required to pay the entire cost of the care. A term derived from the phrase preferred provider organization (PPO). However, where a PPO generally extends coverage for non-preferred provider services as well as preferred provider services, an EPO provides coverage only for contracted providers, hence, the term exclusive. Technically, many HMOs can also be described EPOs.
Enrollment
The total # of covered persons in a health plan the term also refers to the process by which a health plan signs up groups and individuals for membership or the # of enrollees who sign up in any one group.
EQRO (External Quality Review Organization)
states are required to contract with an entity that is external to and independent of the state and its HMO (Health Maintenance Organization) and HIO (Health Information Organization) contractor.
Equivalent Process
At a minimum, equivalent process must include: evaluate credentials of applicant, evaluate current competence of applicant, peer recommendations, communication/input from individuals, committees, including MEC regarding applicants request for privileges. If equivalent process used by facility, HR standards should be consulted for methodology.
ERAs
Electronic Residency Application Service
ERISA
Employee Retirement Income Security Act: one provision of this act allows self-funded plans to avoid paying premium taxes, complying with state laws and regulations regarding insurance, even when insurance companies and managed care plans that stand risk for medical costs must do so. Another provision requires that plans and insurance companies provide an explanation of benefits (EOB) statement to a member or covered insurance in the event of a denial of a claim, explaining why the claim was denied and informing the individual of his/her right of appeal. It exempts companies that self-insure, or fund their own insurance plans, from state regulations. Most large companies began to self-insure in the 80’s. Now 70% of firms with 5,000 or more workers are self-insured. Only HAWAII has an ERISA waiver, allowing it to regulate such plans. The act is considered to be a major roadblock to state health reform, since it means states cannot require the large companies to provide insurance, pay premium taxes, or cover mandated benefits.
ESC: Evidence of Standards Compliance (ESC)
A report submitted by a surveyed organization within 45-60 days of its survey, which details the actions that it took to bring itself into compliance with a standard or that clarifies why the organization believes it was in compliance with the standard for which it received a recommendation. An ESC must address compliance at the element of performance (EP) level and must include a measure of success (MOS) (see definition) if applicable, for all appropriate EP corrections.
ESC
Evidence of Standards Compliance Report: Report submitted by surveyed organization within 45 or 60 days following the survey.
Ethics
The study and philosophy of human conduct with emphasis on the determination of right and wrong. The principles of right conduct, especially with reference to a specific profession.
Exclusions
Why is it important to check that the practitioner is not currently excluded, suspended, debarred, or ineligible to participate in federal health care programs. The facility won’t get paid for treating patients unless service is provided by authorized provider.
Expected claims
The projected claim level of a covered person or group for a defined contract period. This level also becomes known as a desired loss ration or break even point in relationship to projected premium.
Experience rating
The process of setting rates based partially or in whole on evaluating previous claims experience and then projecting required revenues for a future policy year for a specific group or pool of groups.
Expert witness
one who has special training, experience, skill and knowledge in a relevant area and whose testimony and opinion may be considered as evidence.
External Criteria
External criteria for membership are requirements set by forces outside the organization, including accrediting and certifying bodies such as TJC, NCQA, and state and federal regulations such as COPs. State laws may also describe which providers can be members of the medical staff.
FACIS
FACIS is the database designed to assist healthcare industry personnel search a single database containing information on healthcare individuals and entities that have been excluded from federal healthcare programs as well as adverse actions taken by licensing boards of state governments.
Family Medicine Certification
adolescent medicine, geriatric medicine, hospice and palliative medicine, sleep medicine, sports medicine
FCVS
Federal credentials verification service: a national non profit organization that provides services for state medical and osteopathic licensing authorities. FCVS was developed to provide a centralized, uniform process for medical licensing authorities as well as private, governmental and commercial entities to obtain a verified, primary source record of a physician’s “core” medical credentials.
FDA
Food and Drug Administration: Institution Review boards are overseen by FDA.
Federal Medicaid Managed Care Waiver Program
The process used by states to receive permission to implement managed care programs for their Medicaid or other categorically eligible beneficiaries.
Federal Physician Self-Referral
Prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment or compensation) unless an exception applies.
Federal Qualification
A status defined by the HMO act, conferred by HCFA/CMF after conducting an extensive evaluation of the HMO’s organization and operations. An organization must be federally qualified or be designated as a CMP (competitive medical plan) to be eligible to participate in Medicare cost and risk contracts. Likewise, an HMO must be federally qualified or state plan defined to participate in the Medicaid managed care program.
Fee Schedule
A comprehensive listing of fee maximums used to reimburse a physician and/or other provider on a fee for service basis, with certain fee-maximums for each procedure.
FFS Fee for Service Equivalency
A quantitative measure of the difference between the amount a physician and/or other provider receives from an alternative reimbursement system, e.g. capitation, compared to fee-for service reimbursement.
FFS
Fee for Service: A payment system by which doctors, hospitals and other providers are paid a specific amount for each service performed as identified by a claim for payment.
FFS: Fee for Service Reimbursement
The traditional healthcare payment system under which physicians and other providers receive a payment that does not exceed their billed charge for each unit of service provided.
FFS: Fee for Services
A payment system by which doctors, hospitals and other providers are paid a specific amount for each service performed as identified by a claim for payment.
FFS:Fee for Services (Cont.)
1) A form of payment to providers where the provider receives payment on a per service basis.
2) Refers to a group that charges the patient according to a fee schedule set for each service and/or procedure to be provided and the patient’s total bill will vary by the # of services/procedures actually received.
Field Underwriting
The process performed by sales personnel for screening prospective buyers of the carrier’s products. The purpose is to ensure profitable contracting with groups and to screen out those prospects that are not in the carrier’s best interests.
Final Order
courts final decision in a lawsuit
First Dollar Coverage
A policy that like an HMO has no deductibles and covers the first dollar of an insured’s expenses.
Fiscal soundness
The requirement that managed care organizations have sufficient operating funds, on hand or available in reserve, to cover all expenses associated with services for which they have assumed financial risk.
Fixed order of business
follows a fixed order of business - agenda, call to order, roll call, review/approval of minutes from last meeting, officers reports, committee reports, special orders - important business previously designated for consideration at this meeting, unfinished business, new business, announcements, adjournment
Focused Survey
A survey conducted during the Joint Commission accreditation cycle to assess the degree to which an organization has improved its level of compliance relating to specific recommendations. The subject matter of the survey is typically an area(s) of identified deficiency in compliance, however other performance areas may also be assessed by a surveyor(s) even though they may not have been previously identified as deficiencies.
Formal Peer Review Process
NPDB: The conduct of professional review activities through formally adopted written procedures that provide or adequate notice and an opportunity for a hearing.
Frequency
The # of times a service was provided.
FOIA: Freedom of Information Act
the law that provides public access to federal governmental records - like the NPDB.
FSMB: Federation of State Medical Boards
According to NCQA standards, FSMB is an acceptable source for primary source verification of Medicare and Medicaid sanction activity against physicians.
Organization to which all state licensing boards, the armed forces, and the federal Medicare Program report disciplinary actions taken against physicians.
Is a national non-profit organization representing the 70 medical boards of the United States and its territories. The FSMB’s mission is to continuously improve the quality, safety and integrity of health care through developing and promoting high standards for physician licensure and practice.
When verifying licensure sanctions for physicians, NCQA allows verification to be done with NPDB, HIPDB, the appropriate state agencies and FSMB - The Federation of State Medical Boards.
Funding Level
the level of funding required to finance a medical care program. Lender an insured program, it is usually the insurance or HMO premium. Under a self-funded program, the amount is usually set by the employee designee.
Funding Method
Refers to the method by which funding a medical care program occurs. Under an HMO plan, the funding method is usually a prospective rate only. Under insurance plans there are many variations of payment methods or liabilities to employers, both prospective and retrospective.
Gatekeeper
A primary care physician in an HMO who makes referrals. His/her function is to reduce healthcare utilization and costs. An arrangement in which a primary care provider serves as the patient’s agent, arranges for and coordinates appropriate medical care and other necessary and appropriate referrals.
Gatekeeper model
An informal, though widely used term that refers to a primary care case management model health plan. In this model, all care from providers other than the primary care physician, except for emergencies, must be authorized by the primary care physician before care is rendered. The gatekeeper is a predominant feature of almost all HMOs.
Governance structure
Governance structure of the medical staff is the organized medical staff.
Governing Board
The individuals, group or agency that has ultimate authority and responsibility for establishing policy, maintaining care quality and providing for organization management and planning; other names for this group include the board, board of trustees, board of governors, board of commissioners, and partners (networks). The governing body is responsible to determine whether to grant, deny, continue, revise, discontinue, limit or revoke specified privileges, including medical staff membership, after considering the recommendation of the medical staff. In all instances the governing’s body determination must be consistent with the established hospital medical staff criteria, as well as state and federal laws and regulations. Only the governing body has the authority to grant a practitioner privileges to provide care in the hospital. Governing body has the ultimate authority for granting privileges in the hospital environment. Governing body determines, in accordance with state law, which categories of practitioners are eligible for appointment to the medical staff.
Group Model HMO
There are two kinds of group model HMOs. The first type of group model is called the closed panel, in which medical services are delivered in the HMO-owned health center or satellite clinic by physicians who belong to a specially formed but legally separate medical group that only serves the HMO. The group is paid a negotiated monthly capitation fee by the HMO, and the physicians in turn are salaried and generally prohibited from carrying on any fee for service practice. In the second type of group model, the HMO contracts with an existing, independent group of physicians to deliver medical care. Usually, an existing multi-specialty group practice adds a prepaid component to its fee for service mode and affiliates with or forms an HMO. Medical services are delivered at the group’s clinic facilities (both to fee fee-for service patients and to prepaid HMO members). The group may contract with more than one HMO.
Group or Network HMO
An HMO that contracts with one or more independent group practice to provide services to its members in one or more locations.
Group Practice
The American Medical Association defines group practice as three or more physicians who deliver patient care, make joint use of equipment and personnel, and divide income by a prearranged formula.
GSA
General Services Administration GSA is the centralized procurement for the federal government offering products, services and facilities that federal agencies need to serve the public. GSA offers businesses the opportunity to sell billions of dollars worth of products and services to federal agencies.
Guaranteed Eligibility
A defined period of time (3-6 months) that all patients enrolled in prepaid health programs are considered eligible for Medicaid, regardless of their actual eligibility for Medicaid. A state may apply to HCFA for a waiver to incorporate this into their contracts.
HA Health Alliances
Regional alliances may be nonprofit corporations, independent state agencies or agencies of state government, appointed by statewide councils composed of representative of employer and consumer organizations. If the individual does not choose a health plan within 30 days, the alliance assigns the individual to the lowest-cost plan available.
DEA registration
high abuse potential: no medical use (I)
DEA registration 2
High abuse potential with dependence liability (II)
DEA registration 3
less abuse potential, moderate dependence? (III)
What is a committee of the whole?
the medical staff as a whole carries out the governance functions
When did the organized medical staff get it’s start?
1917
Who published the “hospital standards”?
American College of Surgeons
What federal system is a list of individuals and firms excluded by federal government agencies from receiving federal contracts or federally approved subcontracts and from certain types of federal financial and nonfinancial assistance and benefits?
EPLS
What is statuary law?
legislation passed by democratically elected state legislatures and federal congress
DEA 4
DEA: less abuse potential, limited dependence (IV)
Subsidiary motions include
1) Lay on the table 2) previous question (and debate) 3) commit or refer (committee)
DEA 5
Limited abuse potential (V)
Motions are ranked in the following order
1) privileged 2) subsidiary 3) main
HIPPA regulations are divided into four standards or rules
1) security 2) identifiers 3) transactions and code sets 4) privacy
A main motion
brings an item of business to the body for consideration
CMS criteria for selection to the medical staff
character, competence, training, experience, judgement
The three main reasons for credentialing are
1) patient safety 2) risk management concerns 3) required by accrediting and regulatory agencies
What does COPs stand for?
Medicare Conditions of Participation - the COPs are contained in the code of federal regulations are intended to protect patient health and safety and to ensure quality of care for hospitalized patients.
Why get accredited?
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.
Other reasons to become accredited?
1) may favorably influence liability insurance premiums 2) may be required in order to obtain managed care contracts 3) employers and unions may require accreditation for providing health care coverage to employers.
After CMS approves an Accreditor they are given deemed status, name the accreditors that have deemed status:
1) the joint commission (tjc) 2) american osteopathic association health facilities accreditation program (AOA-HFAP) 3) det norske veritas healthcare inc (DNV) 4) national integrated accreditation for healthcare organizations (NIAHO) 5) National committee for quality assurance (NCQA) 6) URAC 7) Accreditation association for ambulatory health care (AAAHC)
What is compliance?
participate in the development implementation, an ongoing assessment of bylaws, rules and regulations, policies and procedures to ensure continuous compliance with accreditation regulatory standards.
What is the MSO?
Medical staff organization - although various regulatory agencies and accreditation bodies require certain organizational components, the formal structure and specific operational mechanisms are at the discretion of the MSO and governing body of the healthcare organization.
What are the functions of the MSO?
Providing patient care, evaluation of the quality of patient care, maintenance of the MSO.
What is the Medical staff?
It is a self governing entity which exists as an extension of the healthcare facility.
How is the medical staff structured?
the organizational structure of the medical staff as delineated in it’s bylaws defined the framework within which medical staff appointees act and interact in hospital related activities.
Bylaws - why are they written?
bylaws are written to conform to generally accepted guidelines for broad content categories, they ensure compliance with legal requirements and accreditation and regulatory agencies.
Why review your bylaws?
bylaws are reviewed and appropriate amendments are essential to keep up with changes in accreditation standards and regulatory requirements.
How often should your bylaws be reviewed?
typically MSO’s make provision for at least a biennial review of the bylaws.
Bylaws committee-purpose
the purpose of the bylaws committee is to review the bylaws and to make recommendations to the medical staff’s executive committee (MEC).
