A physician's residency academic year is from July 1 through June 30 of each year.
A patient's ability to obtain medical care.
The process by which an organization recognizes a provider, a program of study or an institution as meeting predetermined standards.
The ACGME is responsible for the accreditation of the post-MD medical training programs within the United States.
Hospital where care is given to patients who generally require a stay of several days and which focuses on a physical or mental condition requiring immediate intervention and constant medical attention, equipment and personnel.
The basis for calculating the Medicare capitation payment an HMO receives per beneficiary for a given county, equal to 95 percent of the historical Medicare fee-for-service payment per beneficiary in that county.
The formal process of registering a patient for service at a healthcare facility.
Privileges authorizing a clinician to admit patients to a healthcare facility.
A document which patients complete to direct their medical care when they are unable to communicate their own wishes due to a medical condition.
A registered nurse who has had advanced education and has met clinical practice requirements beyond the two to four years of higher education required.
There are four types of APNs: 1) certified registered nurse anesthetist (CRNA); 2) clinical nurse specialist (CNS); 3) certified nurse practitioner (CNP); and 4) certified nurse midwife (CNM).
An event involving a physician that must be reported to the National Practitioner Data Bank (such as a competency issue).
Any incident in which the use of medication at any dose, a medical device, or a special nutritional product may have resulted in an adverse outcome in a patient.
An injury resulting from a medical intervention that is not due to the underlying condition of the patient.
Physicians and other healthcare professionals who admit to a hospital on a limited basis or do not have admitting privileges.
Services following hospitalization or rehabilitation, individualized for each patient's needs. Aftercare gradually phases the patient out of treatment while providing follow-up attention to prevent relapse.
All payers of healthcare bills pay rates set by the government for services. The payers, including the government, private insurers, large companies and individuals, may be assigned different rates.
AHPs or MLPs are individuals trained to support, complement, or supplement the professional functions of physicians, dentists, and other health professionals in the delivery of healthcare to patients. They include physician assistants, dental hygienists, medical technicians, nurse midwives, nurse practitioners, physical therapists, psychologists, and nurse anesthetists.
The system of medical practice which treats disease by the use of remedies which produce effects different from those produced by the disease under treatment. MDs practice allopathic medicine.
Charges for services rendered or supplies furnished by a healthcare provider that qualify as covered expenses for insurance purposes.
An alternative to traditional inpatient care system such as ambulatory care, home healthcare and same-day surgery.
Treatment with modalities other than the normal and customary. Alternative Medicine encompasses therapies such as chiropractic, hypnosis, acupuncture, homeopathy, etc.
Healthcare services provided on an outpatient basis, where patients do not require overnight hospitalization.
A facility where surgical procedures are performed on an outpatient basis, which may be freestanding or affiliated with a hospital.
A federal law prohibiting employers of more than 25 employees from discriminating against any individual with a disability who can perform the essential functions, with or without accommodations, of the job that the individual holds or wants.
Diagnostic or therapeutic services, such as laboratory, radiology, pharmacy and physical therapy, performed by non-nursing departments.
A federal law that prohibits the paying or receiving of remuneration in exchange for the referral of patients or business paid by a federal healthcare program.
A situation in which a single entity, such as an integrated delivery system, controls enough of the practices in any one specialty in a relevant market to have monopoly power (e.g., the power to increase prices).
A voluntary contract between two or among more than two persons to place their capital, labor, and skills, and corporation in business with the understanding that there will be a sharing of the profits and losses between/among partners. Outside of North America, it is normally referred to simply as a Partnership Agreement.
The average number of days a patient stays in the hospital.
A minimum set of health services that should be generally and uniformly available in order to provide adequate health protection of the population from disease or to meet some other criteria or standards.
A standard by which something can be measured, compared, or judged. Benchmarking involves measuring another organization's or person's product or service by specific standards and comparing it with one's own product or service.
Any individual who is eligible as a participant, subscriber, or dependent for healthcare services provided under a health plan, as defined in the benefits package. The term is frequently used in reference to Medicare and Medicaid participants.
A clinician who has passed the national examination in a particular field. Board certification is available for most physician specialties, as well as for many allied medical professions.
Refers to the status of an individual who has been notified by a specialty board that he or she possesses the qualification necessary to be admitted to the board's certification examination.
Board Qualified is sometimes used to describe the status of an individual who possesses a certificate or qualification from a specialty board. It is also used to refer to the status of an individual who has been notified by a specialty board that he or she possesses the qualifications necessary to be admitted to the board's certification examination.
