AAPCC Adjusted Average Per Capita Cost, the amount of funding a managed care plan receives from HCFA to cover its costs. The formula, calculated by region, allows for 95% of fee-for-service rates.

Admissions The number of patients registered for inpatient hospital care during a specific period of time.

ADT Admission, Discharge, Transfer systems, software systems used by healthcare facilities to track patients from arrival to departure.

Advance Directive A statement in which a patient expresses preferences regarding medical treatment and/or designates another person to make treatment choices on his/her behalf.

AGPA American Group Practice Association

AHA American Hospital Association

ALOS Average length of stay, the average duration of patient's inpatient stay during a specific period of time.

AMA American Medical Association

Ambulatory Care Also referred to as outpatient care, healthcare provided at medical offices, clinics, outpatient departments and free-standing health centers for patients who do not stay overnight.

Ancillary Services Tests, procedures, imaging and other healthcare support services.

ANSI American National Standards Institute, a non-profit organization that works to establish acceptance of electronic data standards, the U.S. member of the International Committee for Standardization (ISO).

AOB Assignment of Benefits, authorization indicated by the patient's signature that health plan reimbursement for services should be paid directly to the provider.

Benchmarking Comparison of performance either within an organization or among organizations.

Beneficiary The person designated to receive benefits from an insurance policy or health plan.

Capitation Payment A pre-determined fixed fee paid by a health plan to a professional caregiver on behalf of its members regardless of whether care or what care was provided- opposite of fee-for-service.

Case Management A coordinated, ongoing, personalized strategy for patients with complex or ongoing healthcare needs.

Case Mix The collective pool of patients in a health system or physician practice, described by age, gender or health status.

CCU Coronary care unit

CDC Center for Disease Control, a governmental agency.

Census The number of inpatients who receive care per day on average.

CEU Continuing education unit- credit earned by healthcare professionals who participate in accredited educational programs.

CHAMPUS Civilian Health and Medical Program of the Veteran's Administration- a cost-sharing health plan for dependents of qualified disabled veterans.

CHIN Community Health Information Network- providers and payors within a specific geographic area whose systems are networked to exchange medical and administrative information.

Claim Request by a patient or medical practice for services to be paid by an insurance or health plan in the form of a bill submitted to the health insurance plan.

Closed Panel HMO Also called a staff model HMO, a health maintenance (managed care) organization in which staff physicians work for only one HMO and have no private practice.

COB Coordination of Benefits- a verification system used by health insurance plans when the patient has more than one type of coverage to ensure the claim is not paid in duplicate.

Co-insurance A pre-determined ratio of expenses for which the patient is responsible.

CON Certificate of Need- documentation verifying particular care is needed.

Coordination of Benefits Coordination of benefits (COB) applies to the payment of healthcare benefits when a member is covered by two or more benefit plans. One of the health plans will be primary and the other secondary. The primary plan pays first following its schedule of benefits; then the payments under the secondary plan are coordinated so that combined plan payments do not exceed 100 percent of covered charges. COB is sometimes called liability recovery. Employees If the employee is covered by a group contract and also by a spouse's plan, the employee's plan is primary. If the employee is covered by two group contracts, the plan with the earliest effective date is considered the primary plan. Dependents To determine which plan is primary for dependent children covered by more than one health plan, insurers use the birthday or gender rule. If the health plans of both parents use the birthday rule, the plan of the parent whose birthday falls earlier in the year (month and day) is primary for the dependent children. If the month and day are the same, the policy that was in effect first is primary. If the health plans of both parents use the gender rule, the father's plan is always primary for dependent children. If the health plan of one parent uses the birthday rule and the other uses the gender rule, the gender rule prevails, and the father's plan is primary. There are exceptions when a divorce decree determines which health plan is primary.

Co-payment The flat fee paid by the patient, usually at the time service is provided.

Cost-shifting A leveling method used by health insurers whereby one group of patients is charged more in order to make up for another group's underpayment or inability to pay.

CPR Computerized patient record, also referred to as EMR, electronic medical record, or PHR, patient health record, it includes the medical chart, health history, insurance information, lab results, drug allergies, etc.

