ccmc glossary.txt

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  1. Community Alternatives
    Agencies outside an institutional setting, which provide care, support,
  2. and/or services to people with disabilities.
  3. Community Skills
    Those abilities needed to function independently in the community. They may
  4. include telephone skills, money management, pedestrian skills, use of public transportation, meal
  5. planning and cooking.
  6. Community-Based Programs
    Support programs which are located in a community environment,
  7. as opposed to an institutional setting.
  8. Accessible
    A term used to denote building facilities that are barrier-free thus enabling all members
  9. of society safe access, including persons with physical disabilities.
  10. Activity Limitations
    Difficulties an individual may have in executing activities. An activity limitation
  11. may range from a slight to a severe deviation in terms of quality or quantity in executing the activity in
  12. a manner or to the extent that is expected of people without the health condition.
  13. Barrier-Free
    A physical, manmade environment or arrangement of structures that is safe and
  14. accessible to persons with disabilities.
  15. Developmental Disability
    Any mental and/or physical disability that has an onset before age 22
  16. and may continue indefinitely. It can limit major life activities. Individuals with mental retardation,
  17. cerebral palsy, autism, epilepsy (and other seizure disorders), sensory impairments, congenital
  18. disabilities, traumatic brain injury, or conditions caused by disease (e.g., polio and muscular
  19. dystrophy) may be considered developmentally disabled.
  20. Disability
    1) A physical or neurological deviation in an individual makeup. It may refer to a physical,
  21. mental or sensory condition. A disability may or may not be a handicap to an individual, depending
  22. on one's adjustment to it. 2) Diminished function, based on the anatomic, physiological or mental
  23. impairment that has reduced the individual's activity or presumed ability to engage in any substantial
  24. gainful activitity. 3) Inability or limitation in performing tasks, activities, and roles in the manner or
  25. within the range considered normal for a person of the same age, gender, culture and education.
  26. Can also refer to any restriction or lack (resulting from an impairment) of ability to perform an activity
  27. in the manner or within the range considered normal for a human being.
  28. Disability Case Management
    A process of managing occupational and nonoccupational diseases
  29. with the aim of returning the disabled employee to a productive work schedule and employment.
  30. Disability Income Insurance
    A form of health insurance that provides periodic payments to replace
  31. income when an insured person is unable to work as a result of illness, injury, or disease.
  32. Handicap
    The functional disadvantage and limitation of potentials based on a physical or mental
  33. impairment or disability that substantially limits or prevents the fulfillment of one or more major life
  34. activities, otherwise conisdered norml for that individual based on age, sex, and social and cultural
  35. factors, such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking,
  36. breathing, learning, working, etc. Handicap is a classification of role reduction resulting from
  37. circumstarnces that place an impaired or disabled person at a disadvantage compared to other
  38. persons.
  39. Handicapped
    Refers to the disadvantage of an individual with a physical or mental impairment
  40. resulting in a handicap.
  41. Learning Disability
    A lack of achievement or ability in a specific learning area(s) within the range of
  42. achievement of individuals with comparable mental ability. Most definitions emphasize a basic
  43. disorder in psychological processes involved in understanding and using language, spoken or written.
  44. SSDI
    Social Security Disability Income. Federal benefit program sponsored by the Social Security
  45. Administration. Primary factor
    disability and/or benefits received from deceased or disabled parent,
  46. benefit depends upon money contributed to the Social Security program either by the individual
  47. involved and/or the parent involved.
  48. Total Disability
    An illness or injury that prevents an insured person from continuously performing
  49. every duty pertaining to his/her occupation or engaging in any other type of work.
  50. Adverse Events
    Any untoward occurrences, which under most conditions are not natural
  51. consequences of the patienfs disease process or treatment outcomes.
  52. Affect
    The observable emotional condition of an individual at any given time.
  53. Algorithm
    The chronological delineation of the steps in, or activities of, patient care to be applied in
  54. the care of patients as they relate to specific conditions/situations.
  55. Alternate Level of Care
    A level of care that can safely be used in place of the current level and
  56. determined based on the acuity and complexity of the patient's condition and the type of needed
  57. services and resources.
  58. Anclllarv Services
    Other diagnostic and therapeutic services that may be involved in the care of
  59. patients other than nursing or medicine. Includes respiratory, laboratory, radiology, nutrition, physical
  60. and occupational therapy, and pastoral services.
  61. Appropriateness of Setting
    Used to determine if the level of care needed is being delivered in the
  62. most appropriate and cost-effective setting possible.
  63. Assessment
    The process of collecting in-depth information about a person's situation and
  64. functioning to identify individual needs in order to develop a comprehensive case management plan
  65. that will address those needs. In addition to direct client contact, information should be gathered from
  66. other relevant sources (patient/client, professional caregivers, non-professional caregivers,
  67. employers, health records, educational/military records, etc.).
  68. Care Management
    A healthcare delivery process that helps achieve better health outcomes by
  69. anticipating and linking clients with the services they need more quickly. It also helps avoid
  70. unnecessary services by preventing medical problems from escalating.
  71. Case Management
    A collaborative process that assesses, plans, implements, coordinates,
  72. monitors, and evaluates the options and services required to meet an individual's health needs, using
  73. communication and available resources to promote quality, cost-effective outcomes.
  74. Case Management Plan
    A timeline of patient care activities and expected outcomes of care that
  75. address the plan of care of each discipline involved in the care of a particular patient. It is usually
  76. developed prospectively by an interdisciplinary healthcare team in relation to a patient's diagnosis,
  77. health problem, or surgical procedure.
  78. Case Manager
    A healthcare professional who is responsible for coordinating the care delivered to
  79. an assigned group of patients based on diagnosis or need. Other responsibilities include
  80. patient/family education, advocacy, delays management, and outcomes monitoring and management.
  81. Case managers work with people to get the healthcare and other community services they need,
  82. when they need them, and for the best value.
  83. Case-Based Review
    The process of evaluating the quality and appropriateness of care based on
  84. the review of individual medical records to determine whether the care delivered is acceptable. It is
  85. performed by healthcare professionals assigned by the hospital or an outside agency (e.g., Peer
  86. Review Organization [PRO]).
  87. Caseload
    The total number of patients followed by a case manager at any point in time.
  88. Clinical Pathway
    See Case Management Plan.
  89. Coding
    A mechanism of identifying and defining patient care services/activities as primary and
  90. secondary diagnoses and procedures. The process is guided by the IC0-9-CM coding manual, which
  91. lists the various codes and their respective descriptions. Coding is usually done in preparation for
  92. reimbursement for services provided.
  93. Communication Skills
    Refers to the many ways of transferring thought from one person to another
  94. through the commonly used media of speech, written words, or bodily gestures.
  95. Consensus
    Agreement in opinion of experts. Building consensus is a method used when
  96. developing case management plans.
  97. Continuous Quality Improvement (CQI)
    A key component of total quality management that uses
  98. rigorous, systematic, organization-wide processes to achieve ongoing improvement in the quality of
  99. healthcare services and operations. It focuses on both outcomes and processes of care.
  100. Continuum of Care
    The continuum of care matches ongoing needs of the individuals being served
  101. by the case management process with the appropriate level and type of health, medical, financial,
  102. legal and psychosocial care for services within a setting or across multiple settings.
  103. Coordination
    The process of organizing, securing, integrating, and modifying the resources
  104. necessary to accomplish the goals set forth in the case management plan.
  105. Custodial Care
    Care provided primarily to assist a patient in meeting the activities of daily living but
  106. not requiring skilled nursing care.
  107. Delay in Service
    Used to identify delays in the delivery of needed services and to facilitate and
  108. expedite such services when necessary.
  109. Discharge Outcomes (criteria)
    Clinical criteria to be met before or at the time of the patient's
  110. discharge. They are the expected/ projected outcomes of care that indicate a safe discharge.
  111. Discharge Planning
    The process of assessing the patient's needs of care after discharge from a
  112. healthcare facility and ensuring that the necessary services are in place before discharge. This
  113. process ensures a patient's timely, appropriate, and safe discharge to the next level of care or setting
  114. including appropriate use of resources necessary for ongoing care.
  115. Discharge Status
    Disposition of the patient at discharge (e.g., left against medical advice, expired,
  116. discharged home, transferred to a nursing home).