Another, almost synonymous term, for global fees. Although some commentators use the terms interchangeably, there is properly an assumption implicit in global fees that all providers necessary for a full episode of care are included, where bundled payments may merely include a subset of necessary providers. A “case rate” is the same approach limited to a single provider. Bundle Payment has been approved for dialysis component exclusive of physician fees, for implementation in 2011.
The organization with authority to grant specialty certifications on behalf of the American Osteopathic Association.
Dollar amount needed to purchase into practice ownership (or shareholder).
Capitation pays the provider a fixed amount for each of the patients for whom he or she agrees to provide care, regardless of whether those patients seek care or not. Payment is typically based on a set number of dollars "per member-per month."
Care Management Protocols specify utilization and treatment standards for various diagnoses.
A strategy used by some managed care plans to separately manage certain high-cost or specialty services, such as mental health and substance abuse services, vision or dental benefits, etc. The aim is to manage care on an individual basis and make money available to pay for selected high-cost services that the patient needs, rather than tailoring treatment to available coverage. Also called clinical exclusions.
The process by which all health-related matters of a case are managed by a healthcare professional to ensure continuity of services and accessibility and to avoid misuse of facilities and resources.
An experienced professional (nurse, doctor, or social worker) who works with patients, providers, and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate healthcare.
A method of accounting for the difference in the severity of illness or resource intensity between patients at different hospitals.
The agency within the US Department of Health and Human Services principally responsible for administration of disease control, health promotion, occupational health and public health programs.
An agency within the US Department of Health and Human Services responsible for the administration of the Medicare and Medicaid programs.
A certificate issued by a governmental body to an individual or organization proposing to construct or modify a health facility or to offer a new or different health service.
Code of Federal Regulations (A codification of the general and permanent rules published in the Federal Register by the Executive departments and agencies of the Federal Government).
Healthcare provided at a substantial discount to those unable to pay. Hospitals either do not attempt to collect a portion of charges or agree to write off charges.
A selected, last-year resident who has leadership responsibilities within the training program.
Diseases which have one or more of the following characteristics: they are permanent, leave residual disability, are caused by nonreversible pathological alteration, require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care.
A liability insurance policy under which coverage applies to claims filed during the policy period. Medical professional liability insurance is typically written on a claims-made basis.
A treatment protocol that combines the best scientific evidence for effectiveness.
A type of cost sharing that requires the insured or subscriber to pay a specified, flat-fee, out-of-pocket payment at the time a service is rendered, with the insurer reimbursing some portion of remaining charges.
The percentage of the amount collected versus the amount charged. For example, for every dollar charged the practice collects 60 cents. The collection rate equals 60%. According to Renal Physician Association, the nephrology collection rate for 2008 was 48%.
Computer physician order entry (CPOE) is an electronic prescribing system. With CPOE, physicians enter orders into a computer rather than on paper. Orders are integrated with patient information, including laboratory and prescription data. The order is then automatically checked for potential errors or problems.
Healthcare Financing Administration (HCFA) regulations that Medicare certified providers must follow.
The 1985 federal spending plan which included several health provisions and protections, including protection against denial of emergency medical care to patients who are unable to pay and the opportunity to extend employer insurance coverage following the termination of employment.
Widely used as an indicator of changes in the cost of living, as a measure of inflation, and as a means of studying price trends. Measures the change in cost of a constant bundle of goods and services purchased by consumers.
A uniform unit of measurement used to assess all levels of noncredit continuing education.
The continuing education of practicing physicians and nurses through refresher courses, journals and texts, educational programs and self-study courses.
A comprehensive set of services ranging from preventive and ambulatory services to acute care to long-term and rehabilitative services. By providing continuity of care, the continuum focuses on prevention and early intervention and provides easy transition from service to service as needs change.
An additional certificate to the federal DEA certificate, which is required in some states.
Basic plan of benefits provided to all subscribers of a health insurer.
Surgical therapy of ischemic coronary artery disease, achieved by grafting a section of saphenous vein, internal mammary artery, or other substitute between the aorta and the obstructed coronary artery distal to the obstructive lesion.
A phenomenon occurring in the United States' healthcare system in which providers are inadequately reimbursed for their costs by some payers and subsequently raise their prices to other payers in an effort to recoup costs.
People who are insured, whether by commercial insurance carriers, Medicare, or Medicaid.
Specific healthcare benefits, services and products for which a health plan or insurer will provide reimbursement.
The process of reviewing and validating a practitioner's academic, clinical and professional ability to determine if criteria for clinical privileges are met.
Established under the Balanced Budget Act of 1997, CAHs are limited-service hospitals located in rural areas with no more than 15 acute-care beds. They receive cost-based reimbursement for Medicare patients and are relieved from some Medicare regulations.