CPT Current Procedural Terminology- a system for billing of healthcare services by assigning a five-digit code to each procedure provided (as opposed to the ICD-10 system which classifies the diagnosis, this system classifies the procedure or service provided).

Credentialing The examination of a healthcare professional's credentials, practice history and medical certification or license.

Data Mining Comparison of large databases in order to discover relationship among the data to generate new insights regarding outcomes or treatments.

Data Repository A database in which information is stored- it does not have the analysis or querying functionality of a data warehouse.

Data Warehouse A database in which information is stored with analysis and querying functionality beyond that of a data repository.

DEA Drug Enforcement Agency- a federal agency that controls narcotics and other drugs that can be abused.

Deductible The amount of healthcare service for which the patient is responsible to pay in a given calendar year. This may be calculated per person or per family.

Demand Management Customer service programs such as hotlines, scheduling and referral systems, patient education resources.

Dictation The process by which physicians communicate medical information into a recording device (dictation unit) for transcription (typing).

Digital Dictation Dictation in which voice files are saved in computerized (digital) form and can be played back at any speed without distortion.

Disability A medical condition that prevents someone from working.

Disease Management Integrated treatment plans for patients with chronic or recurring conditions so that each encounter is not viewed as a distinct event but as part of an overall care process.

Disenrollment Termination of the membership of a patient (or group of patients) in a health plan.

Document Imaging Scanning a paper document into a computer file for storage or transmission across a network or the World Wide Web.

DPR Drug Price Review, a monthly report that lists the average wholesale prices (AWP) of prescription drugs.

DRG Diagnosis Related Group- used to calculate a formula by which the amount of money providers will be paid for various procedures and services, based upon patient study groups classified by age, gender, health condition and predicted treatment needs.

DUR Drug Utilization Review- a study of drug prescriptions to evaluate a medication's usage and cost-effectiveness, may also be used to analyze treatment choices by individual practitioners, to suggest alternative medications or to update an organization's drug formulary.

ED Emergency Department

EEG Electroencephalogram

Elective Admission A situation in which a patient's medical condition would allow him/her to be admitted to the hospital on a later date without harm.

Eligibility The ability to be covered by a health plan, including definition of specific benefits for which a member is qualified, and the time frame of coverage.

Emergency Admission A situation in which a patient's medical condition requires immediate admission and treatment.

Employee Contribution The portion of health insurance plan premiums paid by an employee to the company's contracted payor.

Employer Mandate The requirement that companies that provide employee health insurance must pay for at least part of the insurance premiums.

EMR Electronic Medical Record, also referred to as CPR, Computerized Patient Record or PHR, Patient Health Record, it includes the medical chart, health history, insurance information, lab results, drug allergies, etc.

Enrollee A member of a health plan or the member's qualified dependent.

EOB Explanation of Benefits- a billing summary provided to a patient with detailed information regarding charges for services rendered, which portions are paid by the health plan and which portions the patient is responsible to pay.

Episode of care The healthcare services provided for a specific condition during a specific time period.

ER Emergency Room

ERISA Employee Retirement Income Security Act of 1974- federal regulation of employee benefit plans including health plans sponsored by or insured by an employer.

Exclusion Service for a medical condition that is not covered by the patient's health insurance plan.

Experience Rating A method of determining health insurance premiums for a group of people by estimating their future healthcare risks, including work environment, age, gender and health history.

FDA Food and Drug Administration

FEC Free standing emergency center- a non-hospital facility equipped to handle medical emergencies.

Fee Schedule A list of maximum fees per procedure or service that a provider will be reimbursed by a health plan, in a fee-for-service payment system.

FFS Fee for Service- the method of reimbursement in which healthcare providers determine the rates they will charge for services performed and are paid after each service is delivered, opposite of capitated flat-rate plans.

Formulary also called Drug Formulary- a list of pharmaceutical products and dosages deemed acceptable (most economical and appropriate) by a healthcare organization, used as a prescribing guide or restriction.

Gatekeeper A managed care physician who oversees various services provided to patients, coordinating and pre-approving specialist referrals and screening out unnecessary services to control costs.

GPWW Group Practice Without Walls- a hybrid between a private practice and an HMO, in which a physician group owns the assets of the collective practices and shares some costs, but each physician controls their own patient appointments and staff.