  117. Disease Management A system of coordinated healthcare interventions and
  118. communications for populations with chronic conditions in which patient self-care efforts are
  119. significant. It supports the physician or practitioner/patient relationship. The disease
  120. management plan of care emphasizes prevention of exacerbations and complications
  121. utilizing evidence-based practice guidelines and patient empowerment strategies, and
  122. evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of
  123. improving overall health.
  124. Effectiveness of Care
    The extent to which care is provided correctly (i.e., to meet the patient's
  125. needs, improve quality of care, and resolve the patient's problems), given the current state of
  126. knowledge, and the desired outcome is achieved.
  127. Efficacy of Care
    The potential, capacity or capability to produce the desired effect or outcome, as
  128. already shown, e.g. through scientific research (evidence-based) findings.
  129. Efficiency of Care
    The extent to which care is provided to meet the desired effects/outcomes to
  130. improve quality of care and prevent the use of unnecessary resources.
  131. First-Level Reviews
    Conducted while the patient is in the hospital, care is reviewed for its
  132. appropriateness.
  133. Hospice
    A system of inpatient and outpatient care, which is supportive and palliative familycentered
  134. care, designed to assist the individual with terminal illness to be comfortable and maintain a
  135. satisfactory lifestyle through the end of life.
  136. Implementation
    The process of executing specific case management activities and/or interventions
  137. that will lead to accomplishing the goals set forth in the case management plan.
  138. Independent Case Management
    Also known as private case management or external case
  139. management, it entails the provision of case management services by case managers who are either
  140. self-employed or are salaried employees in a privately owned case management firm.
  141. Independent Living
    A service delivery concept that encourages the maintenance of control over
  142. one's life based on the choice of acceptable options that minimize reliance on others performing
  143. everyday activities.
  144. Indicator
    A measure or metric that can be used to monitor and assess quality and outcomes of
  145. important aspects of care or services. It measures the performance of functions, processes, and
  146. outcomes of an organization.
  147. Injury
    Harm to a worker subject to treatment and/or compensable under workers' compensation.
  148. Any wrong, or damages done to another
    either done to his/her person, rights, reputation, or property.
  149. Integrated Delivery System (IDS)
    A single organization or group of affiliated organizations that
  150. provides a wide spectrum of ambulatory and tertiary care and services. Care may also be provided
  151. across various settings of the healthcare continuum.
  152. Intensity of Service
    An acuity of illness criteria based on the evaluation/treatment plan,
  153. interventions, and anticipated outcomes.
  154. Intermediate Outcome
    A desired outcome that is met during a patient's hospital stay. It is a
  155. milestone in the care of a patient or a trigger point for advancement in the plan of care.
  156. Intervention
    Planned strategies and activities that modify a maladaptive behavior or state of being
  157. and facilitate growth and change. Intervention is analogous to the medical term TREATMENT.
  158. Intervention may include activities such as advocacy, psychotherapy, or speech language therapy.
  159. Level of Care
    The intensity of effort required to diagnose, treat, preserve or maintain an individual's
  160. physical or emotional status.
  161. Levels of Service
    Based on the patient's condition and the needed level of care, used to identify
  162. and verify that the patient is receiving care at the appropriate level.
  163. License
    A permit to practice medicine or a health profession that is
  164. jurisdiction in the United States
    and 2) required for the performance of job functions.
  165. Managed Competition
    A state of healthcare delivery in which a large number of consumers choose
  166. among health plans that offer similar benefits. In theory, competition would be based on cost and
  167. quality and ideally would limit high prices and improve quality of care.
  168. Management Service Organization
    A management entity owned by a hospital, physician
  169. organization, or third party. It contracts with payers and hospitals/physicians to provide certain
  170. healthcare management services such as negotiating fee schedules and handling administrative
  171. functions, including utilization management, billing, and collections.
  172. Medical Loss Ratio (MLR)
    The ratio of healthcare costs to revenue received. Calculated as total
  173. medical expense divided by total revenue.
  174. Medical Necessity on Admission
    A type of review used to determine that the hospital admission is
  175. appropriate, clinically necessary, justified, and reimbursable.
  176. Medically Necessary
    A term used to describe the supplies and services provided to diagnose and
  177. treat a medical condition in accordance with nationally recognized standards.
  178. Minimum Data Set (MDSJ
    The assessment tool used in skilled nursing facility settings to place
  179. patients into Resource Utilization Groups (RUGs), which determines the facilities reimbursement rate.
  180. Monitoring
    The ongoing process of gathering sufficient information from all relevant sources about
  181. the case management plan and its activities and/or services to enable the case manager to determine
  182. the plan's effectiveness.
  183. Multidisciplinary Action Plan (MAP)
    See Case Management Plan (CMP).
  184. Nondisablinq Injury
    An injury which may require medical care, but does not result in loss of
  185. working time or income.
  186. Nursing Case Management
    See also Case Management. A process model using the components
  187. of case management in the delivery aspects of nursing care. In nursing case management delivery
  188. systems, the role of the case manager is assumed by a registered professional nurse.
  189. Outcome
    The result and consequence of a healthcare process. A good outcome is a result that
  190. achieves the expected goal. An outcome may be the result of care received or not received. It
  191. represents the cummulative effects of one or more processes on a client at a defined point in time.
  192. Outcome and Assessment Information Set (OASIS)
    A prospective nursing assessment
  193. instrument completed by home health agencies at the time the patient is entered for home health
  194. services. Scoring determines the Home Health Resource Group (HHRG).
  195. Outcome Indicators
    Measures of quality and cost of care. Metrics used to examine and evaluate
  196. the results of the care delivered.
  197. Outcomes Management
    The use of information and knowledge gained from outcomes monitoring
  198. to achieve optimal patient outcomes through improved clinical decision making and service delivery.
  199. Outcomes Measurement
    The systematic, quantitative observation, at a point in time, of outcome
  200. indicators.
  201. Outcomes Monitoring
    The repeated measurement over time of outcome indicators in a manner
  202. that permits causal inferences about what patient characteristics, care processes, and resources
  203. produced the observed patient outcomes.
  204. Outlier
    Something that is significantly well above or below an expected range or level.
  205. Outlier Threshold
    The upper range (threshold) in length of stay before a patient's stay in a hospital
  206. becomes an outlier. It is the maximum number of days a patient may stay in the hospital for the same
  207. fixed reimbursement rate. The outlier threshold is determined by the Centers for Medicare and
  208. Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA).
  209. Overutilizatlon
    Using established criteria as a guide, determination is made as to whether the
  210. patient is receiving services that are redundant, unnecessary, or in excess.
  211. Partial Disability
    The result of an illness or injury which prevents an insured from performing one or
  212. more of the functions of his/her regular job.
  213. Performance Improvement
    The continuous study and adaptation of the functions and processes of
  214. a healthcare organization to increase the probability of achieving desired outcomes and to better
  215. meet the needs of patients.
  216. Physical Disability
    A bodily defect that interferes with education, development, adjustment or
  217. rehabilitation
    generally refers to crippling conditions and chronic health problems but usually does
  218. not include single sensory handicaps such as blindness or deafness.
  219. Planning
    The process of determining specific objectives, goals, and actions designed to meet the
  220. client's needs as identified through the assessment process. The plan should be action-oriented and
  221. time-specific.
  222. Practice Guidelines (Guidelines)
    Systematically developed statements on medical practices that
  223. assist a practitioner in making decisions about appropriate diagnostic and therapeutic healthcare
  224. services for specific medical conditions. Practice guidelines are usually developed by authoritative
  225. professional societies and organizations such as the American Medical Association.
  226. Premature Discharge
    The release of a patient from care before he or she is deemed medically
  227. stable and ready for terminating treatmenVcare (e.g., discharging a patient from a hospital when he or
  228. she is still needing further care and/or observation).
  229. Primary Care
    The point when the patient first seeks assistance from the medical care system. It
  230. also is the care of the simpler and more common illnesses.
  231. Principal Diagnosis
    The chief complaint or health condition that required the patient's admission to
  232. the hospital for care.
  233. Principal Procedure
    A procedure performed for definitive rather than diagnostic treatment, or one
  234. that is necessary for treating a certain condition. It is usually related to the primary diagnosis.