A summary of a candidate's personal history and professional qualifications
The portion of healthcare expenses that a health plan member or insured person must pay out-of-pocket before any insurance coverage applies or reimbursement for expenses begins.
The formal and informal relationships among facilities and providers through which care is coordinated and delivered. In the US, most care is delivered on an ad hoc basis.
A Latin expression meaning "from the beginning," "afresh," "anew," "beginning again." This is an industry term referring to a brand-new dialysis clinic.
A non-cash expense that reduces the value of an asset as a result of wear and tear, age, or obsolescence.
A method of classifying inpatients into groupings based on common characteristics, each of which can be expected to require similar services.
The evaluation of patients' health needs for appropriate care after discharge from an inpatient setting.
The allocated time frame and how bonus will be distributed throughout the year.
An advance directive that patients may make to forego cardiopulmonary resuscitation or other resuscitative efforts.
A physician who is a graduate of an accredited school of allopathic medicine.
A physician who is a graduate of an accredited school of osteopathic medicine.
A federal agency that issues three-year certificates to healthcare providers and entities prescribing or dispensing controlled substances.
A listing of prescription medications and appropriate dosages felt to be the most useful and cost effective for patient care. Health plans that have adopted a "closed, select or mandatory" formulary limit coverage to those drugs in the formulary.
Equipment that can stand repeated use is 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, such as hospital beds, wheelchairs and oxygen equipment.
An advance directive that designates a family member or friend to make decisions about a patient's care should the patient become unable to do so. The durable power of attorney has a wider scope than a Living Will.
The use of the Internet to facilitate healthcare transactions between patients, providers, insurers and other entities.
A certification program, consisting of a series of exams, required for foreign medical school graduates who wish to enter a ACGME-accredited residency or fellowship program in the United States.
A patient's computerized health information as recorded and maintained by a provider system.
The area in a healthcare facility with personnel and equipment for the care of acute illness, trauma, or other conditions needing immediate medical attention.
Services intended for care in medical emergencies, including those of ambulances, emergency rooms, emergency telephone numbers and hot lines.
A person certified to provide basic medical services before or during transport to a hospital.
An act created by Congress as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985. It is designed to prevent hospitals from refusing to treat patients or transferring them to "charity" or "county" hospitals because they are unable to pay or are covered by Medicare or Medicaid programs.An act created by Congress as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985. It is designed to prevent hospitals from refusing to treat patients or transferring them to "charity" or "county" hospitals because they are unable to pay or are covered by Medicare or Medicaid programs.
A federal law created in 1974, that exempts self-insured health plans from state laws governing health insurance, including contribution to risk pools, prohibitions against disease discrimination and other state health reforms.
A legal requirement that employers provide health insurance and/or coverage for specific services for their employees.
An agreement between an employer and employee specifies the rights and obligations of each party to the agreement.
A person eligible to receive benefits from a health maintenance organization or insurance policy. Also called a member, the term includes both those who have enrolled or subscribed and their eligible dependents.
A federal agency that administers environmental protection programs to control air pollution, noise, solid waste disposal and water pollution.
A grouping of services, treatments, procedures, and diagnoses rendered to one patient over a period of time that is billed and paid in one lump payment.
A managed care organization similar to a PPO, but providing benefits only when the services of contracting providers are used.
A method of calculating health insurance premiums for a group based entirely or partly on the risks the group presents, as measured by past use and demographics. An employer whose employees are unhealthy will pay higher rates than another whose employees are healthier.
A nursing facility that qualifies for participation in both Medicare and Medicaid.
An official publication of the federal government that provides final and proposed regulations of federal legislation.
A federal agency created to protect consumers against unfair methods of competition and deceptive business practices, such as sales fraud and price fixing. Investigates and applies antitrust laws.
A primary care clinic located in an underserved area that meets the healthcare needs of special populations and receives special reimbursement for doing so.
FLEX was a national examination used to grant medical licensure, prior to the United States Medical Licensing Examination (USMLE).
The traditional practice of providers billing for each encounter or service rendered.
A physician who has completed medical school, a residency and who is completing advanced training in a medical specialty.
A physician who has completed medical school, a residency and who is completing advanced training in a medical specialty.
Additional postgraduate training that follows a physician's residency.
An avenue, prior to June 30, 2009, by which students who have attended four years at a foreign medical school completed their supervised clinical work at a United States medical school, to become eligible for entry to United States residency training, and ultimately obtained a license to practice in the
The federal agency responsible for regulating the safety, efficacy, labeling and packaging of food, drugs, biologics and cosmetics offered for sale in the United States.