Group Model HMO a form of health maintenance (managed care) organization in which a partnership or company provides services and pays for the facility and salaries.

Group Practice Any medical practice consisting of three or more physicians.

HCFA HealthCare Financing Administration- the federal agency within the U.S. Department of Health and Human Services that is responsible for administration of Medicare and the federal portion of Medicaid.

HCPCS HCFA Common Procedural Coding System- an expansion of CPT billing codes to account for additional services such as ambulance transport, supplies and equipment.

Health Plan The package of health benefits (or the organization providing the benefits) provided to an individual.

HEDIS Health Plan Employer Data and Information Set- performance standards for health plans used by employers to compare plans, developed by the National Committee for Quality Assurance (NCQA).

HIPAA Health Insurance Portability and Accountability Act of 1996- a law that protects a person's credit for previous healthcare insurance to cover pre-existing conditions when changing health plans, and provides standards for electronic healthcare transactions and data including health claims, enrollment, eligibility, payments, referral authorizations, etc.

HIPC Health Insurance Purchasing Cooperative- a method of insurance rate-setting and purchasing in which all individuals within a geographic area are considered for purposes of determining insurance rates (based upon a risk pool) which then gives equal purchasing power to both large and small companies.

HISB Healthcare Informatics Standards Board- a group within ANSI that works on standards for computer-based patient records, coding, terminology, international data exchange and patient privacy.

HMO A Health Maintenance Organization (HMO) is a state-designated insurance entity authorized to sell commercial, Medicare or Medicaid health insurance in certain counties. HMO's are known for emphasizing preventative medicine, and paying their doctors and hospitals a fixed dollar capitation for each member assigned to a provider group.

HMO Health Maintenance Organization- a form of health insurance plan that offers services to its members for a pre-paid fixed-rate premium. Various approaches include the staff model, group model, Independent Practice Association and network model.

Home Healthcare Agency An organization that arranges for and provides healthcare services within patients' homes.

ICD-9 or ICD-10 International Classification of Diseases, 9th or 10th revision- a list of codes assigned to various types of illnesses or conditions (it represents the diagnosis, whereas the CPT code represents procedures or services provided).

ICF Intermediate Care Facility- a facility at which nursing care is provided, with a supervising registered nurse or licensed practical nurse on duty during each daily shift.

ICU Intensive Care Unit

IDS Integrated Delivery Systems (IDS) are physician, hospital and insurance company joint ventures which are authorized to sell health insurance.

IDS Integrated Delivery System- a unified healthcare system of healthcare provision for its members including physician, hospital and ambulatory care services by contracting with several provider sites and health plans.

Inpatient Care Services provided to patients who need medical care for at least 24 hours.

Intermediate Care Facility A facility that provides medical care to patients who don't need the full range of services available in a hospital.

IOM Institute of Medicine- An organization within the National Academy of Sciences that acts as an advisory in health and medicine, by conducting policy studies on health issues.

IPA An Independent Practice Association (IPA) is typically a group of physicians who organize themselves into a contracting entity to care for an HMO's members. It can also be a licensed HMO owned by its member physicians.

IPA Independent Practice Association- a type of HMO that contracts with a group of physicians for services to its members, allowing physicians to keep their own private practices and work for more than one HMO.

JCAHO Joint Commission on Accreditation of Health Care Organizations- an independent non-profit group that accredits healthcare organizations and monitors quality of care provided.

Liability A situation in which an individual is responsible OR a bill owed for services received.

Longitudinal Patient Record see CPR or EMR.

LOS Length of stay in an inpatient setting.

LPN Licensed practical nurse.

Managed Care An approach to healthcare delivery based on the concept of prepaid membership rather than payment for service each time care is provided.

MD Doctor of medicine.

Medical Savings Account A private equity fund, much like an Individual Retirement Account (IRA) set up to cover future healthcare expenses.

Medically Indigent A patient who cannot afford basic medical service.

Medicare Risk Contract A program by which patients pay a flat fee to the MRC (rather than a premium) which then assumes responsibility for delivering healthcare through its qualified providers.

Member Physician A physician who has signed a contract with a health plan or managed care organization to provide care for its members and receive reimbursement.