  235. Prospective Review
    A method of reviewing possible hospitalization before admission to determine
  236. necessity and estimated length of stay.
  237. Protocol
    A systematically written document about a specific patient's problem. It is mainly used as
  238. an integral component of a clinical trial or research. It also delineates the steps to be followed for a
  239. particular procedure or intervention to meet desired outcomes.
  240. Provider
    A person or entity that provides health care services. This includes both practitioners and
  241. facilities.
  242. Quality Assurance
    The use of activities and programs to ensure the quality of patient care. These
  243. activities and programs are designed to monitor, prevent, and correct quality deficiencies and
  244. noncompliance with the standards of care and practice.
  245. Quality Improvement
    An array of techniques and methods used for the collection and analysis of
  246. data gathered in the course of current healthcare practices in a defined care setting to identify and
  247. resolve problems in the system and improve the processes and outcomes of care.
  248. Quality Indicator
    A predetermined measure for assessing quality
  249. Quality Management
    A formal and planned, systematic, organizationwide (or networkwide)
  250. approach to the monitoring, analysis, and improvement of organization performance, thereby
  251. continually improving the extent to which providers conform to defined standards, the quality of
  252. patient care and services provided, and the likelihood of achieving desired patient outcomes.
  253. Quality Monitoring
    A process used to ensure that care is being delivered at or above acceptable
  254. quality standards and as identified by the organization or national guidelines.
  255. Report Card
    An emerging tool that is used by healthcare providers, purchasers, policymakers,
  256. governmental agencies, and consumers to compare and understand the actual performance of health
  257. plans and other service delivery programs. It usually includes data in major areas of accountability
  258. such as quality, utilization of resources, consumer satisfaction, and cost.
  259. Resource Utilization Group (RUG)
    Classifies skilled nursing facility patients into 7 major
  260. hierarchies and 44 groups. Based on the MDS, the patient is classified into the most appropriate
  261. group, and with the highest reimbursement.
  262. Retrospective Review
    A form of medical records review that is conducted after the patient's
  263. discharge to track appropriateness of care and consumption of resources.
  264. Risk Management
    The science of the identification, evaluation, and treatment of financial (and
  265. clinical) loss. A program that attempts to provide positive avoidance of negative results.
  266. Root Cause Analysis
    A process used by healthcare providers and administrators to identify the
  267. basic or causal factors that contribute to variation in performance and outcomes or underlie the
  268. occurrence of a sentinel event.
  269. Second Opinion
    An opinion obtained from another physician regarding the necessity for a
  270. treatment that has been recommended by another physician. May be required by some health plans
  271. for certain high-costs cases, such as cardiac surgery.
  272. Severity of Illness
    An acuity of illness criteria that identifies the presence of significant/debilitating
  273. symptoms, deviations from the patient's normal values, or unstable/abnormal vital signs or laboratory
  274. findings.
  275. Skilled Care
    Patient care services that require delivery by a licensed professional such as a
  276. registered nurse or physical therapist, occupational therapist, speech pathologist, or social worker.
  277. Social Work
    The social work profession promotes social change, problem solving in human
  278. relationships and the empowerment and liberation of people to enhance well-being. Utilizing theories
  279. of human behavior and social systems, social work intervenes at the points where people interact
  280. with their environments. Principles of human rights and social justice are fundamental to social work.
  281. Special Education
    A broad term covering programs and services for children who deviate
  282. physically, mentally or emotionally from the normal to an extent that they require unique learning
  283. experience, technology or materials in order to be maintained in the regular classrooms and
  284. specialized classes and programs of the problems are more severe.
  285. Subacute Care Facility
    A healthcare facility that is a step down from an acute care hospital and a
  286. step up from a conventional skilled nursing facility intensity of services.
  287. Telephone Triage
    Triaging patients to appropriate levels of care based on a telephonic assessment
  288. of a patient. Case managers use the findings of their telephone-based assessment to categorize the
  289. patient to be of an emergent, urgent, or nonurgent condition.
  290. Telephonic Case Management
    The delivery of healthcare services to patients and/or families or
  291. caregivers over the telephone or through correspondence, fax, e-mail, or other forms of electronic
  292. transfer. An example is telephone triage.
  293. Total Quality Management
    See Quality Management.
  294. Transitional Planning
    The process case managers apply to ensure that appropriate resources and
  295. services are provided to patients and that these services are provided in the most appropriate setting
  296. or level of care as delineated in the standards and guidelines of regulatory and accreditation
  297. agencies. It focuses on moving a patient from most complex to less complex care setting.
  298. Treatment
    The course of action adopted to care for a patient or to prevent disease.
  299. Variance
    Any expected outcome that has not been achieved within designated timeframes. It also
  300. means delay of specific diagnostic or therapuetic intervention. Categories include system, patient,
  301. and practitioner.
  302. Access to Care
    The ability and ease of patients to obtain healthcare when they need it.
  303. Actionable Tort
    A legal duty, imposed by statute or otherwise, owing by defendant to the one
  304. injured.
  305. Actuarial Study
    Statistical analysis of a population based on its utilization of healthcare services
  306. and demographic trends of the population. Results used to estimate healthcare plan premiums or
  307. costs.
  308. Acuity
    Complexity and severity of the patient's health/medical condition.
  309. Actuary
    A trained insurance professional who specializes in determining policy rates, calculating
  310. premiums, and conducting statistical studies.
  311. Administrative Services Only (ASO)
    An insurance company or third party administrator (TPA) that
  312. delivers administrative services to an employer group. This usually requires the employer to be at
  313. risk for the cost of health care services provided, which the ASO processes and manages claims.
  314. Adjuster
    A person who handles claims (also referred to as Claims Service Representative)
  315. Admission Certification
    A form of utilization review in which an assessment is made of the medical
  316. necessity of a patient's admission to a hospital or other inpatient facility. Admission certification
  317. ensures that patients requiring a hospital-based level of care and length of stay appropriate for the
  318. admission diagnosis are usually assigned and certified and payment for the services are approved.
  319. Ambulatory Payment Classification (APC) System
    An encounter-based classification system for
  320. outpatient reimbursement, including hospital-based clinics, emergency departments, observation, and
  321. ambulatory surgery. Payment rates are based on categories of services that are similar in cost and
  322. resource utilization.
  323. Appeal
    The formal process or request to reconsider a decision made not to approve an admission
  324. or healthcare services, reimbursement for services rendered, or a patient's request for postponing the
  325. discharge date and extending the length of stay.
  326. Approved Charge
    The amount Medicare pays a physician based on the Medicare fee schedule.
  327. Physicians may bill the beneficiaries for an additional amount, subject to the limiting charge allowed.
  328. Assignment of Benefits
    Paying medical benefits directly to a provider of care rather than to a
  329. member. This system generally requires either a contractual agreement between the health plan and
  330. provider or written permission from the subscriber for the provider to bill the health plan.
  331. Assumption of Risk
    A doctrine based upon voluntary exposure to a known risk. It is distinguished
  332. from contributory negligence, which is based on carelessness, in that it involves a comprehension
  333. that a peril is to be encountered and a willingness to encounter it.
  334. Assurance/Insurance
    The term "assurance" is used more commonly in Canada and Great Britain.
  335. The term "insurance" is the spreading of risk among many, among whom few are likely to suffer loss.
  336. The terms are generally accepted as synonymous.
  337. Authorization
    See Certification.
  338. Beneficiary
    An individual eligible for benefits under a particular plan. In managed care
  339. organizations beneficiaries may also be known as members in HMO plans or enrollees in PPO plans.
  340. Benefit Package
    The sum of services for which a health plan, government agency, or employer
  341. contracts to provide. In addition to basic physician and hospital services, some plans also cover
  342. prescriptions, dental, and vision care.
  343. Benefits
    The amount payable by an insurance company to a claimant or beneficiary under the
  344. claimant's specific coverage.
  345. Capitation
    A fixed amount of money per-member-per-month (PMPM) paid to a care provider for
  346. covered services rather than based on specific services provided. The typical reimbursement method
  347. used by HMOs. Whether a member uses the health service once or more than once, a provider who
  348. is capitated receives the same payment.
  349. Captive
    An insurance company formed by an employer to assume its workers' compensation and
  350. other risks, and provide services.