When do bylaw changes go into effect?
bylaw changes are adopted by majority vote of the medical staff. bylaw changes are not effective until approved by the governing body.
What should be in your bylaws?
bylaws should include all items necessary to provide a basic framework for the MSO and to fulfill requirements of the law, regulatory agencies, and accreditation bodies. Also some states have specific requirements for elements to be included in bylaws.
Detail what medical staff appointees may or may not do. Such as requirements for specific clinical processes, rules of each clinical department, requirements for ER coverage, guidelines for obtaining consultation, membership dues, provisions for leave of absense, medical records completion, community call coverage requirements, meeting attendance, and other staff responsibilities and prerogatives.
Rules and Regulations
How can changes be made for rules and regulations for individual departments?
the medical staff may delegate the authority for changing the rules and regulations to the MEC
Describe the course of conduct or action pursued or the management of a matter in certain circumstances. Policies are often used to address internal matters and may be subject to frequent change. The medical staff may delegate the authority for changing the rules and regs to the MEC.
Policies and procedures
Why should MSPs be familiar with the regs and accreditation standards that apply to their organization?
it is a good idea to audit bylaws, rules, regs and policies to make sure that they comply with state regs and accreditation standards.
Who gets credentialed?
Hospitals governing body and medical staff define medical staff membership criteria in the bylaws.
Who do the credentialing standards apply to?
They apply to all licensed practitioners or groups of practitioners who provide care to the organizations members.
What criteria must the bylaws include to meet COPs requirements?
Your bylaws must describe the qualifications required of a candidate in order for the medical staff to recommend appointment by the governing body.
Main Motion
This motion introduces items to membership for consideration and cannot be made when any other motion is on the floor.
Subsidiary Motion
This motion changes or affects how a main motion is handled. Subsidiary motion is voted on before a main motion.
Call for order of the day
A request to follow the agenda
Privileged motion
This motion brings up items that are urgent - unrelated to pending business. Take precedence over all other motions.
A motion to divide the assemble
A more explicit type of vote (show of hands)
Incidental motions
Resolve particular questions that arise in connections with the assembly’s conduct of business. They take priority over main motions.
Incidental motions to include:
10 things - objection to considerations, point of order, request for information, parliamentary inquiry, request to withdraw a motion, motion to determine manner of voting, request for division of a question, request for division of the assembly, appeal of a ruling from the chair and a motion to suspend a rule.
Main motions
bring an item of business to the assembly for consideration.
Negligent Tort has 4 elements, what are they?
1) Duty to exercise due care; standard of care, 2) Breach of Duty, 3) Injury (no injury - no liability) 4) Proximate cause, injury must be caused by breach of duty.
Recall Motions
to correct inadvertent errors reexamine actions on proposals and reverse them. 2 types of motions
Secondary Motions
Facilitate the discussion of main motions and are divided into privileged, subsidiary, incidental, and recall motions.
Requirements for appointment are called
criteria-reflective of education, training, current competence, health status and licensure.
External Criteria
set by forces outside the organization, accrediting & certifying bodies such as JC, NCQA, state and federal regulations such as CMS.
Internal Criteria
Defined by the hospitals medical staff and governing board of the MCO’s board.
Do MCO’s utilize bylaws?
No MCO’s use policies and procedures to delineate required functions.
What do rules and regulations describe?
what medical staff appointees may or may not do
What do policies and procedures describe?
The course of conduct or action pursued or the management of a matter in certain circumstances
The Medical staff may delegate the authority to whom for changing the rules and regulations?
The MEC
Reasons for credentialing?
Patient Safety; Risk Management Concerns; Required by accrediting & Regulatory Agencies
Where are COPs contained?
Code of Federal Regulations
Who gets credentialed at Hospitals?
All hospital accreditation standards require the medical staff membership criteria be defined in the medical staff bylaws in compliance with state regulations. The hospital may choose to allow both licensed independent practitioners and other non-independent practitioner appointment to the medical staff.
Minimum criteria for appointment to the medical staff/granting of medical staff privileges to include:
C: Character, C: Competence, T: Training, E: Experience, J: Judgement
How many member boards and specialties and subspecialties does the ABMS have?
24 Member boards, 145 Specialties and Subspecialties
What prohibits unlawful employment discrimination based on race or color, religion, gender and national origin?
the civil rights act of 1871
What is current competence?
a determination of an individual’s capability to perform up to defined expectations
Which accreditation standards address consent and release for credentialing?
none
The release form should permit release of?
1) professional evaluations; 2) information from insurance carriers; 3) information from hospitals licensure boards, certification boards, insurance plans, etc.
CAMH
Comprehensive Accreditation Manual for Hospitals
Urology Cert
Female Pelvic Medicine and Reconstructive Surgery, Pediatric Urology
USMLE
United States Medical Licensing Exam
Utilization
The frequency with which a benefit is used. For example, utilization may be reported as 3,200 doctor’s office visits per 1,000 HMO members per year. Utilization experience multiplied by the average cost per unit of service delivered equals captitated costs.
Utilization Management
The examination and evaluation of the appropriateness of the utilization of an organization’s resources. Also referred to as utilization review.
A process that measures use of available resources (including professional staff, facilities, and services) to determine medical necessity, cost effectiveness, and conformity to criteria for optimal use.
The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria.
Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidleines and under the provisions of an applicable health benefits plan. Utilization management describes proactive procedures, including discharge planning, case management, utilization review, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient.
Utilization Review
The review of services delivered by a healthcare provider to determine whether, according to pre-established standards, the services were medically necessary.
VISA’s
J1-Exchange visitor physician, H1B - Specialty Occupation worker-employer, F-1 Student (enrolled as degree/non-degree student/no patient care, J2-dependent, B1 visitor - no patient contact, 6 month max no compensation, J-1 Research Scholar: incidental patient contact, H1B: Physicians of national or international renown. O1: Extraordinary ability: advanced subspecialist
Information on visa eligiblity and deadlines is available from ECFMG Exchange Visitor Sponsorship program.
Voir dire
“to look and say” the plaintiff has the ability to review the hearing panel to determine conflict of interest, economic competition.
Void
A retraction of a report in its entirety. Voided reports are not disclosed in response to queries, including self-queries and practitioners. Reports may be voided only by the reporting entity or the secretary of HHS through secretarial review.
Withhold
A percentage of payment to the provider held back by the HMO until total cost of referral or hospital services has been determined. Physicians exceeding the amount determined as appropriate by the HMO lose the amount held back. The amount of withhold returned depends on individual utilization by the gatekeeper, financial indicators for the overall capitated plan and referral patterns through the year by the gatekeeper, groups or physicians or the overall plan pool.
Work History: JC
At the time of appointment to membership and initial granting of privileges, verification of relevant training or experience must be obtained from primary source (s) whenever feasible. The hospital requirements are to evaluate voluntary or involuntary termination of medical staff membership and voluntary or involuntary limitation, reduction or loss of clinical privileges. “Simply verifying affiliation would not meet these requirements. If you ask the questions of the applicant, usually in the application and the applicant’s answers do no conflict with the information obtained when you query the NPDB, then there is no need to contact the other facilities or licensing/registration bodies. You would only need to contact them if the information conflicts.
CPD was CEC
Continuing Professional Development Education (CPD) - All required CPD credits must be earned during the physician’s biennial license renewal cycle. All licenses are renewed on the physician’s birth date every two years. It is not necessary to earn a specified number of CPD credits during each year of the two year cycle, or during any calendar year, so long as the full CPD requirement is met during the two year license renewal period. (CPD was CEC - continuing education credit); How many CPD are required? during each two year licensing cycle, you must earn a minimum of 100 credit hours, at least 40 of which must be in category 1. the remainder may be in category 1 or 2. Please note: the new requirements outlined below are effective February 1, 2012. In order to renew your medical license: 1) all physicians must have completed two (2) credits of CPDs in end of life care issues, and 2) any physician that prescribes controlled substances must have completed 3 credits of CPDs in opiod and pain management.
ACCME
Accreditation Council for Continuing Medical Education - education joint commission resources is accredited by the accreditation council for continuing medical education to provide continuing medical education for physicians. Joint Commission Resources takes responsibility for the content, quality, and scientific integrity of this CME activity. Joint Commission resources designates this educational activity for the list contact hours of AMA PRA Category 1 Credit (s). Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Main Motions
The purpose of a main motion is to introduce items to the membership for their consideration. They cannot be made when any other motion is on the floor, and yield to privileged, subsidiary, and incidental motions.
Subsidiary Motions
Their purpose is to change or affect how a main motion is handld, and is voted on before a main motion.
Privileged Motions
Their purpose is to bring up items that are urgent about special or important matters unrelated to pending business.
Incidental Motions
Their purpose is to provide a means of questioning procedure concerning other motions and must be considered before the other motion.
Point of Privilege
Pertains to noise, personal comfort, etc. - may interrupt only if necessary.
Parliamentary Inquiry
Inquire as to the correct motion to accomplish a desired result, or raise a point of order.
Point of Information
Generally applies to information desired from the speaker: “I should like to ask the speaker a question”.
Orders of the Day (agenda)
a call to adhere to the agenda (a deviation from the agenda requires suspending the rules)
Point of Order
Infraction of the rules, or improper decorum in speaking must be raised immediately after the error is made.
Main Motion
Brings new business (the next item on the agenda) before the assembly.
Divide the question
Divides a motion into two or more sperate motions (must be able to stand on their own).
Limit debate
closing debate at a certain time, or limiting to a certain period of timeLa
Lay on the table
Temporarily suspends further consideration/action on pending question; may be made after motion to close debate has carried or is pending.
Take from the table
Resumes item previously “laid on the table” state the motion to take from the table.
Reconsider
Can be made only by one on the prevailing side who has changed position or view.
Postpone Indefinitely
Kills the question/resolution for this session/exception: the motion to reconsider can be made this session.
Previous Question
Closes debate if successful - may be moved to “close debate” if preferred.
Postpone to a Certain Time
State the time the motion or agenda item will be resumed.
Object to Consideration
Objection must be stated before discussion or another motion is stated.
Informal Consideration
Move that the assembly go into “Committee of the whole” informal debate as if in committee; this committee may limit number or length of speeches or close debate by other means by a 2/3 vote. All votes, however, are formal.
Appeal Decision of the Chair
Appeal for the assembly to decide - must be made before other business is resumed; NOT debatable if relates to decorum, violation of rules or order of business.
Suspend the rules
Allows a violation of the assembly’s own rules (except constitution); the object of the suspension must be specified.
Consider by Paragraph
Adoption of paper is held until all paragraphs are debated and amended and entire paper is satisfactory; after all paragraphs are considered, the entire paper is then open to amendment, and paragraphs may be further amended. Any preamble can not be considered until debate on the body of the paper has ceased.
Amend
Inserting or striking out words or paragraphs or substituting whole paragraphs or resolutions.
Withdraw/Modify Motion
Applies only after question is stated; mover can accept an amendment without obtaining the floor.
Commit/Refer/Recommit to Committee
State the committee to receive the question or resolution; if no committee exists include size of committee desired and method of selecting the members (election or appointment).
Extend Debate
Applies only to the immediately pending question; extends until a certain time or for a certain period of time.
ADA
Americans with Disabilities Act
AHP
Allied Health Provider
AMA
American Medical Association
Certified Provider Credentialing Specialist (CPCS)
Typically employed or contracted by a healthcare organization including, but not limited to, hospitals (health systems), health plans, ambulatory care settings, group practices, and credentialing verification organizations.
HP
Health Plan
MBHO
Managed Behavioral Healthcare Organization;
HP’s and MBHO’s must have documented credentialing policies and procedures that apply to all practitioners who provide care to the organization members.
Initial appointment, clinical privileges, practitioners covered according to the NCQA
Breach of Duty
a breach of duty is a legal concept that occurs when someone fails to act with the level of care that a reasonable person would have used in similar circumstances, resulting in harm. It is a key component in personal injury cases, specifically used to establish negligence.
Centers for Medicare & Medicaid Services (CMS)
this government organization is a division of the US Dept. of Health & Human Services. CMS does not directly survey healthcare organizations rather, it surveys them through state organizations, such as the dept. of health. CMS develops the COPs that healthcare organizations must meet to begin and maintain participation in the Medicare and Medicaid programs.
The Joint Commission
this organization offers accreditation programs for a variety of health-care entities, including hospitals, freestanding ambulatory care facilities, office based surgery practices, behavioral healthcare facilities, critical access hospitals, long-term care organizations, homecare organizations, laboratory and point of care testing facilities, and disease-specific services, such as stroke, total joint, etc.
National Committee for Quality Assurance (NCQA)
This organization has established credentialing standards and offers accreditations that are applicable to health plans, managed behavioral healthcare organizations, credentials verification organizations, physician organizations, and hospitals.
DNV
Det Norske Veritas; this organization was granted deeming status by CMS in 2008. Hospitals must comply with its national integrated accreditation for healthcare organizations (niaho) standards to receive accreditation. Unlike other accrediting organizations, DNV’s standards integrate compliance with the international organization for standardization (ISO) 9001 quality management system.
Accreditation Commission for Health Care (ACHC)/Healthcare Facilities Accreditation Program (HFAP)
In october of 2020, ACHC and HFAP merged to form a single company. HFAP operates under the ACHC brand. ACHC has CMS deeming authority for home health, hospice, renal dialysis, home infusion therapy, and durable medical equipment, prosthetics, orthotics & suppliers (DMEPOS). The newly expanded ACHC adds HFAP programs with CMS deeming authority for hospitals, ambulatory surgery centers, clinical laboratories, and critical access hospitals.
AAAHC - Accreditation Association for Ambulatory Health Care
this organization primarily accredits freestanding ambulatory care centers such as surgery centers, birthing centers, lithotripsy centers, and pain management centers. It also accredits group practices, managed care organizations, and independent physician organizations.