Morbidity A measurement of potential or expected (not actual) illness or accident risk based upon age, geography, occupation, etc.

Mortality Statistical death rates, usually broken down by age or gender.

MPI Master Patient Index- a software database program that collects a patient's various identification numbers from lab, radiology, inpatient admission, etc. and stores them under a single enterprise-wide identification number.

MSO Management Services Organization, an organization that provides practice management services to physicians groups and hospitals, controlling the business assets of the group it services.

NCQA National Committee on Quality Assurance- a non-profit organization that monitors the quality of care delivered by managed care plans and physician organizations through HEDIS and patient satisfaction surveys.

Negligence Failure to provide care that a reasonably prudent professional would have provided under similar circumstances.

Network Model HMO Also called an open-panel HMO, a health maintenance (managed care) organization that contracts with multiple groups of physicians for care delivery to its members.

NLM National Library of Medicine- a branch of the National Institutes of Health which contains a library of > 5 million documents and sponsors fellowships and grants for healthcare research and training.

NPI National Provider Identifier- the intended replacement for the Unique Physician Identifier Number system under development by HCFA, it will assign a unique eight-character ID to each provider who bills services under Medicare or HIPAA.

Occupancy The ratio of census beds to the number of beds in use.

Open-ended HMO Also called a point-of-service HMO, a healthcare maintenance (managed care) plan that encourages but does not require use of participating providers, charging higher deductibles and co-payments for use of non-listed providers.

Open-panel HMO Also called a network model HMO, a health maintenance (managed care) organization that contracts with multiple groups of physicians for care delivery to its members.

OR Operating room.

OSHA Occupational Safety and Health Administration- the federal agency that is responsible for enforcement of industrial health and safety regulations.

OT Occupational therapy.

OTC Over the counter medicines, those available for purchase without need for a prescription.

Outcomes Assessment of a treatment's effectiveness by evaluating its success as a care solution as well as its cost, side effects and risk.

Outpatient Care also referred to as ambulatory care- healthcare provided at medical offices, clinics, outpatient departments and free-standing health centers for patients who do not stay overnight.

PA Physician's assistant

PACS Picture Archiving and Communications system- used to exchange X-rays, CT scans, ultrasound and other medical images over a network.

Patient Education Health and wellness information provided to patients in electronic, video or print formats.

Payor A company or agency that purchases health services on behalf of its members or employees.

PDR Physician's Desk Reference- a listing of pharmaceutical products, their ingredients, uses, manufacturers, etc.

PHO Physician Hospital Organizations (PHO) are physician and hospital joint ventures typically organized to attract members from HMOs and self-insured employers.

PHO Physician Hospital Organization- a managed care system jointly owned by the physicians and the hospital with responsibility for arranging contracts with managed care plans and care facilities.

PHP Prepaid Health Plans (PHP), sometimes referred to as MPHP's (Medicaid Prepaid Health Plans) or LHSO's (Limited Health Services Organizations), are state-approved organizations which accept a capitation for services rendered to Medicaid members. An LHSO can be just about any special state-authorized entity approved to insure a limited risk, i.e., psychiatry HMO, dental HMO, etc.

Physician Incentive Plan Guidelines These are federal mandates requiring physician groups with less than 25,000 members to purchase stop loss.

POS Point of Service- also referred to as an open-ended HMO, a healthcare maintenance (managed care) plan that encourages but does not require use of participating providers, charging higher deductibles and co-payments for use of non-listed providers.

POS Plan A point of service (POS) Plan is a program of commercial or Medicare health insurance which offers the customer two options of how they can receive care-in-plan care and out-of-plan care. In-plan care allows members to save 30-40 percent of out-of-pocket expenses when they receive care from a provider within the panel of approved providers. Point of service plans are designed to provide members greater choice to choose doctors and hospitals which are not on the HMO panel.

Power of Attorney Authorization of another individual to make decisions on one's behalf, as evidenced by a legal document.

PPC Progressive patient care.

PPO Preferred Provider Organization, also referred to as Physician Practice Organization- a form of managed care organization similar to an HMO except that physicians are typically paid for services provided and patients may opt to use non-network physicians.