  351. Carrier
    The insurance company or the one who agrees to pay the losses. A carrier may be
  352. organized as a company, either stock, mutual, or reciprocal, or as an Association or Underwriters.
  353. Carve out
    Services excluded from a provider contract that may be covered through arrangements
  354. with other providers. Providers are not financially responsible for services carved out of their contract.
  355. Case Rates
    Rate of reimbursement that packages pricing for a certain category of services.
  356. Typically combines facility and professional practitioner fees for care and services.
  357. Case Reserve
    The dollar amount stated in a claim file which represents the estimate of the amount
  358. unpaid.
  359. Casualty Insurance
    A general class of insurance and workers' compensation insurance.
  360. Certification
    The approval of patient care services, admission, or length of stay by a health benefit
  361. plan (e.g., HMO, PPO) based on information provided by the healthcare provider.
  362. Claim
    A request for payment of reparation for a loss covered by an insurance contract.
  363. Claimant
    One who seeks a claim or one who asserts a right or demand in a legal proceeding.
  364. Claims Service Representative
    A person who investigates losses and settles claims for an
  365. insurance carrier or the insured. A term preferred to adjuster.
  366. Clinical Review Criteria
    The written screens, decision rules, medical protocols, or guidelines used
  367. to evaluate medical necessity, appropriateness, and level of care.
  368. Coinsurance
    A type of cost sharing in which the insured person pays or shares part of the medical
  369. bill, usually according to a fixed percentage.
  370. Continued Stav Review
    A type of review used to determine that each day of the hospital stay is
  371. necessary and that care is being rendered at the appropriate level. It takes place during a patient's
  372. hospitalization for care.
  373. Contractor
    A business entity that performs delegated functions on behalf of the organization.
  374. Coordination of Benefits (COB)
    An agreement that uses language developed by the National
  375. Association of Insurance Commissioners and prevents double payment for services when a
  376. subscriber has coverage from two or more sources.
  377. Copavment
    A supplemental cost-sharing arrangement between the member and the insurer in
  378. which the member pays a specific charge for a specified service. Copayments may be flat or variable
  379. amounts per unit of service and may be for such things as physician office visits, prescriptions, or
  380. hospital services. The payment is incurred at the time of service.
  381. Current Procedural Terminology (CPT)
    A listing of descriptive terms and identifying codes for
  382. reporting medical services and procedures performed by health care providers and usually used for
  383. billing purposes.
  384. Days per Thousand
    A standard unit of measurement of utilization. Refers to an annualized use of
  385. the hospital or other institutional care. It is the number of hospital days that are used in a year for
  386. each thousand covered lives.
  387. Deductible
    A specific amount of money the insured person must pay before the insurer's payments
  388. for covered healthcare services begin under a medical insurance plan.
  389. Delegation
    The process whereby an organization permits another entity to perform functions and
  390. assume responsibilities on behalf of the organization, while the organization retains final authority to
  391. provide oversight to the delegate.
  392. Demand Management
    Telephone triage and online health advice services to reduce members'
  393. avoidable visits to health providers. This helps reduce unnecessary costs and contributes to better
  394. outcomes by helping members become more involved in their own care.
  395. Denial
    No authorization or certification is given for healthcare services because of the inability to
  396. provide justification of medical necessity or appropriateness of treatment or length of stay. This can
  397. occur before, during, or after care provision.
  398. Diagnosis-Related Group (DRGJ
    A patient classification scheme that provides a means of relating
  399. the type of patient a hospital treats to the costs incurred by the hospital. DRGs demonstrate groups of
  400. patients using similar resource consumption and length of stay. It also is known as a statistical
  401. system of classifying any inpatient stay into groups for the purposes of payment. DRGs may be
  402. primary or secondary
    an outlier classification also exists. This is the form of reimbursement that the
  403. CMS uses to pay hospitals for Medicare and Medicaid recipients. Also used by a few states for all
  404. payers and by many private health plans (usually non-HMO) for contracting purposes.
  405. Disengagement
    The closing of a case is a process of gradual or sudden withdrawal of services, as
  406. the situation indicates, on a planned basis.
  407. Disenrollment
    The process of terminating healthcare insurance coverage for an enrollee/insured.
  408. Domestic Carrier
    An insurance company organized and headquartered in a given state is referred
  409. to in that state as a domestic carrier.
  410. Eligibility
    The determination that an individual has met requirements to obtain benefits under a
  411. specific health plan contract.
  412. Encounter
    An outpatient or ambulatory visit by a heatth plan member to a provider. It applies mainly
  413. to physician's office but may also apply to other types of encounters.
  414. Enrollee
    An individual who subscribes for a health benefit plan provided by a public or private
  415. healthcare insurance organization.
  416. Enrollment
    The number of members in an HMO. The process by which a health plan signs up
  417. individuals or groups of subscribers.
  418. Exclusive Provider Organization (EPO)
    A managed care plan that provides benefits only if care is
  419. rendered by providers within a specific network.
  420. Experience
    A term used to describe the relationship, usually in a percentage or ratio, of premium to
  421. claims for a plan, coverage, or benefits for a stated period of time. Insurance companies in worker's
  422. compensation report three types of experience to rating bureaus
    1) policy year experience
  423. calendar year experience
    and 3) accident year experience. *Policy year experience
  424. premiums and losses on all policies that go into effect within a given 12 month period. *Calendar
  425. Year Experience
    Represents losses incurred and premiums earned within a given 12-month period.
  426. *Accident Year Experience
    Represents accidents that occur within a given 12-month period and the
  427. premiums earned during that time.
  428. Experience Rating
    The process of determining the premium rate for a group risk, wholly or partially
  429. on the basis of that group's experience
  430. Experience Refund
    A provision in most group policies for the return of premium to the policyholder
  431. because of lower than anticipated claims.
  432. Fee Schedule
    A listing of fee allowances for specific procedures or services that a health plan will
  433. reimburse.
  434. Fee-for-Service (FFS)
    Providers are paid for each service performed, as opposed to capitation. Fee
  435. schedules are an example of fee-for-service.
  436. Formulary
    A list of prescription drugs that provide choices for effective medications from which
  437. providers may select, that are covered under a specific health plan.
  438. Gatekeeper
    A primary care physician (usually a family practitioner, internist, pediatrician, or nurse
  439. practitioner) to whom a plan member is assigned. Responsible for managing all referrals for specialty
  440. care and other covered services used by the member.
  441. Global Fee
    A predetermined all-inclusive fee for a specific set of related services, treated as a
  442. single unit for billing or reimbursement purposes.
  443. Group Model HMO
    The HMO contracts with a group of physicians for a set fee per patient to
  444. provide many different health services in a central location. The group of physicians determines the
  445. compensation of each individual physician, often sharing profits.
  446. Health Benefit Plan
    Any written health insurance plan that pays for specific healthcare services on
  447. behalf of covered enrollees.
  448. Health Insurance
    Protection which provides payment of benefits for coverage for covered sickness
  449. or injury. Included under this heading are various types of insurance such as accident insurance,
  450. disability income insurance, medical expense insurance, and accidental death and dismemberment
  451. insurance.
  452. Health Maintenance Organization (HMO)
    An organization that provides or arranges for coverage
  453. of designated health services needed by plan members for a fixed prepaid premium. There are four
  454. basic models of HMOs
    group model, individual practice association {IPA), network model, and staff
  455. model. Under the Federal HMO Act an organization must possess the following to call itself an HMO
  456. (1) an organized system for providing healthcare in a geographical area, (2) an agreed-on set of basic
  457. and supplemental health maintenance and treatment services, and (3) a voluntarily enrolled group of
  458. people.
  459. Home Health Resource Group (HHRG)
    Groupings for prospective reimbursement under Medicare
  460. for home health agencies. Placement into an HHRG is based on the OASIS score. Reimbursement
  461. rates correspond to the level of home health provided.
  462. Hospital-Issued Notice of Noncoverage (HINNJ
    A letter provided to patients informing them of
  463. insurance noncoverage in case they refuse hospital discharge or insist on continued hospitalization
  464. despite the review by the peer review organization (PRO) that indicates their readiness for discharge.
  465. ICD-9-CM
    International Classification of Diseases, Ninth Revision, Clinical Modification, formulated
  466. to standardize diagnoses. It is used for coding medical records in preparation for reimbursement,
  467. particularly in the inpatient care setting. ICD-10 is expected to be published soon.