URAC (formerly known as Utilization Review Accreditation Commission)
URAC sets the standard nationally to meet the pressing need of health plans to conduct utilization review. URAC accredits programs such as health and dental plans, digital health and telehealth, pharmacy, mental health/substance use disorder party, patient care management, and administrative management (eg patient-centered medical home management, independent review organization, credentials verification organization, etc.)
BPHC
Bureau of Primary Health Care
HRSA
Health Resources and Services Admin
AAAASF
American Association for Accreditation of Ambulatory Surgery Facilities
AAAHC
Accreditation Association for Ambulatory Health Care
AACOM
American Association of Colleges of Osteopathic Medicine
AADE
American Association of Dental Examiners
AAEM
American Academy of Emergency Medicine
AAFP
American Academy of Family Physicians
AAHP
American Association of Health Plans
AAMC
Association of American Medical Colleges
AAMEDA
American Academy of Medical Administrators
AAMSE
American Association of Medical Society Executives
AANA
American Association of Nurse Anesthetists
AAPA
American Academy of Physician Assistants
AAPI
American Association of Physicians of Indian Origin
AAPS
American Association of Physician Specialists
AAPM
American Academy of Pain Medicine
AAOE
American Association of Osteopathic Examiners
ABFM
American Board of Family Medicine
ABIM
American Board of Internal Medicine
ABMS
American Board of Medical Specialties
ABO
American Board of Otolaryngologists
ABPM
American Board of Pain Medicine
ABPMR
American Board of Physical Medicine and Rehabilitation
ABPN
American Board of Psychiatry and Neurology, Inc.A
ABPS
American Board of Physician Specialties
ABS
American Board of Surgery
ACA
American Chiropractic Association
ACAM
American College for Advancement in Medicine
ACCME
Accreditation Council for Continuing Medical Education
ACEP
American College of Emergency Physicians
ACGME
Accreditation Council for Graduate Medical Education
ACLS
Advanced Cardiac Life Support
ACMC
Association of Faculties of Medicine of Canada
ACOEP
American College of Osteopathic Emergency Physicians
ACOFP
American College of Osteopathic Family Physicians
ACOI
American College of Osteopathic Internists
ACOOG
American College of Osteopathic Obstetricians and Gynecologists
ACOS
American College of Osteopathic Surgeons
ACPC
Assessment Center Program Committee
ACP
American College of Physicians
ACPE
American College of Physician Executives
ACS
American College of Surgeons
ADA
Americans with Disabilities Act
AHA
American Hospital Association
AHD
American Hospital Directory
AHME
Association for Hospital Medical Education
AHP
Allied Health Professional
AHRQ
Agency for Healthcare Research & Quality
AIM
Administrators in Medicine
ALP
All licensed physicians
AMA
American Medical Association
ANCC
American Nurses Credentialing Center
AOA
American Osteopathic Association
AODME
American Assoc. Of Osteopathic Directors of Medical Educators
APA
American Psychiatric Association
APS
American Pain Society
APRN
Advanced Practice Registered Nurse (also known as: ARNP)
ARC-PA
Accreditation Review Commission on education for the Physician Assistant
ASA
American Society of anesthesiologists
ASAE
American Society of Association Executives
ASLME
American Society of Law Medicine and Ethics
ATLS
Advanced Trauma Life Support
BLS
Basic Life Support
BOD
Board of Directors
BOS
Bureau of Osteopathic Specialists (AOA)
BOT
Board of Trustees
CAAHEP
Commission on Accreditation of Allied Health Education Programs
CAC
Citizens Advocacy Center
CAM
Complementary and Alternative Medicine
CBT
Computer Based Testing
CCS
Computer Based Case Simulations
CARF
Commission on Accreditation of Rehabilitation Facilities
CAQH
Council for Affordable Quality Healthcare
CDC
Centers for Disease Control & Prevention
CEJA
Council on Ethics & Judicial Affairs of the AMA
CFC
Conditions for Coverage CMS also known as Conditions of Participation
CFPC
College of Family Physicians of Canada
CGFNS
Commission on Graduates of Foreign Nursing Schools
CHAP
Community Health Accreditation Program
CJA
Clinical Judgement Analysis
COP
Conditions of Participation (centers for Medicare & Medicaid)
CMA
Christian Medical Associations
CMDA
Christian Medical Dental Association
CME
Continuing Medical Education
CMS
Centers for Medicare & Medicaid
COCA
Commission on Osteopathic College Accreditation
COP
Conditions of Participation (CMS Standards)
COPT
Council on osteopathic post-doctoral training
CPE
Coalition for Physician Enhancement
CPEP
Center for Personalized Education for physicians
CPD
Continuing Professional Development
CPPA
Center for Patient and Professional Advocacy
CRAF
Conclusions, Recommendations, Actions, Follow up - format used for documenting minutes of a meeting
CRNA
Certified Registered Nurse Anesthetist
CSAT
Center for Substance Abuse Treatment
CSE
Clinical Skills Examination
DEA
Drug Enforcement Administration
DHHS
Department of Health and Human Services
DHS
Department of Homeland Security
DOC
Department of Commerce
DOD
Department of Defense
DMAT
Disaster Medical Assistance Team
DMQ
Disaster Management Qualified
DNV
DNV Accreditation (Det Norske Veritas) - “the norwegian truth”
EAP
Employee Assistance Program
ECFMG
Educational Commission for Foreign Medical Graduates
EEOC
Equal Employment Opportunities Commission
EMT
Emergency Medical Technician
EP
Element of Performance (the joint commission requirements under each standard)
ERAS
Electronic residency application services
ESAR - VHP
The Emergency System for the Advanced Registration of Volunteer Health Professionals
EUC
Edge u Cate
FACIS
Fraud and Abuse Control Information System
FAMIR
Foundation for Advancement of International Medical Education and Research
FAQ
Frequently Asked Questions
FCLB
Federation of Chiropractic Licensing Boards
FCVS
Federation Credentials Verification Service
FDA
Food & Drug Administration
Flex
Federation Licensing Examination
FPMB
Federation of Pediatric Medical Boards
FPPE
Focused Professional Practice Evaluation (term used by the joint commission)
FR
Federal Register
FSMB
Federation of State Medical Boards
FTC
Federal Trade Commission
GAO
General Accounting Office
HCQIA
Healthcare Quality Improvement Act, 1986
HFAP
Healthcare Facilities Accreditation Program
HHA
Home Health Agency
HIPAA
Health Insurance Portability and Accountability Act of 1996
HIPDB
Health care integrity and protection data base
HMO
Health Maintenance Organization
HQA
Hospital Quality Alliance
HRSA
Health Resources & Services Administration
IBT
Internet Based Testing
ICE
Immigration and Customs Enforcement
ICHP
International Commission on Healthcare professions
IMED
International Medical Education Directory
IMG
International Medical Graduate
IOM
Institute of Medicine
IRB
Institutional Review Board - Committee charged with reviewing applications for medical investigations on humans
ISO
International Standards Organization
JCAHO
The Joint Commission (JCAHO - old acronym)
LCME
Liaison Committee on Medical Education
LIP
Licensed Independent Practitioner
LTC
Long term care
MCPME
Ma coalition for prevention of medical errors
MILT
Military Personnel Records Center
MOC
Maintenance of Certification
MRC
Medical Reserve Corp
MSP
Medical Service Professional
NABP
National Association of Boards of Pharmacy
NAMSS
National Association of Medical Staff Services
NASCSA
National Association of State Controlled Substances Authorities
NBME
National Board of Medical Examiners
NBOME
National Board of Osteopathic Medical Examiners
NCCPA
National Commission on Certification of Physician Assistants
NCF
National Credentialing Forum
NCFMEA
National Committee on Foreign Medical Education and Accreditation
NCQA
National Committee for Quality Assurance
NDMS
National Disaster Medical System
NIAHO
National Integrated Accreditation for Healthcare Organizations
NCQA
National Committee on Quality Assurance
NCBSN
National Council of State Boards of Nursing
NPDB
National Practitioner Data Bank
NPSD
Network of Patient Safety Data
NQF
National Quality Forum
OIG
Office of Inspector General
OPPE
Ongoing Professional Practice Evaluation (term used by TJC)
OT
Occupational Therapist
PA
Physician Assistant
PAEA
Physician Assistant Education Association
PALS
Pediatric Advanced Life Support
PAR
Physician Achievement Program (Canadian College of Physicians & Surgeons)
PFP
Pay for Performance
PHS
Public Health Service
Prep
Practitioner Remediation and Enhancement Partnership
PSO
Patient Safety Organization
PSQLA
Patient Safety & Quality Improvement Act of 2005
PSV
Primary Source Verification
PT
Physical Therapist
QIO
Quality Improvement Organization
RCGP
Royal College of General Practitioners
RCPSC
Royal College of Physicians & Surgeons of Canada
RCSE
Royal College of Surgeons of England
RT
Respiratory Therapist
SBAR
Situation, Background, Assessment & Recommendation - a technique for communication
SO: Sarbanes-Oxley Act of 2002
a federal law in the US that mandates certain practices for corporations in financial record keeping & reporting.
SPEX
Special Purpose Examination
TJC
The Joint Commission
URAC
American Accreditation Healthcare Commission
USMLE
United States Medical Licensing Examination
USMLE Step 2
USMLE clinical skills examination (step 2)
USP
United States Pharmacopeia
WFME
World Federation for Medical Education
WHO
World Health Organization
EMTALA
The emergency medical treatment and active labor act is a statute which governs when and how a patient may be (1) refused treatment or (2) transferred from one hospital to another when he is in an unstable condition.
- was passed in 1986 - also known as “the COBRA law”
PHI
Protected Health Information - governing body rules
HIPAA - which of the following methods not acceptable?
(tossing in dumpster0
Harm or Injury
any wrong or damage done to another, either to his/her persoanl rights, person or property.
HCFA
Healthcare Financing Administration: the federal agency formerly responsible for administering Medicare and overseeing states’ administration of Medicaid. On June 14, 2001 the healthcare financing administration (HCFA) announced that it has changed its name to the Centers for Medicare and Medicaid Services. The official acronym is CMS.
HCPS - HCFA Common Procedural Coding System:
A listing of services, procedures, and supplies provided by physicians and other providers. HCPCS includes CPT (current procedural terminology) codes, national alpha-numeric codes and local alpha-numeric codes. The national codes are developed by HCFA/CMS in order to supplement CPT codes. They include physician services not included in CPT as well as non-physician services such as ambulance, physical therapy and durable medical equipment. The local codes are developed by local Medicare carriers in order to supplement the national codes. HCPS codes are digit codes with the first digit being a letter followed by four numbers. HCPS codes beginning with A through V are national and those beginning with W through Z are local.
HCQIA - the Health Care Quality Improvement Act - passed in 1986
Patrick vs Burget case was instrumental in the development of HCQIA
began accepting reports in 1999
made through IQRS - Integrated Querying and Reporting Service
- HCQIA requires that if a hearing is requested, then the place, time and date of hearing-30 days, and list of witnesses must be given to the doctor.
- Peer review protection applies to peer review conduct on MD, DO and Dentists
- this law provides immunity for liability for damages resulting from good faith peer reviews. Created in response to Patrick v Burget, in which reviewers were held liable by the courts for triple damages for “bad faith” peer reviews.
- This federal law was enacted for the purpose of encouraging good faith professional review activities.
- HCQIA requires a query of the NPDB for a physician, dentist or other health care provider at initial appointment, reappointment, and when requesting additional privileges.
- Federal legislation passed in 1986 for the purpose of restricting the ability of incompetent physicians to move from state to state without disclosure or discovery of their prior damaging or incompetent performances. The Act established the National Practitioner Data Bank (NPDB) to which medical and healthcare organizations must report disciplinary actions taken against a practitioner. All healthcare organizations are required to query the NPDB at initial appointment and at reappointment.
Healthcare Delivery System
The system of practitioners, facilities, institutions and programs that deliver health services. This term may also apply to a specific delivery system such as one offered by a health maintenance organization.
Healthcare Programs
Why is it important to check that the practitioner is not currently excluded, suspended, debarred, or ineligible to participate in Federal health care programs? The Facility won’t get paid for treating patients unless service is provided by authorized provider.
Hearsay Rule
Rule of evidence that restricts the admissibility of evidence that is not the personal knowledge of the witness.
Health care entity
A hospital, an entity, or a professional society, that provides health care services and follows a formal peer review process for the purpose of furthering quality health care.
HEDIS: Healthcare Employers Data Information Set
The Health Plan Employee Data and Information Set is a set of performance measures developed to support health plan and Medicaid agency efforts to improve the health status of Medicaid beneficiaries, support the strengthening of health care delivery systems for the Medicaid population, promote standardization of managed care reporting across public and private sectors, and promote the application of performance measurement technology across Medicaid programs.
- A core set of performance measures to assist employer and other health purchasers to compare and understand the actual performance of health plans. This is the so called “report card on healthcare”. The system is currently in its second generation of evolution. 21 managed care plans are now participating in a one-year project in which HEDIS will be utilized to compare performance among plans. It is projected to become a critical marketing tool for health plans.
HFAP: 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.
The accrediting organization for AOA
HFAP requirement
Applicant must provide employment and affiliation. PSV required to include pending investigations, disciplinary actions, voluntary resignations, relinquishment of memberships/privileges and contracts.
Hill Burton Act
provides subsidies for hospitals after WWII. Subsidies for construction/expansion of hospitals and requires the provision of a percentage of free care, passed in 1946.
HIO
An entity that contracts on a prepaid, capitated risk basis to provide comprehensive health services to recipients.
HIPAA
HIPAA Privacy Rule covers protected health information in any medium while HIPAA Security Rule specifically covers Electronic protected health information. (Electronic: EMRs, databases, digital or scanned photographs or documents, etc).
- Both civil and monetary penalties and criminal prosecution penalties may apply to covered entities and individuals who knowingly obtain or disclosed individually identifiable health information.
- Complaints regarding potential HIPAA violations can be filed, either on paper or electronically, with the office of civil rights within 180 days of the date of the complainant.
