PPD 509 Healthcare Vocabulary
Accountable Care Organization
A group of health care providers who give coordinated care, chronic disease
management, and thereby improve the quality of care patients get. The organization's
payment is tied to achieving health care quality goals and outcomes that result in cost
savings.
Accreditation
A process of review that healthcare organizations participate in to demonstrate the
ability to meet predetermined criteria and standards of accreditation established by a
professional accrediting agency
Affordable Care Act (ACA)
The comprehensive health care reform law enacted in March 2010 (sometimes known
as ACA, PPACA, or "Obamacare").
The law has 3 primary goals:
1. Make affordable health insurance available to more people. The law provides
consumers with subsidies ("premium tax credits") that lower costs for households with
incomes between 100% and 400% of the federal poverty level.
2. Expand the Medicaid program to cover all adults with income below 138% of the
federal poverty level. (Not all states have expanded their Medicaid programs.)
3. Support innovative medical care delivery methods designed to lower the costs of
health care generally.
Allowed Charge
Discounted fees that insurers will recognize and pay for covered services. Insurers
negotiate these discounts with providers in their health plan network, and network
providers agree to accept the allowed charge as payment in full. Each insurer has its
own schedule of allowed charges.
Benefits
The health care items or services covered under a health insurance plan. Covered
benefits and excluded services are defined in the health insurance plan's coverage
documents.
Capitation
Capitated payment systems are based on a payment per person, rather than a payment
per service provided. There are several different types of capitation, ranging from
relatively modest per member per month (pmpm) case management payments to
primary care physicians involved in patient centered medical homes, to pmpm
, payments covering all professional services, to pmpm payments covering the total risk
for all services: professional, facility, pharmaceutical, clinical laboratory, durable medical
equipment, etc.
Care Coordination
The process of organizing your treatment across several health care providers. Medical
homes and accountable care organizations (see definition) are two common ways to
coordinate care.
Centers for Medicare & Medicaid Services (CMS)
The federal agency that runs the Medicare, Medicaid, and Children's Health Insurance
Programs, and the federally facilitated Marketplace. For more information, visit cms.gov.
Chronic Disease Management
An integrated care approach to managing illness - typically using multiple healthcare
providers (physicians, nurses, etc.) -which includes screenings, check-ups, monitoring
and coordinating treatment, and patient education. It can improve quality of life while
reducing health care costs if you have a chronic disease, by preventing or minimizing
the effects of a disease
Co-Insurance
A form of medical cost sharing in a health insurance plan that requires an insured
person to pay a stated percentage of medical expenses after the deductible amount, if
any, was paid.
Copayment
A flat dollar amount you must pay for a covered program. Example: you may have to
pay a $15 copayment for each covered visit to a primary care doctor.
CPT Code
A five digit numeric code that is used to describe medical, surgical, radiology,
laboratory, anesthesiology, and evaluation/management services of physicians,
hospitals, and other health care providers. There are approximately 7,800 CPT codes
ranging from 00100 through 99499.
Deductible
The amount you must pay for covered care before your health insurance begins to pay.
Insurers apply and structure deductibles differently.
Diagnosis-Related Group (DRG)
Diagnosis-related group (DRG) is a system which classifies hospital cases according to
certain groups, also referred to as DRGs, which are expected to have similar hospital
resource use (cost). They have been used in the United States since 1983. There is
more than one DRG system being used in the United States, but only the MS-DRG
(CMS-DRG) system is used by Medicare. A variety of other payers have adapted
Accountable Care Organization
A group of health care providers who give coordinated care, chronic disease
management, and thereby improve the quality of care patients get. The organization's
payment is tied to achieving health care quality goals and outcomes that result in cost
savings.
Accreditation
A process of review that healthcare organizations participate in to demonstrate the
ability to meet predetermined criteria and standards of accreditation established by a
professional accrediting agency
Affordable Care Act (ACA)
The comprehensive health care reform law enacted in March 2010 (sometimes known
as ACA, PPACA, or "Obamacare").
The law has 3 primary goals:
1. Make affordable health insurance available to more people. The law provides
consumers with subsidies ("premium tax credits") that lower costs for households with
incomes between 100% and 400% of the federal poverty level.
2. Expand the Medicaid program to cover all adults with income below 138% of the
federal poverty level. (Not all states have expanded their Medicaid programs.)
3. Support innovative medical care delivery methods designed to lower the costs of
health care generally.
Allowed Charge
Discounted fees that insurers will recognize and pay for covered services. Insurers
negotiate these discounts with providers in their health plan network, and network
providers agree to accept the allowed charge as payment in full. Each insurer has its
own schedule of allowed charges.
Benefits
The health care items or services covered under a health insurance plan. Covered
benefits and excluded services are defined in the health insurance plan's coverage
documents.
Capitation
Capitated payment systems are based on a payment per person, rather than a payment
per service provided. There are several different types of capitation, ranging from
relatively modest per member per month (pmpm) case management payments to
primary care physicians involved in patient centered medical homes, to pmpm
, payments covering all professional services, to pmpm payments covering the total risk
for all services: professional, facility, pharmaceutical, clinical laboratory, durable medical
equipment, etc.
Care Coordination
The process of organizing your treatment across several health care providers. Medical
homes and accountable care organizations (see definition) are two common ways to
coordinate care.
Centers for Medicare & Medicaid Services (CMS)
The federal agency that runs the Medicare, Medicaid, and Children's Health Insurance
Programs, and the federally facilitated Marketplace. For more information, visit cms.gov.
Chronic Disease Management
An integrated care approach to managing illness - typically using multiple healthcare
providers (physicians, nurses, etc.) -which includes screenings, check-ups, monitoring
and coordinating treatment, and patient education. It can improve quality of life while
reducing health care costs if you have a chronic disease, by preventing or minimizing
the effects of a disease
Co-Insurance
A form of medical cost sharing in a health insurance plan that requires an insured
person to pay a stated percentage of medical expenses after the deductible amount, if
any, was paid.
Copayment
A flat dollar amount you must pay for a covered program. Example: you may have to
pay a $15 copayment for each covered visit to a primary care doctor.
CPT Code
A five digit numeric code that is used to describe medical, surgical, radiology,
laboratory, anesthesiology, and evaluation/management services of physicians,
hospitals, and other health care providers. There are approximately 7,800 CPT codes
ranging from 00100 through 99499.
Deductible
The amount you must pay for covered care before your health insurance begins to pay.
Insurers apply and structure deductibles differently.
Diagnosis-Related Group (DRG)
Diagnosis-related group (DRG) is a system which classifies hospital cases according to
certain groups, also referred to as DRGs, which are expected to have similar hospital
resource use (cost). They have been used in the United States since 1983. There is
more than one DRG system being used in the United States, but only the MS-DRG
(CMS-DRG) system is used by Medicare. A variety of other payers have adapted