  468. Incentive
    A sum of money paid at the end of the year to healthcare providers by an
  469. insurance/managed care organization as a reward for the provision of quality and cost-effective care.
  470. Indemnity
    Security against possible loss or damages. Reimbursement for loss that is paid in a
  471. predetermined amount in the event of covered loss.
  472. Indemnity Benefits
    Benefits in the form of payments rather than services. In most cases after the
  473. provider has billed the patient, the insured person is reimbursed by the company.
  474. Individual Practice Association (IPA) Model HMO
    An HMO model that contracts with a private
  475. practice physician or healthcare association to provide healthcare services in return for a negotiated
  476. fee. The IPA then contracts with physicians who continue in their existing individual or group practice.
  477. Insurance
    A system/plan for a large number of people who are subject to the same loss and agree
  478. to have an insurer assess a premium, so when one suffers a loss, there is economic relief from the
  479. pooled resources. It also is known as protection by written contract against the financial hazards, in
  480. whole or part of the happenings of specified fortuitous events
  481. Insured
    The person, organization, or other entity who purchases insurance.
  482. Insurer
    The insurance company or any other organization which assumes the risk and provides the
  483. policy to the insured.
  484. Legal Reserve
    The minimum reserve which a company must keep to meet future claims and
  485. obligations as they are calculated under the state insurance code.
  486. Length of Stay
    The number of days that a health plan member/patient stays in an inpatient facility,
  487. home health, or hospice.
  488. Long-Term Disability Income Insurance
    Insurance issued to an employee, group, or individual to
  489. provide a reasonable replacement of a portion of an employee's earned income lost through a serious
  490. prolonged illness during the normal work career.
  491. Loss Control
    Efforts by the insurer and the insured to prevent accidents and reduce loss through
  492. the maintenance and updating of health and safety procedures.
  493. Loss Expense Allocated
    That part of expense paid by an insurance company in settling a
  494. particular claim, such as legal fees, by excluding the payments to the claimant.
  495. Loss Ratio
    The percent relationship which losses bear to premiums for a given period.
  496. Loss Reserve
    The dollar amount designated as the estimated cost of an accident at the time the
  497. first notice is received.
  498. Managed Care
    A system of healthcare delivery that aims to provide a generalized structure and
  499. focus when managing the use, access, cost, quality, and effectiveness of healthcare services. Links
  500. the patient to provider services.
  501. Medicaid
    A joint federal/state program which provides basic health insurance for persons with
  502. disabilities, or who are poor, or receive certain governmental income support benefits (i.e. Social
  503. Security I nco me or SSI) and who meet income and resource limitations. Benefits may vary by state.
  504. May be referred to as "Title XIX" of the Social Security Act of 1966.
  505. Medicaid Waiver
    Waiver Programs, authorized under Section 1915(C) of the Social Security Act,
  506. provide states with greater flexibility to serve individuals with substantial long-term care needs at
  507. home or in the community rather than in an institution. The federal government "waives" certain
  508. Medicaid rules. This allows a state to select a portion of the population on Medicaid to receive
  509. specialized services not available to Medicaid recipients.
  510. Medicare
    A nationwide, federally administered health insurance program that covers the cost of
  511. hospitalization, medical care, and some related services for eligible persons. Medicare has two parts.
  512. Part A covers inpatient hospital costs (currently reimbursed prospectively using the DRG system).
  513. Medicare pays for pharmaceuticals provided in hospitals but not for those provided in outpatient
  514. settings. Also called Supplementary Medical Insurance Program. Part B covers outpatient costs for
  515. Medicare patients (currently reimbursed retrospectively).
  516. Network Model HMO
    This is the fastest growing form of managed care. The plan contracts with a
  517. variety of groups of physicians and other providers in a network of care with organized referral
  518. patterns. Networks allow providers to practice outside the HMO.
  519. Panel of Providers
    Usually refers to the healthcare providers, including physicians, who are
  520. responsible for providing care and services to the enrollee in a managed care organization. These
  521. providers deliver care to the enrollee based on a contractual agreement with the managed care
  522. organization.
  523. Payer
    The party responsible for reimbursement of healthcare providers and agencies for services
  524. rendered such as the Centers for Medicare and Medicaid Services and managed care organizations.
  525. Peer Review
    Review by healthcare practitioners of services ordered or furnished by other
  526. practitioners in the same professional field.
  527. Peer Review Organization (PRO)
    A federal program established by the Tax Equity and Fiscal
  528. Responsibility Act of 1982 that monitors the medical necessity and quality of services provided to
  529. Medicare and Medicaid beneficiaries under the prospective payment system.
  530. Per Diem
    A daily reimbursement rate for all inpatient hospital services provided in one day to one
  531. patient, regardless of the actual costs to the healthcare provider. The rate can vary by service
  532. (medical, surgical, mental health, etc.) or can be uniform regardless of intensity of services.
  533. Physician-Hospital Organization
    Organization of physicians and hospitals that is responsible for
  534. negotiating contractual agreements for healthcare provision with third-party payers such as managed
  535. care organizations.
  536. Point-of-Service (POS) Plan
    A type of health plan allowing the covered person to choose to
  537. receive a service from a participating or a nonparticipating provider, with different benefit levels
  538. associated with the use of participating providers. Members usually pay substantially higher costs in
  539. terms of increased premiums, deductibles, and coinsurance.
  540. Preadmission Certification
    An element of utilization review that examines the need for proposed
  541. services before admission to an institution to determine the appropriateness of the setting,
  542. procedures, treatments, and length of stay.
  543. Preauthorization
    See Precertification.
  544. Precertification
    The process of obtaining and documenting advanced approval from the health plan
  545. by the provider before delivering the medical services needed. This is required when services are of a
  546. nonemergent nature.
  547. Pre-Existing Condition
    A physical and/or mental condition of an insured which first manifested
  548. itself prior to the issuance of the individual policy or which existed prior to issuance and for which
  549. treatment was received.
  550. Preferred Provider Organization (PPO)
    A program in which contracts are established with
  551. providers of medical care. Providers under a PPO contract are referred to as preferred providers.
  552. Usually the benefit contract provides significantly better benefits for services received from preferred
  553. providers, thus encouraging members to use these providers. Covered persons are generally allowed
  554. benefits for nonparticipating provider services, usually on an indemnity basis with significant
  555. copayments.
  556. Premium
    The periodic payment required to keep a policy in force.
  557. Prepaid Health Plan
    Health benefit plan in which a provider network delivers a specific complement
  558. of health services to an enrolled population for a predetermined payment amount (see capitation).
  559. Primary Care Provider
    Assumes ongoing responsibility for the patient in both health maintenance
  560. and treatment. Usually responsible for orchestrating the medical care process either by caring for the
  561. patient or by referring a patient on for specialized diagnosis and treatment. Primary care providers
  562. include general or family practitioners, internists, pediatricians, and sometimes OB/GYN doctors.
  563. Prior Approval
    See Precertification.
  564. Prior Authorization
    See Precertification.
  565. Prospective Pavment System
    A healthcare payment system used by the federal government since
  566. 1983 for reimbursing healthcare providers/agencies for medical care provided to Medicare and
  567. Medicaid participants. The payment is fixed and based on the operating costs of the patient's
  568. diagnosis.
  569. Rate
    The charge per unit of payroll which is used to determine workers' compensation or other
  570. insurance premiums. The rate varies according to the risk classification within which the policyholder
  571. may fall.
  572. Rating
    The application of the proper classification rate and possibly other factors to set the amount
  573. of premium for a policyholder. The three principle forms of rating are
    1) manual rating
  574. rating
    and 3) retrospective rating.
  575. Reimbursement
    Payment regarding healthcare and services provided by a physician, medical
  576. professional, or agency.
  577. Relative Weight
    An assigned weight that is intended to reflect the relative resource consumption
  578. associated with each DRG. The higher the relative weight, the greater the payment/reimbursement to
  579. the hospital.
  580. Risk
    The uncertainty of loss with respect to person, liability, or the property of the insured OR
  581. Probability that revenues of the insurer will not be sufficient to cover expenditures incurred in the
  582. delivery of contracted services.