- the federal health insurance portability and accountability act was enacted by the US congress in 1996. (to combat waste, fraud and abuse in health insurance and health care delivery).
HIPDB: Healthcare Integrity and Protection Databank
contains criminal convictions against a healthcare provider related to the delivery of healthcare, exclusion of a healthcare provider from participation in federal or state healthcare programs, and civil judgements against a healthcare provider related to the delivery of a health care item or service. Clinical privilege actions are reported to the NPDB.
- Data bank created by the Health and Insurance Portability and Accountability Act of 1996, HIPDB is a national healthcare fraud and abuse data collection program for reporting and disclosure of certain final adverse actions taken against healthcare providers, suppliers or practitioners. It was established to combat fraud and abuse in health insurance and healthcare delivery. It contains information related to delivery of healthcare items or service on healthcare providers, suppliers, or practitioners as follows: civil judgements in federal or state courts; federal or state criminal convictions; actions by federal or state agencies responsible for licensing and certification of healthcare providers, suppliers or practitioners; exclusion from participation in federal or state healthcare programs; and any other adjudicated actions or decisions that the Secretary establishes by regulations. Information from the HIPDB is available to federal and state government agencies, health plans, and via self-query for healthcare providers, suppliers and practitioners. Currently there are no mandatory querying requirements.
- HIPDB information is not available to the general public or to hospitals.
HMO: Health Maintenance Organization
An entity that provides, offers or arranges for coverage of designated health services needed by members for a fixed prepaid premium. There are three basic models of HMOs: group model, individual practice association (IPA) and staff model. Originally, an HMO was defined as a prepaid organization that provided healthcare to a voluntarily enrolled member in return for a preset amount of money on a PMPM basis. With the increase in self-insured business, or with financial arrangements that do not rely on prepayment, that definition is no longer accurate. Now the definition encompasses two possibilities: a health plan that places at least some of the providers at risk for medical expenses, and utilizes primary care physicians as gatekeepers (although there are some HMOs that do not).
An organization of healthcare personnel and facilities that provides a comprehensive range of health services to an enrolled population for a fixed sum of money paid in advance. These health services include a wide variety of medical treatments and counsel, inpatient and outpatient hospitalization, home health service, ambulance service, and sometimes dental and pharmacy services. The HMO may be organized as a group model, an individual practice association (IPA), a network model or a staff model.
Hold Harmless
A clause frequently found in managed care contracts, whereby athe HMO and the physician hold each other to not be liable for malpractice or corporate malfeasance if either of the parties is found to be liable. This language does not preclude a managed care company from being sued if one of its physicians is sued. It may also refer to language that prohibits the provider from billing patients in the event a managed care company becomes insolvent. State and federal regulations may require this language.
Hospital Surgery Centers
Assure that only qualified practitioners are granted membership and privileges.
ITP-ICD Transfer Program
ICD transfer program is a program that transmits interface control documents report and query files to and from the NPDB-HIPDB. This is an option used by entities that do not have access to the IQRS.
ICD
Interface Control Document - a file format for the NPDB that represents all components of reports and queries.
Initial report
the original record of a medical malpractice payment or adverse action submitted by a reporting entity.
IBNR
Incurred but not reported; the amount of money that the plan should accrue for medical expenses not yet known, that is, medical expenses that the authorization system has not captured and for which claims have not yet been received. Unexpected IBNRs have caused more problems for managed care plans than any other issue.
ICD-9; International classification of diseases
a listing of diagnoses and identifying codes for reporting diagnosis of health plan enrollees identified by physicians. The coding and terminology provide a uniform language that will accurately designate primary and secondary diagnosis and provide for reliable, consistent communication on claim forms.
Incidental motion
enforce rules - point of order - no vote
submit matter to assembly - appeal from the decision of the chair - majority vote
- suspends rules - I move to suspend the rules which… 2/3 vote
- avoid main motion altogether - I object to the consideration of the question - 2/3 vote
- divide motion - i move to divide the question - majority vote
- demand rising vote - i call for a division - no vote
- parliamentary law question/inquiry - no vote
-request for information - no vote
Incremental cost
The additional cost of a service or program (over time, or serving a larger population) compared with another program.
Incurred claims
A term that refers to the actual carrier liability for a specified period and includes all claims with dates of service within a specified period, usually called the experience period. Due to the time lag between dates of service and the dates claims payments are actually processed, adjustments must be made to any paid claims data to determine incurred claims.
Incurred claims loss ration
the result of incurred claims divided by premiums; a defined time period is usually specified
indemnity
a benefit paid by an insurance company for an insured loss
Indicator
a measure used to determine, overtime an organization’s performance of functions, processes and outcomes.
Individual stop-loss coverage
a practice in experience rating which isolates claim amounts per individual over a defined level (e.g. # 30,000). These isolated or pooled amounts are charged to a pool funded by the pool charges of all groups who share this same pooling level. Pooling large claim amounts helps stabilize significant premium In-fluctuations more prominent with small group sizes. Smaller groups generally will have lower pooling points and larger groups will have larger pooling points.
Infection Control Program or Process
an organization-wide program or process, including policies and procedures, for the surveillance, prevention, and control of infection.
Information Management
In a hospital, managed care company, physician office, CVO you have to have a process to manage and maintain information and documents. Documents include paper documents and electronic documents.
Database
a database is a collection of information organized so that it can easily be accessed, managed, and updated. Databases, can be classified according to types of content: bibliographic, full-text, numeric, and images. Computer databases contain data records or files. Typically, a database manager provides users the capabilities of controlling read/write access, specifying report generation, and analyzing usage.
SQL: (Structured Query Language) is a standard language for making interactive queries from and updating a database.
TJC IM Standard: staff and licensed independent practitioners, selected by the hospital, participate in the assessment, selection, integration, and use of information management systems for the delivery of care, treatment and services.
Software Programs
healthcare types - credentialing, quality, risk management, computerized physician order entry (CPOE), electronic medical record (EMR), stand alone or combined/integrated questions to ask:
will your data import to new software (data/audits/cleanup)
define customer support/training onsite - online
hardware requirements
frequency of upgrades
type of report writer - user friendly, extra training required, access to other companies who have purchased software, when considering purchase of software, include information management on review team.
Information Technology
IT services would be involved in the selection of credentialing software
Initial appointments
peer joint commission, initial appointments to the medical staff cannot exceed 2 years (now 3)
Inpatient
an individual who has been admitted to a hospital as a registered bed patient and is receiving services under the direction of a physician for at least 24 hours.
Insolvency
A legal determination occurring when a managed care plan no longer has the financial reserves or other arrangements to meet its contractual obligations to patients and subcontractors.
Integrated delivery system
A generic term referring to a joint effort/joint venture of a physician/hospital integration for a variety of purposes. Models include physician hospital organizations, group practice without walls, management service organizations and medical foundations.
Intent of Standard
A scorable, brief explanation of a standard’s rationale, meaning, and significance.
Internal Criteria
Internal criteria for membership are those factors defined by the hospitals medical staff and governing board, or the MCO’s board. this criteria may include board certification, office within a certain distance from the institution, alternate coverage, need for particular specialty, application fee, minimum amounts for professional liability insurance, etc.
Internal Medicine Certification
Adolescent Medicine
Adult Congenital Heart Disease
Advanced Heart Failure and Transplant Cardiology
Cardiovascular Disease
Clinical Cardiac Eletrophysiology
Critical Care Medicine
Endocrinology, Diabetes and MEtabolism
Gastroenterology
Geriatric Medicine
Hematology
Hospice and Palliative Medicine
Infectious Disease
Interventional Cardiology
Medical Oncology
Nephrology
Pulmonary Disease
Rheumatology
Sleep Medicine
Sports Medicine
Transplant Hepatology
Interragatories
A part of the discovery process in which written questions are given to the opposing parties in a lawsuit to get written facts and answers given under oath to questions put forth
IPA; Independent Practice Association
Under this structure physicians practicing in their own office participate in a prepaid healthcare plan. The physicians agree upon rates to enroll patients and bill the IPA on a fee for service basis.
An organization that has a contract with a managed care plan to deliver services in return for a single capitation rate. The IPA, in turn, contracts with individual providers to provide the services either on a capitation basis or on a fee for services basis.
IPA Model
An HMO that contracts with individual practitioners or an association of individual practices to provide health care services in return for a negotiated fee. The individual practice association, in turn, compensates its physicians on a per capita, fee schedule or other agreed basis.
A healthcare model that contracts with an individual practice association entity to provide healthcare services in return for a negotiated fee. The individual practice association, in turn, compensates its physicians on a per capita, fee schedule, or fee for service basis.
IQRS; Integrated Querying and Reporting Service
An electronic, internet-based system for querying and reporting to the NPDB and the HIPDB.
IRB; Institutional Review Board
An institutional review board (IRB) is required by the Food and Drug administration (FDA) for any hospital conducting investigations on human subjects or drugs or medical devices regulated by the FDA.
Institution review boards - protect human subjects of clincial trials. IRB’s are overseen by the FDA. The IRB reviews and monitors bio-medical research involving human subjects. Assures that appropriate steps are taken to protect the rights and welfare of humans participating as subjects in research.
J1 Visa
J1-temporary, non-immigrant visa, full time education/training/not employment. Obligated to reside in the home country for at least 2 years before being eligible to obtain certain non-immigrant visas or adjustment to permanent resident status. Requires ECFMG certification.
JC
The organized medical staff has a leadership role in the organization performance improvement activities to improve quality of care, treatment, and services and patient safety.
An independent not for profit organization dedicated to improving the quality of care in organized healthcare settings. Founded in 1951, its members are the American College of Physicians, the American College of Surgeons, the American Dental Association, the American Hospital Association, and the American Medical Association. The major functions of the joint commission include developing accreditation standards, awarding accreditation decisions, and providing education and consultation to healthcare organizations.
JC requirements
evidence of current competence is required and TJC expects organization to obtain information regarding licensure, education, training, experience and competence. Doctor should provide chronological history of his education, training and experience on application.
Job lock
Staying in a job out of fear of losing health insurance coverage. Re-existing condition waiting periods, high rates and denials plague individuals applying for new policies. Job lock represents a major hidden cost of the current system.
Kilt main motion
I move that the motion be postponed indefinitely-majority vote.
Lag study
A report that tells managers how old the claims being processed are and how much money is paid out monthly (both for the current month and for any earlier months). These items are then compared to the amount of money being accrued for expenses each month. This powerful tool is used to determine whether the plan’s reserves are adequate to meet all expenses.
Laundry List
An exhaustive listing of individual procedures or conditions that a practitioner may request to perform in a healthcare organization
Lay aside temporarily
I move to lay the question on the table - majority vote
Leaders (Joint Commission)
The leaders described in the leadership function include at least the leaders of the governing body, the chief executive officer and other senior managers, department leaders, the elected and the appointed leaders of the medical staff and the clinical departments and other medical staff members in organizational administrative positions, and the nurse executive and other senior nursing leaders.
Liability
an obligation one has incurred or might incur through any act or failure to act. As it relates to damages, an obligation one has incurred or might incur through a negligent act.
License Disciplinary Action
1) revocation, suspension, restriction, or acceptance of surrender of a license.
2) censure, reprimand, or probation of a licensed physician or dentist based on professional competence or professional conduct
Licensing
a process most states employ, which involves the review and approval of applications from HMOs prior to beginning operation in certain areas of the State. Areas examined by the licensing authority include fiscal soundness, network capacity, MIS, and quality assurance. The applicant must demonstrate it, can meet all existing statutory and regulatory requirements prior to beginning operations.
Licensure
licensure following credentials must be tracked on an ongoing basis. state licensure credentials must be tracked on an ongoing basis because licensure will expire and must be kept current.
a legal right that is granted by a government agency in compliance with a statute governing an occupation (such as medicine or nursing) or the operation of an activity (such as in a hospital).
Limit or extend debate
I move that debate be limited to - 2/3 vote
Line of business
refers to source of membership. Members under the age of 64 enrolled through an employee are known as commercial members. Members over age 64 who are Medicare beneficiaries are known as Medicare members.
LIP
LIP or Licensed Independent Practitioner is an individual permitted by law and the organization to provide care without direction or supervision.
Litigation
A trial in court to determine legal issues and the rights and duties between the parties to the litigation.
Lock-in
A contractual provision by which members except in cases of urgent or emergency need, are required to receive all their care from the network health care providers.
Locum Tenens
one practitioner temporarily taking the place of another practitioner.
LOS/ELOS/ALOS
Length of stay, estimated length of stay, average length of stay - the terms all make reference to the number of hospital days.
LOS: Length of Stay: the number of days that a member stayed in an inpatient facility.
Loss ratio
the result of paid claims and incurred claims plus expenses divided by the paid premiums. See also incurred claims loss ration, net loss ration, paid claims loss ration and medical loss ratio.
Medical malpractice payer
an entity that makes a medical malpractice payment through an insurance policy or otherwise for the benefit of a practitioner.
Medical malpractice payment report
the format used by medical malpractice payers to report a medical malpractice payment made for the benefit of a physician, dentist or other health care practitioner.
Malpractice
professional misconduct, improper discharge of professional duties, or failure to meet the standard of care of a professional that results in harm to another. The negligence or carelessness of a professional person, such as a nurse, pharmacist, physician, or accountant.
Managed Care
1) Use of a planned and coordinated approach to providing healthcare with the goal of quality care at a lower cost. Usually emphasizes preventive care and often associated with an HMO.
2) an all encompassing term. at the very least, a system of healthcare delivery that tries to manage the cost of healthcare, the quality of healthcare, and access to care. common denominators include a panel of contracted providers that are less than the entire universe of available providers, some types of limitations of benefits to subscribers who use noncontract providers (unless authorized to do so) and some type of authorization system. Managed healthcare may be described as a spectrum of systems, including so-called managed indemnity, PPOS, POS, open panel HMOs and closed panel HMOs.
3) the term may also apply to indemnity insurers with utilization review. Managed care uses financial incentives to persuade providers not to order unnecessary services, urges patients to use providers in the system and encourages the organization to keep patients as healthy as possible.