A hospital or other healthcare provider whose revenues are subject to federal and state taxation. For-profits are not required to pursue charitable purposes, are relatively unrestricted in providing compensation and benefit packages to physicians and other employees, are able to raise capital through the issuance of public securities, and are subject to securities laws.
Persons who have completed graduation requirements at a medical school outside of the United States.
A list of approved drugs for treating various diseases and conditions.
A standardized accounting of the numbers of full-time and part-time employees.
A Medicare prospective payment system for rehabilitation hospitals and units based on the functional independence measure rehabilitation coding system.
Pertaining to the descriptive or non-trade name of a drug or other product.
A non-partisan investigative arm of United States Congress that evaluates federal programs as an oversight of federal spending, efficiency and performance.
Medical education after receiving the medical doctorate or equivalent degree, including education received as an intern, resident or fellow.
The amount charged before contractual deductions or discounts are subtracted. Gross Charges – discounts = Net Fees (Other terms for Gross Charges is Gross Revenue). The amount charged before contractual deductions or discounts are subtracted. Gross Charges – discounts = Net Fees (Other terms for Gross Charges is Gross Revenue).
Any insurance policy or health services contract by which groups of employees (and often their dependents) are covered under a single policy or contract, issued by their employer or other group entity.v
A group of physicians representing various specialties or a single specialty which negotiates on behalf of its physician members to accept managed care or discounted fee-for-service contracts.
A formal association of three or more physicians, dentists, or other health professionals providing services, with income from the medical practice distributed to the group members according to a prearranged plan.
A tangible and physical item or object of worth that is owned by an individual or a corporation ex: furniture, computer, automobiles, and fixtures.
Healthcare Information Exchange initiatives focus on the areas of technology, interoperability, standards utilization, harmonization, and business information systems.
Federal legislation, enacted in 1996, mandating regulations governing privacy, security and administrative simplification standards for healthcare information. HIPAA governs how healthcare organizations handle all facets of information management, including patient records.
An entity that offers prepaid, comprehensive health coverage for both hospital and physician services with specific healthcare providers using a fixed fee structure or capitated rates. There are four primary HMO models:
Group Model: The HMO rents the services of the physicians in a separate group practice and pays the group a per capita rate. The physician group, in turn, distributes the payment among its members and self-manages the practices of its physicians.
Independent Practice Association (IPA): A group of physicians that has financially organized to enter into patient care contracts to provide services at a negotiated per capita rate, flat retainer or negotiated fee-for-service rate to HMO members.
Network Model: The HMO contracts with two or more independent physician group practices to provide services and pays a fixed monthly fee per patient. The groups manage themselves and decide how fees are distributed.
Staff Model: Physicians are on the staff of the HMO and are usually paid a salary.
A network of hospitals, doctors, clinics, etc., that provides consumers with a comprehensive range of health services.
HPSAs are defined service areas that demonstrate a critical shortage of primary care physicians, dentists or mental health providers. A HPSA can be a distinct geographic area (such as a county or grouping of Census Tracts, townships, or boroughs), a specific population group with a defined contiguous area, or a specific public or non-profit facility (such as a prison). HPSAs are designated by the Division of Shortage Designation (DSD) of the Bureau of Primary Healthcare.
A national healthcare fraud and abuse data collection program for reporting and disclosing certain final adverse actions taken against healthcare providers, suppliers or practitioners.
A corporate body that owns and/or manages multiple entities including hospitals, long-term care facilities, other institutional providers and programs, physician practices, and/or insurance functions. Also called health system, multi-hospital system, or network.
Federal legislation enacted in 1947 which supported the construction and modernization of healthcare institutions. No funds have been appropriated since the late 1960s.
Utilizing prior year’s percentage of collections as a guide for the percentage of collections to be received in the future.
This legislation provides immediate funding for health information technology infrastructure, training, dissemination of best practices, telemedicine, inclusion of health information technology in clinical education, and State grants to promote health information technology. In addition, the legislation provides significant financial incentives through the Medicare and Medicaid programs to encourage doctors and hospitals to adopt and use certified electronic health records. Physicians will be eligible for $40,000 to $65,000 for showing that they are meaningfully using health information technology, such as through the reporting of quality measures.
An organization that provides medical, therapeutic or other health services in patients' homes.
A facility or program that is licensed, certified or otherwise authorized by law that provides supportive care of the terminally ill.
A skilled nursing facility that is attached to and operated by an acute-care hospital.
A physician who provides routine and emergent care to hospital inpatients, subject to the patient's management by the admitting physician.
A physician's first year of supervised practical experience during training.