  583. Risk Management
    A comprehensive program of activities to identify, evaluate, and take corrective
  584. action against risks that may lead to patient or staff injury with resulting financial loss or legal liability.
  585. This program aims at minimizing losses.
  586. Risk Sharing
    The process whereby an HMO and contracted provider each accept partial
  587. responsibility for the financial risk and rewards involved in cost-effectively caring for the members
  588. enrolled in the plan and assigned to a specific provider.
  589. Self-Insurer
    An employer who can meet the state legal and financial requirements to assume by
  590. him or herself all of its risk and pay for the losses, although the employer may contract with an
  591. insurance carrier or others to provide certain essential seNices.
  592. Short-Term Disability Income Insurance
    The provision to pay benefits to a covered disabled
  593. person/employee as long as he/she remains disable up to a specific period not exceeding two years.
  594. SSI
    Supplemental Security Income. Federal financial benefit program sponsored by the Social
  595. Security Administration.
  596. Staff Model HMO
    The most rigid HMO model. Physicians are on the staff of the HMO with some
  597. sort of salaried arrangement and provide care exclusively for the health plan enrollees.
  598. Supp/ementarv Medica/Insurance (SMI)
    A secondary medical insurance plan used by a
  599. subscriber to supplement healthcare benefits and coverage provided by the primary insurance plan.
  600. The primary and secondary/supplementary plans are unrelated and provided by two different
  601. agencies.
  602. Target Utilization Rates
    Specific goals regarding the use of medical seNices, usually included in
  603. risk-sharing arrangements between managed care organizations and healthcare providers.
  604. Third Party Administration
    Administration of a group insurance plan by some person or firm other
  605. than the insurer of the policyholder.
  606. Third Party Administrator (TPA)
    An organization that is outside of the insuring organization that
  607. handles only administrative functions such as utilization review and processing claims. Third party
  608. administrators are used by organizations that actually fund the health benefits but do not find it costeffective
  609. to administer the plan themselves.
  610. Third Party Paver
    An insurance company or other organization responsible for the cost of care so
  611. that individual patients do not directly pay tor seNices.
  612. Underutilization
    Using established criteria as a guide, determination is made as to whether the
  613. patient is receiving all of the appropriate seNices.
  614. Utilization
    The frequency with which a benefit is used during a 1-year period, usually expressed in
  615. occurrences per 1 000 covered lives.
  616. Utilization Management
    Review of seNices to ensure that they are medically necessary, provided
  617. in the most appropriate care setting, and at or above quality standards.
  618. Utilization Review
    A mechanism used by some insurers and employers to evaluate healthcare on
  619. the basis of appropriateness, necessity, and quality.
  620. Withhold
    A portion of payments to a provider held by the managed care organization until year end
  621. that will not be returned to the provider unless specific target utilization rates are achieved. Typically
  622. used by HMOs to control utilization of referral seNices by gatekeeper physicians.
  623. Workers' Compensation
    An insurance program that provides medical benefits and replacement of
  624. lost wages for persons suffering from injury or illness that is caused by or occurred in the workplace.
  625. It is an insurance system for industrial and work injury, regulated primarily among the separate states,
  626. but regulated in certain specified occupations by the federal government.
  627. Workers' Compensation Commission
    One of many terms identifying the state public body which
  628. administers the workers' compensation laws, holds hearings on contested cases, promotes industrial
  629. safety, rehabilitation, etc. It is often located within the state labor department. The national
  630. organization is the International Association of Industrial Accident Boards and Commissions.
  631. ADA
    The federal Americans with Disabilities Act of 1990.
  632. Administrative Law
    That branch of public law that deals with the various organs of federal, state,
  633. and local governments which prescribes in detail the manner of their activities.
  634. Advance Directives
    Legally executed document that explains the patient's healthcare-related
  635. wishes and decisions. It is drawn up while the patient is still competent and is used if the patient
  636. becomes incapacitated or incompetent.
  637. Advocacy
    Acting on behalf of those who are not able to speak for or represent themselves. It is
  638. also defending others and acting in their best interest. A person or group involved in such activities is
  639. called an advocate.
  640. Affidavit
    A written statement of fact signed and sworn before a person authorized to administer an
  641. oath.
  642. Appeal
    The process whereby a court of appeals reviews the record of written materials from a trial
  643. court proceeding to determine if errors were made that might lead to a reversal of the trial court's
  644. decision.
  645. Autonomy
    A form of personal liberty of action in which the patient holds the right and freedom to
  646. select and initiate his or her own treatment and course of action, and taking control for his or her
  647. health
    that is, fostering the patient's independence and self-determination.
  648. Bad Faith
    Generally involving actual or constructive fraud, or a design to mislead or deceive
  649. another.
  650. Beneficence
    The obligation and duty to promote good, to further and support a patient's legitimate h'><'
  651. interests and decisions, and to actively prevent or remove harm
    that is, to share with the patient risks 1'
  652. associated with a particular treatment option.
  653. Bona Fide
    Literally translated as "in good faith"
  654. Burden of Proof
    The duty of producing evidence as the case progresses, and/or the duty to
  655. establish the truth of the claim by a preponderance of the evidence. The former may pass from party
  656. to party, the later rests throughout upon the party asserting the affirmative of the issue.
  657. Case Law
    The aggregate of reported cases forming a body of jurisprudence, or the law of a
  658. particular subject as evidenced or formed by the adjudged cases, in distinction to statutes and other
  659. sources of law.
  660. Civil Case or Suit
    A case brought by one or more individuals to seek redress of some legal injury
  661. (or aspect of an injury) for which there are civil (non-criminal) remedies.
  662. Common Law
    A system of legal principles that does not derive its authority from statutory law, but
  663. from general usage and custom as evidenced by decisions of courts.
  664. Compensation
    Money that a court or other tribunal orders to be paid, by a person whose acts or
  665. omissions have caused loss or injury to another, in order that the person demnified may receive equal
  666. value for 1he loss, or be made whole in respect to the injury.
  667. Competence
    The mental ability and capacity to make decisions, accomplish actions, and perform
  668. tasks that another person of similar background and training, or any human being, would be
  669. reasonably expected to perform adequately.
  670. Confidential Communications
    Certain classes of communications, passing between persons who
  671. stand in a confidential or fiduciary relation to each other (or who, on account of their relative situation,
  672. are under a special duty of secrecy and fidelity), that the law will not permit to be divulged.
  673. Contempt of Court
    Any act that is calculated to embarrass, hinder, delay or obstruct the court in
  674. the administration of justice, or that is calculated to lessen its authority of its dignity.
  675. Cross Examination
    The questioning of a witness during a trial or deposition by the party opposing
  676. those who originally asked him/her to testify.
  677. Damages
    Money awarded by a court to someone who has been injured (plaintiff) and that must be
  678. paid by the party responsible for the injury (defendant). Normal damages are awarded when the
  679. injury is judged to be slight. Compensatory damages are awarded to repay of compensate the
  680. injured party for the injury incurred. Punitive damages are awarded when the injury is judged to have
  681. been committed maliciously or in wanton disregard of the injured plaintiff's interests.
  682. Defendant
    The person against whom an action is brought to court because of alleged responsibility
  683. for violating one or more of the plaintiff's legally protected interests.
  684. Deposition
    The testimony of a witness taken upon interrogatories not in open court, but in
  685. pursuance of a commission to take testimony issued by a court, or under a general law on the
  686. subject, and reduced to writing and duly authenticated, and intended to be used upon the trial of an
  687. action in court.
  688. Direct Examination
    The first interrogation or examination of a witness, on the merits, by the party
  689. on whose behalf he/she is called.
  690. Discovery
    The process by which one party to a civil suit can find out about matters that are relevant
  691. to his/her case, including information about what evidence the other side has, what witnesses will be
  692. called upon, and so on. Discovery devices for obtaining testimony, requests for documents or other
  693. tangibles, or requests for physical or mental examinations.
  694. Distributive Justice
    Deals with the moral basis for the dissemination of goods and evils, burdens
  695. and benefits, especially when making decisions regarding the allocation of healthcare resources.
  696. Evidence
    Any species of proof, or probative matter, legally presented at the trial of an issue, by the
  697. act of the parties and through the medium of witnesses, records, documents, concrete objects, and
  698. the like, for the purpose of inducing beliefs in the minds of the court or jury as to their contention.