4) a method of healthcare cost containment through control of utilization and reimbursement while continuously monitoring quality. In this system, healthcare providers agree to discount their services in exchange for increased patient volume through directed care within a limited provider network.
A system of health care that combines delivery and payment; and influences utilization of services, by employing management techniques designed to promote the delivery of cost-effective health care. Assure that only qualified practitioners are approved to provide services to members.
Managed Health Care Plan
An arrangement that integrates financing and management with the delivery of health care services to an enrolled population. It employs or contracts with an organized system of providers which delivers services and frequently shares financial risk. One or more products which integrate financing and management with the delivery of healthcare services to an enrolled population; employs or contracts with an organized provider network which delivers services and which as a network or individual provider either shares finacial risk or has some incentive to deliver quality cost effective services, uses an information system capable of monitoring and evaluating patterns of members use of medical services and the cost of those services.
Mandated benefits
those benefits which health plans are required by state or federal law to provide to policy holder and eligible dependents.
Mandated providers
providers of medical care, such as psychologists, optometrist, podiatrists and chiropractors, whose licensed services must, under state or federal law, be included in coverage offered by a health plan.
Marginal cost
The additional cost of producing one more unit of outcome. Usually not the same as the average cost. If the marginal benefits are less than the marginal costs, additional treatment represents an inefficient use of resources.
Market share
that part of the total healthcare market potential that a managed care company has captured.
MCO; Managed Care Organization
a generic term applied to a managed care plan. Some people prefer it to the term HMO because it encompasses plans that do not conform exactly to the strict definition of an HMO. It may also apply to a PPO, EPO, or OWA.
Managed Care Organization use policies and procedures to delineate required functions.
Medicaid
A federal program administered and operated individually by participating state and territorial governments which provides medical benefits to eligible low income persons needing healthcare. The costs of the program are shared by the federal and state governments.
Medical Director
Physician responsible for bridging healthcare delivery with management and administration. Major responsibilities include maintaining a provider network, utilization review, and quality assurance.
Medical foundation
a not for profit entity associated with a physician group that provides medical services under a professional services contract. The
foundation acquires the business and clinical assets of the group practice, holds the provider number, and manages the business for both parties.
Medical Genetics and Genomics Certification
Clinical Biochemical Genetics, Clinical Cytogenetics, Clinical Genetics (MO), Clinical Molecular Genetics, Medical Biochemical Genetics, Molecular Genetic Pathology
Medical loss ratio
The cost ratio of health benefits used compared to revenue received. Calculated as: total medical expenses/total revenue.
Medical record Audit
The hospital conducts an ongoing review of medical records at the point of care, based on the following indication: presence, timeliness, eligibility (whether handwritten or printed) accuracy, authentication, and completeness of data and information. The hospital measures its medical record delinquency rate at regular intervals, but no less than every three months.
Medical Record Review
the process of measuring, assessing, and improving the quality of medical record documentation that is, the degree to which medical record documentation is accurate, complete and performed in a timely manner. This process is carried out with the cooperation of relevant departments or services.
Medical staff
a body that has the overall responsibility for the quality of the professional services provided by individuals with clinical privileges and also the responsibility of accounting therefore to the governing body.
the medical staff includes fully licensed physicians and may include other licensed individuals permitted by law and by the organization to provide patient care services independently (that is, without clinical direction or supervision) within the organization. Members have delineated clinical privileges that allow them to provide patient care services independently within the scope of their clinical privileges. See also clinical privileges, licensed independent practitioner.
Medical Staff: JC
According to the Joint Commission, before granting privileges, the medical staff must evaluate: challenges to any licensure or registration, voluntary and involuntary relinquish of license or registration, termination of medical staff membership, limitation, reduction, or loss of clinical privileges, any evidence of an unusual pattern, or an extensive number of professional liability actions resulting in a final judgement against the application.
Medical Staff Bylaws
document required by AOA-HFAP standards describe the qualifications and criteria that must be met by a candidate in order for the medical staff to recommend appointment and privileges to the governing body.
A document that describes the organization, roles and responsibilities of the medical staff. The bylaws are developed, adopted, and periodically reviewed by the medical staff and approved by the governing body.
Medical Staff Executive Committee
A group of medical staff members, a majority of whom are licensed physician members of the medical staff practicing in the organization, selected by the medical staff or appointed in accordance with governing body bylaws. This group is responsible for making specific recommendations directly to the organization’s governing body for approval, as well as receiving and acting on reports and recommendations from medical staff committees, clinical departments or services, and assigned activity groups.
Medical Staff Office
It is a self-governing entity which exists as an extension of the healthcare facility.
Medical Staff Structured
the organizational structure of the medical staff as delineated in its’ bylaws defined the framework within which medical staff appointees act and interact in hospital related activities.
Medicare
was established in 1965 as an amendment to the social security act. Also known as title 18
Title XVII of the Social Security Act, Health Insurance for the Aged. A federal insurance program for persons over 65 years of age.
A nationwide, federally administered health insurance program which covers the cost of hospitalization, medical care, and some related services for eligible persons. Medicare has two parts: part A covers inpatient costs (currently reimbursed prospectively using the DRG system). Medicare pays for pharmaceuticals provided in hospitals, but not for those provided in outpatient settings. Also called supplementary medical insurance program part b covers outpatient costs for Medicare patients. *currently reimbursed retrospectively
Medicare beneficiary
a person who has been designated by the social security administration as entitled to receive medicare benefits
Medicare COPs requirements
regarding medical staff membership, your bylaws must describe the qualifications required of a candidate in order for the medical staff to recommend appointment by the governing body.
Medicare Supplement Policy
A health insurance policy that pays certain cost not covered by Medicare such as coinsurance, deductibles.
Medication Management: JC
The process an organization uses to provide medication therapy to individuals served by the organization. The components of the medication management process include the following: procurement, storage, secure, transcribing, preparing, dispensing, administration.
MEDPAR
Medical Provider Analysis and Review Data - which are collected by the centers for Medicare and Medicaid services (CMS) from hospitals in order for hospitals to receive reimbursement for performed services and procedures.
Member
A participant in a health plan (subscriber/enrollee or eligible dependent) who makes up the plan’s enrollment. Also used to describe an individual specified within a subscriber contract who may or may not receive healthcare services according to the terms of the subscriber policy.
Member category
a group of members classified (usually based on age and used in a capitation environment) to determine physician reimbursement levels. At a minimum, the categories are pediatrics, adults, and Medicare. Also called member type.
Member Month
A unit of volume measurement. A member month is equal to one member enrolled in an HMO for one month, whether or not the member actually receives any services during the period. Two member months are equal to one member enrolled for two months or two members enrolled one month. Many internal operating statistics for HMOs are expressed in terms of members months.
Membership Criteria
Hospitals governing body and medical staff define medical staff membership criteria in the bylaws.
MESH
Medical Staff Hospital Organization
Minutes
Minutes should generally reflect meeting name, time/location of meeting, names/titles of attendees topic, discussions/conclusions, recommendations, follow-up required
MIS; Management Information System
the common term for the computer hardware and software that provides the support for managing the plan.
Mixed Model
A managed care plan that mixes two or more types of delivery systems. This has traditionally been used to describe an HMO that has both closed and open panel delivery systems.
MLP; Mid Level Practitioner
Non-physicians who deliver medical care, generally under the supervision of a physician but for less cost physician’s assistants, clinical nurse practitioners, and nurse midwives are included in this group.
MOC: Maintenance of Certification
Four past process for continuous learning
Part I: licensure and professional standing (holds a valid, unrestricted medical license)
Part II: lifelong learning and self-assessment (educational and self-assessment programs determined by Member Boards)
Part III: Cognitive Expertise (demonstrate specialty-specific skills and knowledge)
Part IV: Practice performance assessment (demonstrate/use of best evidence and practices compared to peers and national benchmarks).
Modified Community Rating
A separate rating of medical service usage in a given geographic area (community) using age, sex, data, etc.
Modify wording of motion
I move to amend the motion by - majority vote
Morbidity Rate
An actuarial term that measures the likelihood of medical care expenses occurring. The ability to accurately predict how many customers will get sick and what diseases they will get sick with helps insurers predict how much money they will spend to provide treatment for insurance customers. Thus, accurate morbidity rates are crucial for keeping insurance companies in business. Morbidity rate should not be confused with mortality rate, which is the frequency of death in a given population.
Mortality Rate
An actuarial term that measures the pro-liability of death occurring.
MOS - Measure of Success
A numerical or quantifiable measure usually related to an audit that determines if an action was effective and sustained. An MOS report is due four months after Evidence of Standards Compliance. (ESC)
Motion
Motions: a method used by members to express themselves. A motion is a proposal that the entire membership take action or a stand on an issue.
Motion to bring question again
Take matter from table - I move to take from the table - majority vote
Motion to bring question again
reconsider motion - I move to reconsider the vote - majority vote
Motions
four basic types of motions:
1) main motions - purpose to introduce items to the membership for consideration
2) Subsidiary motions - purpose is to change or affect how a main motion is handled, and is voted on before a main motion.
3) Privileged motions - purpose is to bring up items that are urgent about special or important matters unrelated to pending business
4) Incidental motions - purpose is to provide a means of questioning procedure.
MSO; Medical Staff Organization
although various regulatory agencies & the accreditation bodies require certain organizational components, the formal structure and specific operational mechanisms are at the discretion of the MSO and governing body of the healthcare organization.
Function of the MSO: providing patient care, evaluation the quality of patient care, maintenance of the MSO.
MSO - Joint Commission
Must evaluate challenges to any licensure or registration, involuntary or voluntary relinquishment of any license or registration, or medical staff membership. voluntary and involuntary limitation, reduction, or loss of clinical privileges. Challenges to any licensure or registration.
MSO: Managed Service Organization
An MSO is an entity that is legally seperate from the hospital or physician entity and in some circumstances, from the PHO. The MSO functions in some situations simply as a practice site, including supplies, personnel and administrative services. The nature of services provided by the MSO are comprehensive. Although the MSO provides certain advantages concerning physician practice autonomy, greater access to managed care plans, and a form of joint practice acquisition, the MSO is perceived as a temporary solution - a small step towards full integration.
MSO; Management Service Organization
Management Service Organization: a legal entity that provides practice management, administrative and support services to individual or group practices. MSO, may be a subsidiary of a hospital, or privately, publicly owned by investors. When a physician sells a private practice to a hospital or for-profit medical services company, he/she is usually selling practice assets to an MSO.
MSP; Medical Services Professional
An individual certified in certified professional medical services management, a certified provider credentialing specialist, or an individual responsible for supervising or conducting activities related to physicians and other providers in many environments, including hospitals, managed care plans, and ambulatory care centers. These activities may include record-keeping (credentials files, meeting minutes, etc.) credentialing healthcare practitioners and providing meeting support.
NARA; Federal Register
Nationally archives and records administration - federal register contains, details of proposed federal legislation, details of recently passed federal legislation and presidential executive orders.
NCGME; National Council on Graduate Medical Education
Rations number of medical students specializing in certain fields “based on the national need for new physicians in specific specialties”.
NCQA: National Committee for Quality Assurance
develops quality standards and performance measures for a broad range of health care entities. These performance tools can be used to identify opportunities for improvements
- initial applications, review of the most recent 5 years information on sanctions, restrictions on licensure and limitations on scope of practice must be covered.
- in the MCO, a review board or governing body may review a credentialing decision after the credentialing committee approval. The decision date of the credentials committee is the date the NCQA use when assessing performance against timeliness requirements for PSV.
- at reappointment requires 4 factors within prescribed time limits
1) DEA or CVS
2) Board Certification
3) Liability Claim/Settled or judgements
4) License
- NCQA requires these factors prior to provisional credentialing - current license, past five years, claims or NPDB report, application with signed attestation
- gaps of more than 6 months must be reviewed and clarified verbally or in writing.
- Verification of future completion date does not meet NCQA requirements for verification of the highest level of education and training completed by the practitioner. NCQA requires an actual completion date.
Considers residency highest level of education
- According to NCQA or organization that discovers sanction information, complaints, or adverse events regarding a practitioner must determine if there is evidence of poor quality that could affect the health and safety of its members.
- According to NCQA the ABMS certified doctor verification program is an acceptable source for verifying board certification for an MD.
- According to NCQA standards an organization must verify sanctions or limitations on licensure in each state where the practitioner provides care for its members.
- According to NCQA standards, is verification from the ECFMG acceptable for education and training completed through the AMA’s Fifth Pathway Program? No, this must be confirmed through primary source verification from the AMA.
NCQA continued
Per NCQA, is there any situation in which it would be acceptable to use confirmation from the state licensing agency in lieu of verification of education, residency training, and board certification? Yes. In order to accept this confirmation from the state licensing agency, the state agency must perform primary source verification of these elements and, at least annually, the organization must obtain written confirmation from the state licensing agency that it performs this primary source verification.
For written verification received by the organization, NCQA uses the date of the official document (date on the letter or report), not the receipt date, to assess performance against timeliness requirements.
NCQA continued…
For internet and electronic verification, NCQA uses the date generated by the source when the information is retrieved. If the source report does not generate a date, what date does NCQA use as the verification date? NCQA uses the date noted in the credentialing file by the organization staff person who verified the credentials.
According to NCQA standards, a copy of which of the following is acceptable certification of the document? Medical School diploma. NCQA need only verify the highest level of education credentials which would be residency/internship/fellowship.
According to NCQA standards, an organization that discovers sanction information complaints, or adverse events regarding a practitioner must take what action? Determine if there is evidence of poor quality that could affect the health and safety of its member.
The major accreditation body for managed care organizations (MCO). It is an independent organization that works with the managed care industry, healthcare purchasers, healthcare researchers, and consumers to develop standards that measure the structure and function of MCO quality improvement programs. A not for profit organization that performs quality-oriented accreditation reviews on HMO’s and similar types of managed care plans.