Traditional health insurance, where the insured is reimbursed for covered expenses without regard to choice of provider. Payment up to a stated limit may be made either to the individual incurring and claiming the expense or directly to providers.
An IRS defined turn which designates an individual contractually engaged by an entity to perform a specific function.
A healthcare delivery model in which an association of independent physicians contracts with health maintenance organizations and preferred provider organizations for physicians' services. The IPA physicians practice in their own offices and continue to see fee-for-service patients.
Care given by healthcare providers to patients who are unable to pay for it.
An individual who has been admitted to a hospital for at least 24 hours.
Medicare's payment system for inpatient hospitals and facilities. The specific amount that is paid is based on the DRG for the hospital admission.
Collaboration between physicians and hospitals for a variety of purposes. Some models of integration include physician-hospital organization, management-service organization, group practice without walls, integrated provider organization and medical foundation.
The area of a hospital where patients with life-threatening illnesses are closely monitored. Also called Critical Care Unit.
A facility providing a level of medical care that is less than the degree of care and treatment that a hospital or skilled nursing facility is designed to provide, but greater than the level of room and board.
A physician who graduated from a medical school outside of the United States.
An agreement the new physician must sign when they join a practice. They are held to the same contractual obligations that the senior physicians have with the Dialysis Companies.
The Joint Commission evaluates and accredits healthcare organizations in the United States, including hospitals, health plans, and other care organizations that provide home care, mental healthcare, laboratory, ambulatory care and long-term services.
A legal business arrangement of two or more parties agreeing to cooperatively manage their existing organizations.
A contract or agreement forming a legal entity where two or more parties work together on a project and share profits, losses, and control. Joint ventures are usually limited to a single project.
The length of a patient's stay in a hospital or other healthcare facility.
The intensity of services performed for an individual or healthcare organization.
A nursing school graduate who has been licensed by a state; occasional synonym, licensed vocational nurse (LVN).
An individual who is licensed by the state to practice social work.
A mandatory system of state-imposed standards that practitioners must meet to practice a given profession.
Written instructional directives that indicate the author's wishes for medical treatment should he or she become incapacitated and unable to make medical decisions.
A physician who temporarily works for another.
Health, rehabilitative or personal services provided on a long-term basis for people who are chronically ill, aged, disabled, etc.
A diagnostic technique that uses radio and magnetic waves, rather than radiation, to create images of body tissue and to monitor body chemistry.
The improper treatment of a patient, as by a physician or nurse, resulting in injury.
There is two types of coverage Occurrence and Claims Made. Occurrence usually is a higher premium; however, you are covered indefinitely for any acts that would have occurred during the policy term.
Claims Made usually cost less than Occurrence; however, if you need to leave your group or policy, you must purchase a Tail Coverage. When you cease paying premiums your policy then ceases. Tail Coverage will insure you for any claims made in the future regarding medical errors made in the past.
A method of healthcare delivery used by healthcare organizations, such as HMOs, to "manage" or coordinate what is spent on healthcare by closely monitoring how physicians and other medical professionals treat patients.
An organization of healthcare providers, such as physicians and hospitals, formed to enhance efficiency of work performed, e.g. HMOs, PPOs, etc., and often includes a capitated payment structure and a limited choice of healthcare providers.
A legal entity that provides practice management, administrative and support services to individual physicians or group practices. An MSO may be a direct subsidiary of a hospital, a joint venture with physicians, a physician-owned organization or an investor-owned expertise.
A person holding a master's degree in nursing.
A person holding a master's degree in social work.
Medicare Capitation Payment
A state-administered program funded partly by the federal government that provides healthcare services for certain low-income persons and certain aged, blind or disabled individuals. Federal funding varies annually, based on a formula related to each state's per capita income.
A physician who provides leadership and is responsible for the oversight of the medical direction of a variety of types of organizations, including all or select hospital departments, clinical teaching services, etc.
A savings plan whereby pre-tax dollars can be used for healthcare expenses, providing an incentive for reduced use of healthcare services.
The organized body of licensed physicians and other health care providers, who are permitted by law and by a healthcare organization, through credentialing and admitting privileges, to provide medical care within that facility.
A basic document of governance for a hospital's medical staff.
A term used to describe the supplies and services provided to diagnose and treat a medical condition in accordance with the standards of good medical practice and the medical community.
MUAs or MUPs identify areas or populations with a shortage of healthcare services.
As a result of the new law(physician pay section), the mid year 2008 Medicare Physician Fee Schedule (MPFS) rate reduction of -10.6 percent is retroactively replaced with the fee schedule rates in effect from January – June, 2008, which reflected a 0.5 percent update from 2007 rates.