  699. Ex Parte
    A judicial proceeding, order, injuction, and so on, taken or granted at the instance and for
  700. the benefit of one party only, and without notice to, or contestation by, any person adversely
  701. interested.
  702. Expert Witness
    A person called to testify because of recognized competence in an area.
  703. Fair Hearing
    One in which authority is executed fairly
  704. principles of justice embraced within the conception of due process of law.
  705. Fiduciarv
    Person in a special relationship of trust, confidence or responsibility in which one party
  706. occupies a superior relationship and assumes a duty to act in the dependent's best interest. This
  707. includes a trustee, guardian, counselor or institution, but it could also be a volunteer acting in this
  708. special relationship.
  709. Fraud
    Knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud
  710. any healtlhcare benefit program or to obtain, by means of false or fraudulent pretenses,
  711. representations, or promises, any of the money or property owned by, or under the custody or control
  712. of, any healthcare benefit program. Fraud is an intentional deception or misrepresentation that
  713. someone makes, knowing it is false, that could result in an unauthorized payment.
  714. Gag Rules
    A clause in a provider's contract that prevents physicians or other providers from
  715. revealing a full range of treatment options to patients or, in some instances, from revealing their own
  716. financial self-interest in keeping treatment costs down. These rules have been banned by many
  717. states.
  718. Guardian
    A person appointed by the court to be a substitute decision-maker for persons receiving
  719. services deemed to be incompetent of making informed decisions for themselves. The powers of a
  720. guardian are determined by a judge and may be limited to certain aspects of the person's life.
  721. Healthcare Proxy
    A legal document that directs the healthcare provider/agency in whom to contact
  722. for approval/consent of treatment decisions or options whenever the patient is no longer deemed
  723. competent to decide for self.
  724. Hearsay
    Evidence not proceeding from the personal knowledge of the witness, but from the mere
  725. repetition of what has been heard from others.
  726. Impeach
    In the law of evidence, it is to call in question the veracity of a witness, by means of
  727. evidence adduced for that purpose.
  728. Informed Consent
    Consent given by a patient, next of kin, legal guardian, or designated person for
  729. a kind of intervention, treatment, or service after the provision of sufficient information by the provider.
  730. A decision based on knowledge of the advantages and disadvantages and implications of choosing a
  731. particular course of action.
  732. Interrogatories
    A set or series of written questions composed for the purpose of being propounded
  733. to a party in equity, a garnishee, or a witness whose testimony is taken in a deposition.
  734. Justice
    Maintaining what is right and fair and making decisions that are good for the patient.
  735. Liability
    Legal responsibility for failure to act appropriately or for actions that do not meet the
  736. standards of care, inflicting harm on another person.
  737. Lien
    A charge or security or encumbrance upon property.
  738. Limitation, Statute of
    A statute prescribing limitations to the right of action on certain described
  739. causes of action
    that is, declaring that no suit shall be maintained on such causes of action unless
  740. brought within a specified period of time after the right accrued.
  741. Litigation
    A contest in a court for the purpose of enforcing a right, particularly when inflicting harm
  742. on another person.
  743. Living will
    A legal document that directs the healthcare team/provider in holding or withdrawing life
  744. support measures. It is usually prepared by the patient while he or she is competent, indicating the
  745. patient's wishes.
  746. Malpractice
    Improper care or treatment by a healthcare professional. A wrongful conduct.
  747. Medical Durable Power of Anornev
    A legal document that names a surrogate decision maker in
  748. the event that the patient becomes unable to make his or her own healthcare decisions.
  749. Motion
    A request to the court to take some action or to request the opposing side to take some
  750. action relating to a case.
  751. Negligence
    Failure to act as a reasonable person. Behavior is contrary to that of any ordinary
  752. person facing similar circumstances.
  753. Nonmaleficence
    Refraining from doing harm to others
  754. Petition
    An application to a court ex parte paying for the exercise of the judicial powers of the court
  755. in relation to some matter that is not the subject for a suit or action, or for authority to do some action
  756. that requires the sanction of the court.
  757. Plaintiff
    A person who brings a suit to court in the belief that one or more of his/her legal right have
  758. been violated or that he/she has suffered legal injury.
  759. Precedent
    A decision by a judge or court that serves as a rule or guide to support other judges in
  760. deciding future cases involving similar or analogous legal questions.
  761. Privacy, .Right of
    The right of an individual to withhold his/her person and property from public
  762. scrutiny, if so desired, as long as it is consistent with the law or public policy.
  763. Release
    The relinquishment of a right, claim, or privilege, by a person in whom it exists or to whom
  764. it accrues, to the person against whom it might have been demanded or enforced.
  765. Remand
    To send back, as in sending a case back to the same court out of which it came for
  766. purposes of having some action taken on it there.
  767. Remedy
    The means by which a right is enforced or the violation of a right is prevented, redressed,
  768. or compensated.
  769. Respondeat Superior
    Literally, "let the master respond." This maxim means that an employer is
  770. liable in certain cases for the wrongful acts of his/her employees, and the principal for those of his/her
  771. agency.
  772. Settlement
    A "meeting of minds" of parties to a transaction or controversy which resolves some or
  773. all of the issues involved in a case.
  774. Statute
    An act of a legislature declaring, commanding, or prohibiting and action, in contrast to
  775. unwritten common law.
  776. Stipulation
    An agreement between opposing parties that a particular fact or principle of law is true
  777. and applicable.
  778. Subrogation
    The right to pursue and lien upon claims for medical charges against another person
  779. or entity.
  780. Subpoena
    A process commanding a witness to appear and give testimony in court.
  781. Tort
    A civil wrong for which a private individual may recover money damages, arising from a breach
  782. of duty created by law.
  783. Tort Liability
    The legal requirement that a person responsible, or at fault, shall pay for the damages
  784. and injuries caused.
  785. Tort-Feasor
    A wrong-doer who is legally liable for damage caused.
  786. Veracity
    The act of telling the truth.
  787. Waiver
    The intentional or voluntary relinquishment of a known right.
  788. Brain Disorder
    A loosely used term for a neurological disorder or syndrome indicating impairment
  789. or injury to brain tissue.
  790. Brain Injury
    Any damage to tissues of the brain that leads to impairment of the function of the
  791. Central Nervous System.
  792. Carpel Tunnel Syndrome
    The name given to the symptoms that occur when the nerves and
  793. tendons running through the carpal tunnel of the wrist are compressed by tissue or bone or become
  794. irritated and swell. The carpal tunnel itself is a narrow passage in the wrist comprised of bones and
  795. ligaments through which nerves and tendons pass into the hand. Also referred to as "Cumulative
  796. Trauma Injury/Disorder," "Repetitive Motion Injury," and "Repetitive Stress Syndrome."
  797. Case Mix Complexity
    An indication of the severity of illness, prognosis, treatment difficulty, need
  798. for intervention, or resource intensity of a group of patients.
  799. Case Mix Group (CMG)
    Each CMG has a relative weight that determines the base payment rate for
  800. inpatient rehabilitation facilities under the Medicare system.
  801. Case Mix Index (CMI)
    The sum of DRG-relative weights of all patients/cases seen during a 1-year
  802. period in an organization, divided by the number of cases hospitalized and treated during the same
  803. year.
  804. Catastrophic Case
    Any medical condition or illness that has heightened medical, social and
  805. financial consequences that responds positively to the control offered through a systematic effort of
  806. case management.
  807. Comorbidlty
    A preexisting condition (usually chronic) that, because of its presence with a specific
  808. condition, causes an increase in the length of stay by about 1 day in 75% of the patients.
  809. Complication
    An unexpected condition that arises during a hospital stay or healthcare encounter
  810. that prolongs the length of stay at least by 1 day in 75% of the patients and intensifies the use of
  811. healthcare resources.
  812. Concurrent Review
    A method of reviewing patient care and services during a hospital stay to
  813. validate the necessity of care and to explore alternatives to inpatient care. It is also a form of
  814. utilization review that tracks the consumption of resources and the progress of patients while being
  815. treated.
  816. Core Therapies
    Basic therapy services provided by professionals on a rehabilitation unit. Usually
  817. refers to nursing, physical therapy, occupational therapy, speech-language pathology,
  818. neuropsychology, social work and therapeutic recreation.