Per NCQA what is the time limit to confirm practitioner holds a current license at the time of credentialing committee’s decision? 180 days.
NCQA continued….
The process by which the managed care organization authorizes contracts with or employs clinicians who are licensed to practice independently to provide services to its members.
A process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provider services to its members.
NCQA requirements
Doctor must provide five year work history on application or cv (month/year in all dates) no verification required but must explain gaps of 6 months or more verbally or in writing; if gap more than one year must explain in writing.
Negligence
Failure to act as an ordinary prudent person, conduct contrary to that of a reasonable person under specific circumstances.
Net loss ratio
The result of total claims liability and all expenses divided by premiums. This is the carrier’s loss ratio after accounting for all expenses.
Network Model HMO
A healthcare model in which the HMO contracts with more than one physician medical groups, IPs and may contact with single and multi-specialty groups. The physician works out of his/her own office. Physician may share in utilization savings, but does not necessarily provide care exclusively for the HMO’s members.
Neurological Surgery Cert.
No subspecialties
Non-par Non Participating Provider
a term used to describe a provider that has not contracted with the carrier or health plan to be a participating provider of healthcare.
NPDB
Opened and began collecting reports in September 1990. If a hospital doesn’t query the Data Bank, the hospital is liable for knowledge of any information. The courts can presume that the institution had or should have had the information available on the report. Payments made by a physician in a malpractice claim is not reportable to the NPDB. Payments made by entities on behalf of the physician are reportable.
Individuals providing information to professional review bodies regarding the competence or conduct of a physician are protected from liability except when the information provided is false and the person providing it knew it was false.
In 3/1/2010, the information collected and disseminated through the NPDB expanded to include all licensure actions taken against all healthcare practitioners, not just physician and dentist as well as healthcare entities.
Hospitals are required to query the NPDB when a physician applies for a position on the medical staff, every 2 years, and when they add or expand existing privileges and when a practitioner submits an application for temporary privileges.
HCQIA requires that hospital query other health care entities that qualify under NPDB regulations. Starting in 2004, a practitioner with a report in the NPDB, had the opportunity to add his or her own statement to the report, which was then disclosed to queries.
A hospital that does not query the NPDB, as required by HCQIA is legally liable for knowledge of any information reported. The courts can presume that the institution had or should have had the information available on the report. The secretary of the DHHS (dept. of health and human services mails a copy of the NPDB report to the named practitioner. If the practitioner wishes to dispute the reports s/he must do so within 60 days.
Denial of a medical license application by a state licensing board is not reportable to the NPDB. Only actions taken against a license.
Report includes certain final actions or recommendations to sanction taken by private accreditation entities and peer review organizations and adverse licensure information on all licensed healthcare practitioners and health care entities.
What is the name of the entity that was established through the health care quality improvement act of 1986 to restrict the ability of incompetent physicians, dentists and other health care practitioners to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history?
NPDB was established through the Health Care quality improvement act of 1986 to restrict the ability of incompetent physicians, dentists and other health care practitioners to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history.
A data bank created by the healthcare quality improvement act which is a central repository of information on physicians, dentists, and in some cases, other healthcare practitioners. It contains reports on medical malpractice payments, adverse licensure actions, adverse clinical privilege actions, and adverse professional society membership actions.
NPDB self query
can the hospital accept a NPDB self query performed by a physician to satisfy the JC requirement for NPDB Query? No - the hospital or its designated agent must perform the query.
NPI
national provider identifier: is a unique provider identifier which was established under HIPAA Administrative simplification standard in 1996.
NPP
National Privacy Panel: responsible for ensuring “privacy, protection as applied to health information”. The board establishes national, unique identifier numbers for plans, providers and patients.
NRMP
National Resident Matching Program; known as the match
NTIS
National Technical Information Services
Nuclear Medicine Certification
no subspecialties
OBRA
Omnibus Reconciliation Act - the tax and budget reconciliation acts passed by congress, much of the act contains language important to managed care, especially with respect to the Medicare market segment.
Obstetrics and Gynecology Certification
critical care medicine, female pelvic medicine and reconstructive surgery, gynecologic oncology, hospice and palliative medicine, maternal and fetal medicine, reproductive endocrinology/infertility
OCC
Osteopathic Continuous Certification; component 1: unrestricted licensure: requires physicians who are board certified by the American Osteopathic Association (AOA) hold a valid, unrestricted license to practice medicine in one of the 50 states. In addition, physicians are required to adhere to the AOA’s code of ethics.
Component 2: Life long learning, continuing medical education: consistent with current commitment to lifelong learning, this component requires all recertifying diplomates fulfill a minimum of 120 hours of continuing medical education (CME) credit during each 3-year CME cycle - though some certifying boards have higher requirements. Of these 120+ CME credit hours, a minimum of 50 credit hours must be in the specialty area of certification. Self-assessment activities will be designated by each of the specialty certifying boards.
Component 3: cognitive assessment: requires provision of one (or more) psychometrically valid and proctored examinations that assess a physician’s specialty medical knowledge as well as core competencies in the provision of healthcare.
Component 4: practice performance assessment and improvement: requires physicians engage in continuous quality improvement through comparison of personal practice performance measured against national standards for applicable medical specialty.
Component 5: continuous AOA membership: membership in the AOA provides physicians with online technology, practice management assistance, national advocacy for DOS and the profession, professional publications and continuing medical education opportunities.
Office of Civil Rights
in 4/2003, their agency is responsible for enforcing the HIPAA privacy rule, security rule, and the confidentiality provisions of the patient safety rule.
OHCA
An organized Health Care Arrangement is an arrangement or relationship, recognized in the HIPAA privacy rules, that allows two or more covered entities (CE) who participate in joint activities to share protected health information (PHI) about their patients in order to manage and benefit their joint operations.
Occupation/field of licensure code
a list of occupational activities/licensure categories for health care practitioners, providers and suppliers, and the code used to identify them.
Open Access
A term describing a member’s ability to self-refer for specialty care. Open access arrangements allow a member to see a participating provider without a referral from another doctor. Also called open panel.
Open enrollment period
a period during which subscribers in a health benefit program have an opportunity to select among health plans being offered to them, usually without evidence of insurability or waiting periods.
Ophthalmology Certification
no subspecialties
Order of motions
an individual member can:
1) call to order
2) second motions
3) debate motions
4) vote on motions
Order of the day
I call for the orders of the day - no vote. a call for the orders of the day, in parliamentary procedure, is a motion to require a deliberative assembly to conform to its agenda or order of business.
Orthopedic Surgery Certification
Orthopedic Sports Medicine; Surgery of the hand
Ostensible Agency
responsibility of liability for another because of the appearance of control
Otolaryngology Certification
Neurotology, pediatric otolaryngology, plastic surgery within the head and neck, sleep medicine
Outcome measurement
a process of systematically measuring individual or collective clinical treatment and response to that treatment.
Out of pocket expenses
costs born by the member that are not covered by the health plan
Parliamentary Procedure
a set of rules for conduct at a meeting, that allows everyone to be heard and to make decisions without confusion.
Pathology certification
pathology - anatomic, pathology - clinical, pathology - blood banking/transfusion medicine, clinical informatics, cytopathology, dermatopathology, neuropathology, pathology, chemical, forensic, hematology, medical microbiology, molecular genetic, pediatric
Patient Records
Health information management, hospital department, should supply a weekly delinquency report for patient records.
Patient Self-Determination Act
1990- federal law requires all health care facilities that receive state funds to provide patients with written information regarding advance directives.
PC/PM per contract per month
the amount of dollars related to each effective contract holder, subscriber or member for each month (PS/PM - per subscriber/per month, CPM/PM - cost per member/per month)
PCCM
A primary care case management program is a freedom of choice waiver program under the authority of the social security act. States contract directly with primary care providers who agree to be responsible for the provision and/or coordination of medical services to Medicaid recipients under their care. Currently, most PCCM programs pay the primary care physician a monthly case management fee in addition to receiving fee for services payment.
PCN
Primary Care Network: a group of primary care physicians who have joined together to share the risk of providing care to their patients who are members of a given health plan.
PCP
Primary Care Physician: the term generally applying to internists, pediatricians, family physicians, general practitioners, and occasionally to obstetrician/gynecologists.
Primary Care Provider - the provider that serves as the initial interface between the member and the medical care system. The PCP is usually a physician, selected by the member upon enrollment, who is trained in one of the primary care specialties who treats and is responsible for coordinating the treatment of members assigned to his/her plan (see gatekeeper)
PCR
Physician Contingency Reserve: the “at-risk” portion of a claim or capitation that is deducted and withheld by the MCO (usually an IPA) before payment is made to a participating physician as an incentive for appropriate utilization and quality of care. This amount for example, 20% of the claim-remains within the MCO and is credited to the doctors account. The PCR or “withhold” can be used in instances where the MCO needs additional funds to pay for specialty or subspecialty care, hospitalization, or pharmaceutical utilization. The withhold is returned to the physician based on achievement of budgeted goals of his/her performance or productivity compared against his/her peers, or a combination of both. Also called “withhold”.
Pediatrics Certification
Adolescent medicine, child abuse pediatrics, developmental-behavioral pediatrics, hospice and palliative medicine, medical toxicology, neonatal -perinatal medicine, neurodevelopmental disabilities, pediatric cardiology, pediatric critical care medicine, pediatric emergency medicine, pediatric endocrinology, pediatric gastroenterology, pediatric hematology-oncology, pediatric infectious diseases, pediatric nephrology, pediatric pulmonology, pediatric rheumatology, pediatric transplant hepatology, sleep medicine, sports medicine
Peer reference - CMS
the medical staff must have a mechanism to examine supporting references of competence.
Peer reference - DNV
the medical staff section outlines qualification to be met by the applicant that include 2 peer recommendations. Requirements do not define the qualifications of a peer.
Peer reference - HFAP
professional references regarding current competence, ability to perform privileges requested (health status). At least 1 reference must be from a peer defined as individual with same professionals credentials as applicant.
Peer reference - JC
According to TJC standards, peer recommendation must include written information regarding six elements. These elements are: medical clinical knowledge, technical and clinical skills, clinical judgement, interpersonal skills, professionalism, and communication skills.
Peer reference - NCQA
A credentialing committee (using a peer review process) is designated to make recommendations regarding credentialing decisions. Credentialing committee is multi-disciplinary, representing various types of practitioners/specialties.
Peer review
evaluation of the clinical work or behavior of an individual by another individual or group of individuals with like credentials whose training and/or skills are similar. For example, physician to physician, podiatrist to podiatrist, dentist to dentist.
Per diem
a total payment per day regardless of what the billed charges are
per diem reimbursement
reimbursement to an institution, usually a hospital, based on a set rate per day rather than on charges. Per diem reimbursement can vary by service (e.g. medical, surgical, obstetrics, mental health, and intensive care) or can be uniform regardless of the intensity of services.
performance improvement
the continuous study and adaptation of a healthcare organization’s functions and processes to increase the probability of achieving desired outcomes and to better meet the needs of individuals and other users of services. This is the third segment of a performance measurement, assessment, and improvement system.
performance improvement program - jc
data collection and analysis for the purpose of providing an indication of the organization’s performance on a specified process or outcome
performance measurement system - jc
a method of gauging organization performance that facilitates improvement through the collection of data and information and the dissemination of process and/or outcome measures over time.
PFP
Priority Focus Process: the process for standardizing the priorities for sampling during an organization’s survey based on information collected about the organization prior to survey. The process also helps to focus the survey on areas that are critical to that organization’s patient safety and quality of care processes. Examples of such information may include but are not limited to, data from the organization’s e-app; the organization’s plan of action prepared as part of the periodic performance review (PPR) process, complaint and sentinel event information, data collected from external sources, such as Medicare Provider Analysis and Review (med-par) data; performance measurement data; and previous survey results.
PHI; Protected Health Information
is individually identifiable health information held or transmitted by a covered entity or its business associate in any form of media. Needs to be disposed by incinerating, pulverizing, shredding but not tossing in a dumpster.
PHO;
Physician Hospital Organization
These are legal (or perhaps informal) organization’s that bond hospitals and the attending medical staff. PHOs are frequently developed for the purpose of contracting with managed care plans. They are sometimes called MESH.
PHP
A prepaid health plan is a entity that either contracts on a prepaid, capitated risk basis to provide services that are not-risk comprehensive services or contracts on a non-risk basis. Additionally, some entities that meet the above definition of HMO’s are treated as PHP’s through special statutory exemptions.
Physical Medicine and Rehabilitation Certification
brain injury medicine, hospice and palliative medicine, neuromuscular medicine, pain medicine, pediatric rehabilitation medicine, spinal cord injury medicine and sports medicine
Physician
Any doctor of medicine (MD) or doctor of osteopathy (DO) who is duly licensed and qualified under the law of jurisdiction in which treatment is received, or is defined in the summary plan description.
Physician Extender
A nurse practitioner or physician assistant who has the authority to act as a principal provider, within certain defined limitations in the specialty area where they are most commonly employed.
Physician Member of the Medical Staff
A doctor of medicine or doctor of osteopathy who, by virtue of education, training, and demonstrated competence, is granted medical staff membership and clinical privileges by the organization to perform specified diagnostic or therapeutic procedures.
Physician Qualified
a doctor of medicine or doctor of osteopathy who, by virtue of education, training, and demonstrated competence, is granted clinical privileges by the organization to perform specific diagnostic or therapeutic procedures and who is fully licensed to practice medicine.
Plaintiff
Party bringing the legal action
Plan of action
A plan detailing the action(s) that an organization will take to come into compliance with a joint commission standard. A plan of action must be completed at the element of performance (EP level), and for some IPs a measure of success (MOS) must also be completed.
Plastic Surgery Certification
Plastic surgery within the head and neck, surgery of the hand
PM/PM
per member per month - the unit of measure related to each effective member for each month the member was effective. The calcuation is # of units/member months (MM).
Podiatrist
an individual who has received the degree of doctor of podiatry medicine and who is licensed to practice podiatry.