The Medicare Payment Advisory Commission was created under the Balanced Budget Act of 1997 to advise the United States Congress on Medicare payment policies and other policy issues affecting Medicare and the broader health system.
Supplemental insurance for the elderly to cover items not covered by Medicare, such as prescriptions. This coverage is available from private insurance companies.
Medical Group Management Association- MGMA serves 22,500 members who lead and manage more than 13,700 organizations in which almost 275,000 physicians practice.
Departure from a state of well-being, either physiological or psychological (illness).
Incidents of illness and accidents in a defined group of individuals.
Death, as in expected mortality (the predicted occurrence of death in a defined population during a specific time interval).
A "Most Favored Nation" (MFN) clause is a contractual agreement between a supplier and a customer that requires the supplier to sell to the customer on pricing terms at least as favorable as the pricing terms on which that supplier sells to other customers.
A nonprofit organization responsible for preparing and administering qualifying examinations for physicians.
Nonprofit organization that accredits managed care organizations such as HMOs.
The agency of the Department of Health and Human Services responsible for most of its medical research programs and related functions.
A central repository containing practitioner reports on medical malpractice, adverse licensure actions and adverse clinical privilege actions.
A national trade association representing rural hospitals, rural health clinics and other rural healthcare providers.
The actual amount paid to the practice. Other terms for Net Fees are Net Collections or Net Revenue.
A hospital or other healthcare provider that is generally exempt from federal and state income taxes (except unrelated business income tax) and state and local property and sales taxes.
A registered nurse who has completed additional training beyond basic nursing education and provides primary healthcare services in accordance with state nurse practice laws or statutes.
The federal agency responsible for promulgating rules, setting health and safety standards, and overseeing enforcement, whether by direct federal effort or by relying on state enforcement programs.
Office of Inspector General (The Office of the Inspector General (OIG) conducts independent investigations, audits, inspections, and special reviews of United States Department of Justice personnel and programs to detect and deter waste, fraud, abuse, and misconduct, and to promote integrity, economy, efficiency, and effectiveness in Department of Justice operations).
A category of expenditures that a business (practice) incurs as a result of performing its normal business operation.
A nonprofit, federally funded organization that aids in the organ transplantation process.
Osteopathic medicine provides all of the benefits of modern medicine including prescription drugs, surgery, and the use of technology to diagnose disease and evaluate injury. It also offers hands-on diagnosis and treatment through osteopathic manipulative medicine.
Assessments to gauge the results of treatment for a particular disease or condition. Outcome measures include the patient's perception of restoration of function, quality of life and functional status, as well as objective measures of mortality, morbidity and health status.
A patient case that falls outside of the established norm for diagnosis related groups.
An individual who receives healthcare services without being admitted to a healthcare facility.
Care for not only physical symptoms, but also for emotional, social, spiritual, psychological and cultural symptoms. Palliative care is usually provided at the end of life or to help deal with chronic conditions.
A healthcare provider who participates through a contractual arrangement with a healthcare service contractor, HMO, PPO, IPA or other managed care organization.
An individual who investigates and mediates patients' problems and complaints in relation to a healthcare provider's services.
Patient flow data identifies the zip code of each patient discharged from a hospital.
An organization (such as the federal government for Medicare or a commercial insurance company) or person who directly reimburses healthcare providers for their services.
Categorizes the patients based on how they pay for their medical services, i.e. Medicaid, Medicare, Insurance, Self-pay.
Review of a health professional's performance of clinical professional activities by peers through formally adopted written procedures.
An organization with which the Medicare program and hospitals contract for quality and utilization review of services covered by the program.
A method of payment in which a provider receives a fixed payment for each day of service provided to a patient.
The continuous study and adaptation of functions and processes to increase the probability of achieving desired outcomes and better meet the needs of patients and other users of services.
The use of genetic information to tailor pharmaceuticals to specific patients.
A healthcare professional licensed to practice medicine with physician supervision; who conducts physical exams, diagnoses and treats illnesses, orders and interprets tests, counsels on preventive healthcare and assists in surgery.
An organization that provides physicians and physician groups with access to capital, information systems, group purchasing power, and management expertise.
An entity sponsored and jointly governed by a hospital and a subset of its medical staff to negotiate and serve managed care contracts and achieve administrative efficiencies.
A health insurance plan in which members do not have to choose how to receive services until they need them. The most common use of the term applies to a plan that enrolls each member in both an HMO (or HMO-like) system and an indemnity plan. These plans provide different benefits, depending on whether the member chooses to use plan providers or go outside the plan for services.
A comprehensive set of health services that follow an individual regardless of his or her employment status.
PGY refers to each year of training after medical school.