Pre-existing Condition A medical condition that was experienced by the patient prior to commencement of the patient's health insurance coverage.

Primary Care Network A group of primary care physicians who contract among themselves and/or with health plans and share financial responsibilities and risks.

PRO Peer review organization.

Professional Courtesy A reduction in fee charged to colleagues for services performed by a physician.

Prognosis A prediction of what course a patient's condition will take.

Prospective Payment Advance payment to a healthcare provider for future services, such as capitation.

Protocol A way of doing things that has become an agreed-upon approach, convention or rule.

Provider Profile An examination of services provided, claims filed and benefits allocated by healthcare providers in order to assess quality and cost-effectiveness of care.

PSO A Provider Sponsored Organization (PSO) is a federal designation given to physican and hospital groups which accept capitation for services rendered to an enrolled group of Medicare members.

PT Physical therapy.

Reinsurance Reinsurance is an insurance which provides coverage for catastropic medical charges incurred by a plan member. The three types of medical reinsurance are HMO reinsurance, Workmans Compensation reinsurance, and CHAMPUS/Tricare reinsurance. Reinsurance applies to re-insuring an insurance policy.

Risk Sharing The combination and sharing of financial losses and gains among all providers in a hospital or physician group.

RN Registered nurse.

RPh Registered pharmacist.

RVS Relative value scale.

Satisfaction Survey Required by HEDIS as part of performance measurements. Surveys are sent to members of a health plan to solicit feedback regarding the organization's service and quality.

Self-insured Also called self-funded- the health plan created and maintained by a company for its employees, rather than contracting with an insurance provider.

Self-pay Payment for services made by patients for their own care.

Smart card A portable, updatable cad that can be used to store personal identification, medical history and health insurance information, capable of holding far more information than a magnetic stripe card, but requiring a special card-reading device.

SNF Skilled Nursing Facility- a facility that provides 24 x 7 medical care with at least one registered nurse scheduled for each day shift.

SNOMed Systematized Nomenclature of Human and Veterinary Medicine- a module-based vocabulary system for medical databases, available in over 12 languages.

Specific Stop Loss/Reinsurance Specific Stop Loss is insurance which pays for medical charges above a selected deductible for an individual person per policy year.

SSA Social Security Administration.

Staff Model HMO Also called a closed panel model- a health maintenance (managed care) organization in which staff physicians work for only one HMO and have no private practice.

Standard of Care Conduct expected of a professional in a given situation. It is the measure against which a defendant's conduct is compared.

Stat Immediately.

Stop Loss Stop loss is an insurance which provides a limit for medical charges incurred by self-funded's employee or by a capitated HMO member. There are two types of medical stop loss - employer stop loss and provider stop loss.

Subrogation Subrogation is the right of recovery of one party against another party. This refers to the rights of the HMO or provider group to recover additional monies from a second insurance policy. In managed care, it refers mostly to an obligation of the provider group to use all legal remedies to repay the reinsurer for any claims paid, and whatever else they can collect.

Subrogation An agreement in which a patient's primary health insurance company can collect funds from his/her other benefits plans as reimbursement for claim costs. Not legal in all states.

Telehealth Efforts of health telecommunicators, information technology and health education to improve the efficiency and quality of healthcare.

Telemedicine Medical imaging technology and other provision of healthcare through use of telecommunications technology.

Third-party Administrator A company that handles health claims independently of the healthcare organization.

Third-party Check A check written by one party to a second party, then offered as payment to a third party.

Transcription Translation of dictated information into written form.

Triage A method for prioritizing care delivered and guiding patients to proper services by use of an intermediary who gathers preliminary information regarding patients' conditions.

Uniform Billing Code Procedural rules regarding patient billing, including what information should appear and how it should be coded.

UPIN Unique Physician Identifier Number- a unique ID for each physician who billed services under Medicare, this system will be replaced by the National Provider Identifier system being developed by HCFA.

UR Utilization review.

Usual and Customary The system for determining allowable payment level for various procedures by health insurance plans.

Utilization Management A review process used to ensure a patient's hospital stay, surgery, tests or other treatment are necessary.

VA Veterans Administration.

VNA Visiting Nurse Association.

Workflow A description of the process by which tasks are done, by whom, in what order, and how quickly.