Point of Service Plan
A type of health plan allowing the covered person to choose to receive a service from a participating or a non-participating provider, with different benefit levels associated with the use of participating providers. Point of service can be provided in several ways:
An HMO may allow members to obtain limited services from nonparticipating providers
An HMO may provide nonparticipating benefits through a supplemental major medical policy
A PPO may be used to provide both participating and non-participating levels of coverage and access
Various combinations of the above may be used
A health services delivery organization that offers the option to its members to choose to receive a service from participating or a nonparticipating provider. Generally the level of coverage is reduced for services associated with the use of non-participating providers.
Policies and Procedures
the formal, approved description of how a governance, management or clinical care process is defined, organized and carried out.
describe the course of conduct or action pursued or the management of a matter in certain circumstances. Policies are often used to address internal matters and may be subject to frequent change. The medical staff may delegate the authority for changing the rules and regulations to the MEC.
Postpone to a certain time
I move to postpone the majority vote.
PPA
Preferred Provider Arrangement: it is the same as a PPO but sometimes refers to somewhat looser type of plan in which the payer (ie: the employer) makes the arrangement rather than the providers.
PPE
Professional Practice Evaluation: is an evaluation of provider’s practice patterns for the purpose of maintaining clinical privileges.
PPO
Preferred Provider Organization:
1) a group of physicians and/or hospitals who contract with an employer to provide services to their employees. In a PPO the patient may go to the physician of his/her choice, even if that physician does not participate in the PPO.
2) A plan that contracts with independent providers at a discount for services
The panel is limited in size and usually has some type of utilization review system associated with it. A PPO may be risk bearing, like an insurance company, or may be non risk-bearing, like a physician sponsored PPO that markets itself to insurance companies or self-insured companies via an access fee.
PPR
Periodic Performance Review: comprehensive assessment toll for management of continuous monitoring and performance improvement activities.
Hospital evaluates its own compliance with applicable standards, accreditation participation requirements (APRs) and national patient safety goals (nspgs) and develops a plan of action for identified areas of noncompliance. A plan of action is a description of how the organization plans to bring into compliance any standard and associated elements of performance (EPs) that are out of compliance. The plan of action should include a description of the action to be taken and target dates for correcting the problem. Completing the PPR is an APR for hospitals. Each hospital must submit a completed full PPR to the Joint Commission or choose option 1, 2, or 3. The hospital can change its PPR type annually. PPRs are required annually. The due date for PPR’s is the date of the hospital’s last full survey (ie: if the hospital’s last full survey ended on August 1, 2007) its next annual PPR will be due on Agust 1, 2008.
PPR continued
In option 1, the hospital completes the PPR like the full PPR but does not submit the data to the joint commission. the surveyors review any required MOS during the full survey. The hsopitals that choose options 2 and 3 undergo a limited anounced survey. The survey is approximately one third the length of the full suvey. In option 2, the surveyors leave a written report of the findings with the hospital.
In option 3, there is no written report and the findings are delivered orally. In option 2, the surveyors will review any required MOS during the full survey. However, in option 3 there is no review of MOS data during the full survey. Will be renamed the Focused Standards Assessment (FSA).
PPR and FSA
The FSA (the improved PPR) effective January 2012; The FSA will only need to be submitted 12 and 24 months following the organization’s last triennial survey. The FSA will not need to be submitted during the third year of accreditation (the year the organization is due for the on site survey). All four of the options for participating in the FSA will continue to be available; results of the FSA will also continue not to impact an organization’s accreditation decision.
Practice guidelines
systematically developed statements on medical practice that assist a practitioner in making decisions about the appropriate healthcare for specific medical organizations. Managed care organizations use these guidelines to evaluate appropriateness and medical necessity of care. synonyms include practice parameters, standard treatment protocols and clinical practice guideline.
Practitioners
Depending on the individual state law independent practitioners can include medical doctors, doctors of osteopathy, dentists, podiatrists, psychologists, advanced practice nurses, etc. Then it is up to the hospital/medical staff as to whether these practitioners will be allowed to practice independently within the institution and if so whether they are eligible for medical staff membership/appointment and/or privileges.
Preferred Provider Organization
A health care delivery system that contracts with providers of medical care to provide services at discounted fees to members. Members may seek care from non-participating providers but generally are financially penalized for doing so by the loss of the discount and subjection to copayments and deductibles.
Preferred Providers
physicians, hospitals, and other healthcare providers who contract to provide health services to persons covered by a particular health plan. See also preferred provider organization.
Premium
money paid out in advance for insurance coverage
Prepayment
a method of paying for the cost of health care services in advance of their use.
Preventive health care
health care that seeks to prevent or foster early detection of disease and morbidity and focuses on keeping patients well in addition to helping them while they are sick.
Preventive Medicine Cert
Aerospace medicine, occupational medicine, public health and general preventive medicine, clinical informatics, medical toxicology, undersea and hyperbaric medicine
Prima Facie
so far as can be judged on the first appearance.
Privacy Act
the law that establishes safeguards for the protection of federal systems of records the government collects and keeps on individual persons.
Primary Care Provider
The physician of an enrollee chooses to be his/her personal healthcare manager, coordinating the delivery of all healthcare services. See gatekeeper
Primary Source
The original source or approved agent of a specific credential that can verify the accuracy of a qualification reported by an individual healthcare practitioner. Examples include medical school, graduate medical education program and state medical board.
Priority Focus Areas (PFA)
Process, systems or structures in a healthcare organization that can significantly impact the provision of safe, high quality care and can create great risk for negative outcomes should the processes, systems, or structures not function properly.
PTCA; Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure that opens blocked coronary arteries.
Interventional cardiologist is the most likely specialty to perform a PTCA
Privileges
When developing clinical privileging criteria, it is important to evaluate, established standards of practice such as, specialty board recommendations.
Privileges - JC
The duties and prerogatives of each category, and not the clinical privileges to provide patient care, treatment and services related to each category. TJC interprets the word “privileges” to mean the duties and prerogatives of each category, and not the clinical privileges to provide patient care, treatment and services related to each category.
Privileging errors
information existed, that could have been known but wasn’t would have impacted the credentialing decision or the known but leaders failed to make the wise decision.
Privileging - JC
the process whereby the specific scope and content of patient care services (clinical privileges) are authorized for a healthcare practitioner by a healthcare organization based on evaluation of credentials and performance.
PRO
Professional Review Organization
PRO: Peer review Organization cont…
an organization established by the tax equity and fiscal responsibility act of 1982 (TEFRA) to review quality of care and appropriateness of
admissions, readmissions and discharges for Medicare and Medicaid.
Procedure
Interventional cardiologist is the most likely specialty to perform a Transesophageal echocardiography
Proctoring
evaluation of practitioner competence by a peer. actual observance of the performance of one practitioner by another practitioner who has previously been deemed qualified to act in this capacity.
Professional Association
an organization made up of members of a profession for the purpose of defining itself, identifying core competencies and translating them into a core curriculum, developing standards of practice, developing a code of ethics, designing and implementing mechanisms for self-regulation including certification from basic to advanced, and promoting professional development of its membership.
Professional Development
A physician sponsored organization charged with reviewing the services provided to patients. The purpose of the review is to determine if the services rendered are medically necessary, provided in accordance with professional criteria, norms and standards, and provided in the appropriate setting.
Professional Review Organization
An organization which reviews the services provided to patients in terms of medical necessity professional standards and appropriateness of setting.
Profile analysis
analysis of statistical profiles of physicians, patients, diseases, operations, etc. which displays trends (patterns) over time so that problems can be identified and changes enacted. Such patterns might not be evident from the review of single cases.
Prospective reimbursement
any method of paying hospitals or other healthcare providers for a defined period (usually one year) according to amounts or rates of payment established in advance (ie - capitation).
Provider
a physician, hospital, group practice, nursing home, pharmacy of any individual or group of individuals that provides a healthcare service.
Professional review activity
an activity of a health care entity with respect to an individual physicians.
1) to determine whether the provider may have clinical privileges with respect to or membership in the entity
2) to determine the scope or condition of such privileges or membership o
3) to change or modify such privileges or membership
Professional review action
an action or recommendation of a health care entity;
1) taken in the course of professional review activity
2) based on the professional competence or professional conduct of an individual physician which could affect adversely the health or welfare of a patient or patients.
3) which adversely affects or may adversely affect the clinical privileges of the physician
4) the term excludes actions which are primarily based on the physician associate or lack of association with a professional.
Professional society
an association of physicians or dentist that follows a formal peer review process for the purpose of furthering quality health care.
Proximate cause
an act from which an injury results as a natural, direct, uninterrupted consequence and without the injury would not have occurred.
PSD - Patient Self Determination Act
(1990) requires healthcare entities to develop policies addressing a patient right to refuse treatment and execute an advance directive. advance directives outline patients health care instructions if they are unable to speak for themselves.
PSV - JC
JC allows primary source verification to be obtained through a secure electronic communication, approved website or by phone contact with the primary source. According to the TJC, a documented telephone conversation can be utilized as primary source verification for all information including licensure, education, training, experience, competence and peer references.
Psychiatry
psychiatry certification
pundit
expect
purported
claimed
QARI
The Quality Assurance Reform Initiative: was unveiled in 1993 to assist states in the development of continuous quality improvement systems, external quality assurance programs, internal quality assurance programs, and focused clinical studies.
QMB
Qualified Medicare Beneficiary: a person whose income level is such that the state pays the Medicare part b premiums, deductibles and copayments.
QOL
Quality of Life: the patient’s ability to lead a normal satisfying life, often measured in terms of functional status, the ability to perform activities of daily living, health status, which includes ability to function, as well as improvement in the physical signs or symptoms of the disease, or the health related quality of life, which includes functional status, plus improved health status, plus the ability to experience greater general satisfaction with life.
Qualified Individual
an individual or staff member who is qualified to participate in one or all of the mechanisms outlined in joint commission standards by virtue of the following: education, training, experience, competence, registration, certification, or applicable licensure, law or regulation.
Quality Adjusted Life Years (QALY)
Years of life, adjusted for their lesser quality due to illness. For example, if a treatment prolongs life for three years, but the patient is in pain and spends most of that time in a skilled nursing facility, we might say their health status is only 25% of normal health. In that case, the additional three years, is only worth 3 x.25, or .75 QALY.
Quality Assurance
a formal set of activities to review and affect the quality of services provided. quality assurance includes quality assessment and corrective actions to remedy any deficiencies identified in the quality of direct patient, administrative and supportive services.
A formal methodology and set of activities designed to access the quality of services provided. Quality assurance includes formal review of care, problem identification, corrective actions to remedy any deficiencies and evaluation of actions taken.
Quality Improvement
a continuous process that identifies problems in healthcare delivery, tests solutions to those problems and constantly monitors the solutions for improvement.
Quality of Care
review of aggregate date, infraction, and clinical performance evaluations.
Quantifiable measure
measure of success is a quantifiable measure used to determine whether an action is effective and sustained.
NPDB query
a request for information submitted to the NPDB by an eligible entity or authorized agent via the IQRS or ICD format.
QUERY=INQUIRY
Radiology certification
diagnostic radiology, interventional radiology and diagnostic radiology, radiation oncology, medical physics, hospice and palliative medicine, neuroradiology, pediatric radiology, vascular and interventional radiolgoy
Rate
the amount of money per enrollment classification paid to a carrier for medical coverage. rates are usually charged on a monthly basis.
Ratify
confirm
Rating process
the process of evaluating a group or individual to determine a premium rate in regard to the type of risk it presents. Key components of the rating formula are the age/sex factor, location, type of industry, base capitation factor, plan design, average/family size, demographics, and the administration costs.
RBRVS: Resource based relative value scale
this classification system is used as a financing mechanism to reimburse physicians and other types of providers by a classification system which measures training and skill required to perform a given healthcare service. Adjusting for overhead costs, geographical differences and services rendered, RBRVS is intended to address Medicare’s tendency to overcompensate for such services as surgery and diagnostic tests and to underpay for primary care services that involve examining and talking with patients. The new RBRVS became effective January 1992 and represents a significant change in the way physicians are compensated for Medicare services.
Rebuttal
refutation
Recividism
the frequency of the same patient returning to the hospital for the same problems. Refers to inpatient hospitilization.
Recipient
A person who has been designated by the Medicaid agency as eligible to receive Medicaid benefits.
Reciprocity
a contractual arrangement among plans whereby participating plans agree to exchange claim data and transfer claim payments in accordance with agreed upon rules when a provider in one plan territory renders services to a member from another plan. This encourages providers to accept member identification cards from participating plans.
Recommendation
A citation requiring corrective action based on the nature, severity, or number of compliance problems which is accompanied by appropriate follow up monitoring.
Reconsideration
appeal mechanism requesting consideration of an adverse determination made by a physician advisor in carrying out review responsibilities regarding a claim affecting the rights of the beneficiary, attending physician or institutional provider within a required time unit.
Recount
to count over again
refer to committee
i move to refer the motion to majority vote
Referral
the recommendation by a physician and/or health plan for a member to receive care from a different physician or facility.
Referral provider
a provider that renders a service to a patient who has been sent to him/her by a participating provider in the health plan.
Register complaint
I rise to a question of privilege - no vote
regs standards
Regs and accreditation standards - it is a good idea to audit bylaws, rules, regs and policies to make sure that they comply with state regs and accreditation standards.
Regulatory Agency
the aim of government that enforces legislation regulating an act or activity in a particular area, for example, the federal Food and Drug administration.
Reinsurance
1) a type of protection purchased by HMOs from insurance companies specializing in underwriting specific risks for a stipulated premium. This becomes a cost of doing business for HMOs. Typical reinsurance risk coverages are:
A) individual stop-loss
B) aggregate stop-loss
C) out of area
D) insolvency protection; As HMOs grow in membership, they usually reduce their reinsurance coverage (and related direct costs) as they reach a financial position to assume such risks themselves.
2) insurance purchased by a health plan to protect it against extremely high cost cases. See also stop-loss.