An illness or other medical condition that a patient has experienced before the effective date of insurance coverage.
A method of monitoring and controlling utilization by evaluating the need for medical service prior to it being performed.
A type of health plan that features elements of fee-for-service and managed care. The PPO contracts with networks of providers who agree to provide services and be paid negotiated rates. Enrollees have lower co-pays and/or improved benefits if they see physicians and hospitals on the preferred list, which is created by insurance companies or employers.
Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination and immunizations.
Basic healthcare; a branch of medicine that accentuates the point when a patient first seeks assistance in a healthcare system and the treatment of simpler, more common illnesses and injuries.
The illness or injury causing most of the patient's inpatient stay.
The illness or injury causing most of the patient's inpatient stay.
The required procedure performed to treat a patient's primary diagnosis.
The formal authorization granted to a provider to carry out a treatment in a hospital.
Acronym for "pro re nata," a Latin phrase meaning "as needed." The term is commonly used on patient charts and on prescriptions referring to the administration of medication.
A statistical code system designed to communicate procedural data to insurance companies or other third-party payers.
An incentive pay system based on decided upon factors. For example, physician salary is 150k and overhead 50%. Physician will receive a bonus after salary + overhead has been met, the threshold would be 300k net collections. Any additional productivity and bonus income would be decided upon in advance in the contract.
A legal entity whose shareholders must be licensed members of the same profession, such as medicine or dentistry. A PC provides limited liability for its professional stockholder(s) and allows for corporate ownership of equipment.
The physician who is in charge of a residency or fellowship training program.
The Medicaid hospital payment system that sets payments in advance for the provision of the service.
Part of the quality assurance process where possible hospitalization is reviewed, prior to admission, to determine appropriateness and medical necessity of the proposed level of care.
A hospital, physician, group practice, nursing home, pharmacy or any individual or group of individuals that provides a healthcare service.
Organizations that provide community-based healthcare delivery systems as an alternative to fee-for-service insurance plans.
Formal affiliation of healthcare providers offering a full range of healthcare services with strong roots in the community.
A federal agency responsible for public health services and programs including biomedical research.
A system by which the quality of care is studied through a combination of data interpretation and peer review.
An organized program of activities intended to assure the quality of care provided in a medical setting or program. Includes quality assessment and corrective actions to remedy any deficiencies identified.
A continuous process that identifies problems in healthcare delivery, tests solutions to those problems, and constantly monitors the solutions for improvement.
An independent organization responsible for ensuring that medical care paid under the Medicare program is reasonable and medically necessary, that it meets professionally recognized standards and that it is provided in the most economical setting.
Amounts charged by healthcare providers that are consistent with charges by similar providers for similar services in a given locale.
Approval of a request for a health plan member to receive medical services or supplies from specialists and/or providers outside of the participating medical group.
A physician who has a patient referred to him by another source for examination, surgery, or to have specific procedures performed, usually because the referring source cannot adequately provide the needed service.
A physician who sends a patient to another source for examination, surgery, or to have specific procedures performed, usually because the referring physician cannot adequately provide the needed service.
A national medical specialty association with a membership comprised of healthcare providers in the subspecialty area of internal medicine known as Nephrology.
A physician's period of advanced training, after medical school.
A designated group of physicians assigned by a residency or fellowship program to assess a resident's performance.
A physician who has completed medical school and who is completing advanced training in a medical specialty.
Resource Utilization Group (RUG)
Method of reimbursement for physicians in Medicare cases that weights different services based on their relative complexity, resource use, and cost.
A specific type of covenant in which someone agrees to be restricted by a contract. The most common type of restrictive covenant is one in which a former employee is restricted from working in his or her field for a specific time and within a specific area after leaving employment.
A part of the quality assurance process that reviews patient care, after hospital discharge, to determine quality, necessity, and appropriateness of care.
The practice of identifying and analyzing loss exposures and taking steps to minimize the financial impact of the risks they impose.
A healthcare organization that is in compliance with the federal Rural Health Clinics Act. RHCs must be located in a medically underserved area or a health professions shortage area, use physician assistants and/or nurse practitioners to deliver services, provide preventive services, and be licensed by the state.
Hospitals located in rural areas that meet certain criteria to be paid the Medicare prospective payment system's urban rate, adjusted by the rural wage index. Qualifying criteria include such things as having at least 275 beds and a minimum volume of discharges annually.
A provision of a statute or a regulation that reduces or eliminates a party's liability under the law, on the condition that the party performed its actions in good faith.
(Also known as Income Guarantee) The primary purpose of Salary Guarantee is for a hospital to help finance the start-up of a new medical practice in the community. Salary guarantee provides a physician with cash flow to fund his salary and capital for the startup and operating expenses of a medical practice. A Salary guarantee is usually one to two years in duration and is based upon gross or net income. The physician will receive a monthly payment from the hospital that equals the difference between the monthly guaranteed amount and between the monthly guaranteed amount and the actual income generated by the physician's practice. Therefore, as the practice's revenue increases the payments received from the hospital will decrease. At the time the practice's revenue is equal to or greater than the guaranteed amount, the monthly payment from the hospital will equal zero. At this point, the purpose of the guarantee is fulfilled.
Here’s a simple income guarantee example where the physician has a salary of $240,000 and the guarantee (amount owed the hospital) at the end of one year equals $100,000.
Month Net Income Monthly Payment
(From the hospital)
1 $0 $20,000.00
2 $0 $20,000.00
3 $0 $20,000.00
4 $10,000.00 $10,000.00
5 $5,000.00 $15,000.00
6 $10,000.00 $10,000.00
7 $15,000.00 $5,000.00
8 $20,000.00 $0
9 $20,000.00 $0
10 $20,000.00 $0
11 $25,000.00 $0
12 $25,000.00 $0
Totals $150,000.00 $100,000.00
One repayment option may be a forgiveness clause in the contract where the physician agrees to work additional time for the hospital and the hospital agrees to forgive the amount owed. Another clause might allow the physician to pay back the funds owed from the income earned.
The geographical area in which a managed care plan is licensed to provide healthcare services to its members; or the region served by a hospital or other healthcare provider.
Specialized hospitals that provide treatment relating to a single specialty (e.g., cardiac or orthopedic services). Many of the physicians who refer patients to an SSH have an ownership interest in the facility.
A facility primarily engaged in providing skilled nursing care that has an organized professional staff of physicians and registered nurses. A patient may be admitted to an SNF after discharge from an acute-care hospital.
Healthcare facility located in an isolated area that serves as the only source of emergency, outpatient, and inpatient care in the region. These facilities receive a special designation from the Healthcare Financing Administration and a different payment formula that provides for greater reimbursement.
Laws which prohibit physicians from referring Medicare and Medicaid patients to clinical laboratories or other ancillary care services in which they have an ownership interest or from which they receive any type of compensation.
State Boards of Medical Examiners are typically responsible for licensure and promulgate regulations governing physicians and AHPs.
Health services provided to patients who are not in an acute or severe stage of illness, but who require more medical care than they would receive in a long-term care setting.
An individual who meets a health plan's eligibility requirements, enrolls in the health plan, and accepts the financial responsibility for any premiums, co-payments, or deductibles.
Acute care hospital beds that can also be used for a different level of care.
Also known as an Extended Reporting Period, an additional period of time after policy expiration during which valid claims will be paid under a claims-made policy of liability insurance. Most hospital and physician medical professional liability policies are written on a claims-made basis. Tail insurance may be needed when an insured changes insurance companies or retires.
A facility that has been approved to participate in residency training by the Accreditation Council for Graduate Medical Education and/or has a residency or internship program(s) approved by the American Osteopathic Association and/or is a member of the Council of Teaching Hospitals.
The use of real-time video transmissions and stored electronic data to facilitate healthcare delivery between distant locations.
Medical care requiring a setting outside of the routine, community standards; care to be provided within a regional medical center having comprehensive training, specialists, and research training.
Any payor other than the patient that pays for provided healthcare services, i.e. insurance companies, government.
A continuous quality improvement management system directed by top management that empowers employees and focuses on systemic, rather than individual, employee problems.
A medical license that some states require physicians to have during their residency and/or fellowship training. The license may not be used for practice outside of the training program.
Any hospital verified by the American College of Surgeons as a level I, II or III trauma center.
The US Department of Labor computes Turnover Rate as: Number of employee separations during the month x 100
Total number of employees at midmonth
High Turnover Rates can be an indicator of structural issues within the practice. Secondly, high turnover rates are very costly in terms of loss productivity, increased training time, loss revenue, employee morale and clinical quality.
Care given for which payment is not received, or for which only a portion of the cost is reimbursed.
A six-character alphanumeric number assigned to each physician for use in billing Medicare.
A three-step examination for medical licensure in the United States. Results of the USMLE are reported to medical licensing authorities for use in granting initial licensure to practice medicine.
The patterns of use of a service or type of service within a specified time, usually expressed in a rate per unit of population-at-risk for a given period (e.g., the number of hospital admissions per year per 1,000 persons in a geographic area).
A hospital department that manages the patient flow in a facility.
Evaluation of the necessity, appropriateness and efficiency of the use of medical services and facilities.