An insurance arrangement whereby the MCO or provider is reimbursed by a third party for costs exceeding a pre-set limit, usually an annual maximum.
Requirement for improvement
A recommendation that was not sufficiently addressed in an organizations evidence of standards compliance (ESC) and needs to be addressed in order for the organization to retain its accreditation decision. Failure to address a requirement for improvement after two opportunities will result in a recommendation to place the organization in conditional accreditation.
Res Ispa Loquitur
“the thing speaks for itself” - when trying to establish the “seasonableness of care”, some things are so obvious that on their face, they are clear proof.
Res Judicata
“the thing has already been decided” - you can’t go back once the case has been decided and add new defendants.
respondent superior
“let the master answer” - the employer is responsible for the legal consequences of the acts of the employee while s/he acts within the scope of his/her employment; the employer may be temporary or have “borrowed” the employee and thus becomes liable for the actions of the “borrowed servant” - in the case of the surgeon and the OR staff, the physician is considered the captain of the ship.
Report - NPDB
record of a medical malpractice payment or adverse action submitted to the NPDB by an eligible entity. Reports may be submitted via the IQRS or by ITP using the appropriate ICD format.
Revision to Action
an action related to and modifying an adverse action previously reported to the NPDB. A revision to an action does not supersede a previously reported adverse action. An entity that reports an initial adverse action must also report any revision to that action.
Retention
That portion of the cost of a medical benefit program which is kept by the insurance company or health plan to cover internal costs or to return a profit. Can also be referred to as administrative costs.
Retrospective Review
a method of determining medical necessity and/or appropriate billing practice for services which have already been rendered.
Risk adjustment
a system of adjusting rates paid to managed care providers to account for the differences in beneficiary demographics, such as age, gender, race, ethnicity, medical condition, geographic location, at risk-population (ie: homeless), etc.
Risk contract
a contract payment agreement between HCFA and an HMO or CMS that requires the delivery of (at least) all Medicare covered services to members as medically necessary in return for a fixed monthly payment rate from the government and (often) a premium paid by the enrollee. The HMO is then liable for these contractually offered services without regard to cost.
Risk Management
An organized approach to identifying, assessing and planning for potential problems that may be encountered during the project. Align medical service processes with applicable case law and changes in the regulatory environment in order to protect the organization, practitioners providers and the public.
Monitor practitioner/provider performance continuously by developing and implementing policies that include the use of peer review data and processes in order to ensure uniformity, fairness, and quality of patient care.
Risk pool
a defined account (e.g. defined by size, geographic location, claim dollars that exceed “x” level per individual, etc.) to which revenue and expenses are posted. A risk pool attempts to define expected claim liabilities of a given defined account as well as required funding to support the claim liability.
A pool of money that is at risk for being used for defined expenses. Whatever funds (if any) are left at the end of a designated risk period are commonly returned to those who manage the risk.
Root Cause Analysis (RCA)
is a process for identifying the causal factors that underlie a variation in performance.
Rules and Regulations
detail what medical staff appointees may or may not do. Such as requirements for specific clinical processes, rules of each clinical department, requirements for ER coverage, guidelines for obtaining consultation, membership dues, provisions for leave of absence, medical records completion, community call coverage requirements, meeting attendance, and other staff responsibilities and prerogatives.
the medical staff may delegate the authority for changing the rules and regulations to the MEC.
sanction
a reprimand, for any number of reasons, of a participating provider.
Scoring
the joint commission scoring and accreditation decisions:
scoring elements of performance (EOP) are the performance expectations for determining if a standard is in compliance.
EPs are scored on a three point scale:
0= insufficient compliance
1= partial compliance
2= satisfactory compliance
Evidence of Standards Compliance (ESC) Scoring
all partially compliant or insufficiently compliant EPs must be addressed via the ESC submission process:
EPs that have a direct impact on patient, individual served or resident care require submission within 45 days.
EPs that have an indirect impact on patient, individual served or resident care require an ESC within 60 days.
Secondary Source
first must attempt to verify primary source. If entity closed or records not available…. may contact another hospital to verify information.
may contact practitioner who served at hospital at same time.
Self-Funding/Self-Insurance
a healthcare program in which employers fund benefit plans from their own resources without purchasing insurance. Self-funded plans may be self-administered, or the employer may contract with an outside administrator for an administrative services only (ASO) arrangement. Employers who self-fund can limit their liability via stop-loss insurance on an aggregate and/or individual basis.
Self-referrals
arrangements for care beyond primary care made by the patient rather than the provider. HMOs generally specify to which in-house departments or services a patient may self-refer. For example, patients may be allowed to self-refer to optometry or mental health services. For Non-HMO services, patients are not allowed to self-refer if the care is to be paid by the HMMO, except in emergencies.
Sensitivity analysis
a “what if” analysis in which several alternative estimates of uncertain variables are used to test the robustness of conclusions.
Sentinel event
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
Service area
the territory within certain boundaries that an HMO designates for providing services to members. Since easy access into the health delivery system is a primary HMO tenet, it is generally believed that a member should not have to drive longer than 30 minutes in order to gain access to the system. Some HMOs establish a mileage radius from their medical delivery sites, some rely on zip codes and others use county boundaries to define service areas.
Service plan
A health insurance plan that has direct contracts with providers but is not necessarily a managed care plan. The archetypal and virtually only service plans are Blue Cross and Blue Shield plans. The contract applies to direct billing of the plan by providers (rather than billing of the member), a provision for direct payment (rather than reimbursement of the member), a requirement that the provider accepts the plans determination of UCR and not balance bill the member in excess of that amount, and a range of other terms. It may or may not address items of utilization and quality.
Self query
A subject request for information contained in the NPDB - HIPDB about himself or herself. All self-query requests are automatically submitted to both the NPDB and the HIPDB. A self-query may not be sent to only one data bank.
Secretarial Review
the recourse provided a practitioner in the event that he or she disputes a report to the NPDB and the reporting entity checks to change the report, or does not respond. The secretary of HHS will review the case and determine whether the report is factually accurate or should have been reported to the NPDB.
Shared risk
In the context of an HMO, an arrangement in which financial liabilities are apportioned among two or more entities. For example, the HMO and the medical group may each agree to share the risk of excessive hospital cost over budgeted amounts on a 50-50 basis.
Shared savings
a provision of most prepaid health care plans where at least part of the provider’s income is directly linked to the financial performance of the plan. If costs are lower than projections, a percentage of these savings are referred to the providers.
Shared visions - new pathways
an initiative to progressively sharpen the focus of the accreditation process on care systems critical to the safety and quality of patient care.
Sherman anti-trust act
federal law that makes illegal contracts, conspiracy, and monopolies to restrain trade. Areas of concern for healthcare organizations include reduced market competition, price fixing, preferred provider organizations and exclusive contracts.
Single carrier replacement
the process by which a purchaser of group healthcare coverage covers all eligible through one carrier and drops all other carriers already in the account.
SMDA
Under the Safe Medical Devices Act of 1990, hospital and nursing homes must report device-related deaths both to the food and drug administration and to the device manufacturer (if known).
Staff Model HMO
This model employs physicians to provide health care to its members. All premiums and other revenue accrue to the HMO, which compensates physicians by salary.
Standard of Care
description of the conduct that is expected of an individual in a given situation. It is a measure against which a defendant’s conduct is compared.
Standards
Authoritative statements enunciated and made known by the profession by which the quality of practice administration or education can be judged.
Subject Statement
a statement of up to 2000 characters or less submitted by a subject practitioner regarding a report contained in the NPDB.
State Medical or Dental Board
a board of medical examiners
Stare Decisis
to abide by the decided cases.
Stark Act
legislation that prohibits a physician with a financial arrangement with an entity from referring Medicare or Medicaid patients to that entity for the provision of a designated health service.
Stark Law
stark law: this legislation prohibits a physician with a financial arrangement with an entity from referring Medicare or Medicaid patients to that entity.
Statutory Law
a law or group of law passed by a legislature or other official governing bodies.
Stop-loss insurance
Insurance coverage taken out by a MCO or self-funded employee to provide protection from losses resulting from claims over a specific dollar amount per member per year (calendar year or illness to illness)
Types of stop-loss insurance:
1) specific or individual - reimbursement is given for claims on any covered individual which exceed a pre-determined deductible, such as $25,000 or $50,000.
2) Aggregate reimbursement is given for claims which in total exceed a predetermined level, such as 125% of the amount expected in an average age year.
Subscriber
the person responsible for payment of premiums or whose employment is the basis for eligibility for membership in an HMO or other health plan.
Sub-specialist
someone who is recognized to have expertise in a specialty of medicine or surgery. within HMOs it usually refers to physicians who are able to receive referrals from primary care physicians.
Supplemental services
optional services that a health plan may cover or provide in addition to its basic health services: for example, many HMOs offer a chiropractic benefit plan for an additional $4-$6 premium PM/PM that allows HMO members to self-refer themselves to chiropractic plan providers for treatment.
Surgery cert
complex general surgical oncology, hospice and palliative, medicine, pediatric surgery, surgery of the hand, surgical critical care, surgery, vascular surgery
Survey Team
the group of healthcare professionals who work together to perform a joint commission accreditation survey.
Take break
i move to recess for majority vote
Taxonomy code
ten position number that digitally identifies medical specialties in order to facilitate electronic billing. updated semi-annually the national uniform claim committee.
TEFRA
tax equity and fiscal responsibility act of 1982: the federal law that created the current risk and cost contract provisions under which health plans contract with HCFA.
Telemedicine
telemedicine originating site is the site where the patient is receiving care is located.
Telemedicine - DNV
If the hospital contracts for telemedicine to be used including the radiologist, the hospital verifies that the radiologist is licensed and meets other applicable standards.
Telemedicine - HFAP
the facility must credential and privilege contracted practitioners with the same process used for the medical staff.
Telemedicine - JC
the originating site can fully privilege and credential the practitioner by Medical Staff Standards OR the practitioner may be privileged at the originating site using credentialing information from the distant site if the distant site is an JC accredited organization.
Telemedicine NCQA and URAC
not addressed
Temporary privileges
according to the joint commission standards, if a medical staff appointee does not return his/her application in a timely fashion and the result is that the appointment will lapse, temporary privileges can NOT be granted.
According to JC, temporary privileges can be granted by the CEO. JC standards allows the CEO or his authorized designee to grant temp privileges on the recommendation of the president of medical staff or authorized designee.
The public health and welfare
Medicare conditions of participation for hospitals are federal regulations relating to the Medicare and Medicaid programs. The COP and updates are published under the publish health and welfare register.
third party payer (payor)
an organization that acts as a fiscal intermediary between the provider and consumer of care. Examples include HMO, insurance carriers, HCFA/CMS.
Thoracic surgery cert
thoracic and cardiac surgery, congenital cardiac surgery
TORT
a civil harm
TPA
Third party administrator; an independent person or corporate entity (third party) who administers group benefits, claims and administration for a self-insured company group. A TPA does not underwrite healthcare risk.
Tracer
analysis of an organization’s systems by following individual patients through the health care process.
Tracer Method
the joint commission scoring and accreditation decisions evaluation method in which surveyors select a patient, resident or client and use that individuals record as a roadmap to move through an organization to assess and evaluate the organizations compliance with selected standards and the organizations systems of providing care and services
Tracer methodology
a process surveyors use during the on-site survey to analyze an organization’s systems, with particular attention to identified priority focus areas, by following individual patients through the organization’s healthcare process in the sequence experienced by the patients. Depending on the healthcare setting, this process may require surveyors to visit multiple care units, departments, or areas within an organization or within a single care unit to “trace” the care, treatment, and services rendered to a patient.
Training - JC
at the time of appointment to membership an initial granting of privileges, verification of relevant training or experience must be obtained from the primary source(s) whenever feasible. AMA and AOA. In addition to contacting primary source (the training program), TJF allows use of the following equivalent sources.
Trend factor
the rate at which medical costs are changing due to such factors as prices charged by medical care providers, changes in the frequency and pattern of utilizing various medical service, cost shifitng and use of expensive medical technology.
Triple option
a type of health plan in which employees may choose from an HMO, PPO, or indemnity plan, depending on how much they are willing to contribute to cost. see also multiple option plan
UB-92
the common claim form used by hospitals to bill for services. some managed care plans demand greater detail than is available on the UB-92, requiring hospitals to send additional itemized bills.
UCR
Usual, Customary or Reasonable
1) a method of profiling prevailing fees in an area and reimbursing providers on the basis of that profile. One common methodology is to average all fees and choose the 80th or 90th percentile, although a plan may use other methodologies to determine what is reasonable. Sometimes the term is used synonymously with a fee allowance schedule when the schedule is set relatively high.
2) The allowance measured and determined by comparing actual provider charges with the charges customarily made for similar services and supplies to individuals with similar medical conditions. When covered charges are based on the UCR allowance, the medical plan will pay the UCR allowance or billed charges, whichever is less.
Unbundling
The practice of a provider billing for multiple components of service that were previously included in a single fee. For example, if dressings and instruments were included in a fee for a minor procedure, the fee for the procedure remains the same, but there are now additional charges for the dressings and instruments.
Underwriting
a review of prospective and renewing cases for appropriate pricing risk assessment and administrative feasibility.
Upcoding
the practice of a provider billing for a procedure that pays better than the service actually performed. For example, an office visit that would normally be reimbursed at $45 is coded as one that is reimbursed at $53.
UPIN
Unique Physician Identification Number; They were discontinued in June 2007 and replaced by National Provider Identifier, or NPI numbers.
Utilization Review (UR)
A formal review of utilization for appropriateness of health care services delivered to a member on a prospective, concurrent, or retrospective basis.
URAC
Required through PSV by URAC at initial credentialing:
1) Board certification or highest level of Education
2) Licensure
According to URAC’s health network standards, each applicant must submit an application that includes state licensure information. The application must include state licensure, information, including current licenses and history of licensure in all jurisdictions.
- Utilization Review Accreditation Commission