  819. Deaf (Deafness)
    Defined as a condition in which the auditory sense is not the primary means by
  820. which speech and language are learned and the sense of hearing is so lacking or drastically reduced
  821. as to prohibit normal function as a hearing person.
  822. Developmental Retardation
    A term that has been suggested as a replacement for mental
  823. retardation. Removes confusion with mental health and mental illness.
  824. MEDICAL Durable Medical Equipment (DME)
    Equipment needed by patients for self-care. Usually it must
  825. withstand repeated use, is used for a medical purpose, and is appropriate for use in the home setting.
  826. Emotional Intelligence
    The ability to sense, understand, and effectively apply the power and
  827. acumen of emotions as a source of energy, information, connection, and influence. It also is the
  828. ability to motivate oneself and persist in the face of frustration
    control impulse
  829. and keep distress from swamping the ability to think, empathize, and hope.
  830. Hearing Impairment
    Loss of or compromised hearing.
  831. Impairment
    A general term indicating injury, deficiency or lessening of function. Impairment is a
  832. condition that is medically determined and relates to the loss or abnormality of psychological,
  833. physiological, or anatomical structure or function. Impairments are disturbances at the level of the
  834. organ and include defects or loss of limb, organ or other body structure or mental function, e.g.
  835. amputation, paralysis, mental retardation, psychiatric disturbances as assessed by a physical.
  836. Mental Retardation
    A broadly used term that refers to significantly sub-average general intellectual
  837. functioning manifested during developmental period and existing concurrently with impairment in
  838. adaptive behavior.
  839. Mobility
    The ability to move about safely and efficiently within one's environment.
  840. Occupational Disease
    Any disease or specified disease that is common to or a result of a
  841. particular occupation of specific work environment.
  842. Sensory Aphasia
    Inability to understand the meaning of written, spoken or tactile speech symbols
  843. because of disease or injury to the auditory and visual brain centers.
  844. Sentinel Event
    An unexpected occurrence, not related to the natural course of illness, that results
  845. in death, serious physical or psychological injury, or permanent loss of function.
  846. Visual Impairment
    Educationally defined as deficiency in eyesight to the extent that special
  847. provisions are necessary in education.
  848. Accreditation
    A standardized program for evaluating healthcare organizations to ensure a specified
  849. level of quality, as defined by a set of national industry standards. Organizations that meet
  850. accreditation standards receive an official authorization or approval of their services. Accreditation
  851. entails a voluntary survey process that assesses the extent of a healthcare organization's compliance
  852. with the standards for the purpose of improving the systems and processes of care (performance)
  853. and, in so doing, improving patient outcomes.
  854. Benchmarking
    An act of comparing a work process with that of the best competitor. Through this
  855. process one is able to identify what performance measure levels must be surpassed. Benchmarking
  856. assists an organization in assessing its strengths and weaknesses and in finding and implementing
  857. best practices.
  858. Caregiver
    The person responsible for caring for a patient in the home setting. Can be a family
  859. member, friend, volunteer, or an assigned healthcare professional.
  860. Credentiallnq
    A review process to approve a provider who applies to participate in a health plan.
  861. Specific criteria are applied to evaluate participation in the plan. The review may include references,
  862. training, experience, demonstrated ability, licensure verification, and adequate malpractice insurance.
  863. Cultural Competency
    A set of congruent behaviors, attitudes, and policies that come together in a
  864. system, agency, or among professionals and enables that system, agency, or those professionals to
  865. work effectively in cross-cultural situations.
  866. Culture
    The thoughts, communications, actions, customs, beliefs, values, and institutions of racial,
  867. ethnic, religious, or social groups.
  868. Database
    An organized, comprehensive collection of patient care data. Sometimes it is used for
  869. research or for quality improvement efforts.
  870. Ergonomics (or human factors)
    The scientific discipline concerned with the understanding of
  871. interactions among humans and other elements of a system. It is the profession that applies theory,
  872. principles, data and methods to environmental design (including work environments) in order to
  873. optimize human well-being and overall system performance.
  874. Ergonomist
    An individual who has (1) a mastery of ergonomics knowledge
  875. methodologies used by ergonomists in applying that knowledge to the design of a product, process,
  876. or environment
    and (3) has applied his or her knowledge to the analysis, design, test, and evaluation
  877. of products, processes, and environments.
  878. Internet
    A public, cooperative creation that operates using national and international
  879. telecommunication technologies and networks, including high-speed data lines, phone lines, satellite
  880. communications, and radio networks.
  881. JCAHO
    Joint Commission on Accreditation of Health Care Organizations.
  882. Licensure
    A mandatory and official form of validation provided by a governmental agency in any
  883. state affirming that a practitioner has acquired the basic knowledge and skill and minimum degree of
  884. competence required for safe practice in his or her profession.
  885. Life Care Plan
    A dynamic document based upon published standards of practice, comprehensive
  886. assessment, research and data analysis, which provides an organized, concise plan for current and
  887. future needs with associated costs for individuals who have experienced catastrophic injury or have
  888. chronic healthcare needs.
  889. Standard (Individual)
    An authoritative statement bu which a profession defines the responsibilities
  890. for which its practitioners are accountable.
  891. Standard (Organization)
    An authoritative statement that defines the performance expectations,
  892. structures, or processes that must be substantially in place in an organization to enhance the quality
  893. of care.
  894. Standards of Care
    Statements that delineate care that is expected to be provided to all clients.
  895. They include predefined outcomes of care clients can expect from providers and are accepted within
  896. the community of professionals, based upon the best scientific knowledge, current outcomes data,
  897. and clinical expertise.
  898. Standards of Practice
    Statements of acceptable level of performance or expectation for
  899. professional intervention or behavior associated with one's professional practice. They are generally
  900. formulated by practitioner organizations based upon clinical expertise and the most current research
  901. findings.
  902. Utilization Review Accreditation Commission (URAC)
    A not-for-profit organization that provides
  903. reviews and accreditation for utilization review services/programs provided by freestanding agencies.
  904. It is also known as the American Accreditation Health Care Commission.
  905. Adaptive Behavior
    The effectiveness and degree to which an individual meets standards of selfsufficiency
  906. and social responsibility for his/her age-related cultural group.
  907. ADL
    Activities of Daily Living. Routine activities carried out for personal hygiene and health and for
  908. operating a household. ADLs include feeding, bathing, showering, dressing, getting in or out of bed
  909. or a chair, and using the toilet.
  910. Assistive Device
    Any tool that is designed, made, or adapted to assist a person to perform a
  911. particular task.
  912. Assistive Technologv
    Any item, piece of equipment, or product system, whether acquired
  913. commercially or off the shelf, modified, or customized, that is used to increase, maintain, or improve
  914. functional capabilities of individuals with disabilities. Examples are listening devices, speech
  915. production equipment and low vision devices.
  916. Assistive Technology Services
    Any service that directly assists an individual with a disability in
  917. the selection, acquisition, or use of an assistive technology device.
  918. Barriers
    Factors in a person's environment that, if absent or present, limit one's functioning and
  919. create disability. Examples are a physical environment that is inaccessible, lack of relevant assistive
  920. technology, and negative attitudes of people toward disability. Barriers also include services,
  921. systems, and policies that are either nonexistent or that hinder the involvement of people with a
  922. health condition in any area of life.
  923. Capacity
    A construct that indicates the highest probable level of functioning a person may reach.
  924. Capacity is measured in a uniform or standard environment, and thus reflects the environmentally
  925. adjusted ability of the individual.
  926. CARF
    Commission on Accreditation of Rehabilitation Facilities. A private, non-profit organization
  927. that establishes standards of quality for services to people with disabilities and offers voluntary
  928. accreditation for rehabilitation facilities based on a set of nationally recognized standards.
  929. Cognitive Rehabilitation
    Therapy programs which aid persons in managing specific problems in
  930. perception, memory, thinking and problem-solving. Skills are practices and strategies are taught to
  931. help improve function and/or compensate for remaining deficits.
  932. Counseling Porcess
    A process that uses relationship and therapeutic skills to foster the
  933. independence, growth, development, and behavioral change of persons with disabilities through the
  934. implementation of a working alliance between the counselor and the client. It involves communication,
  935. goal setting, and beneficial growth or change through self-advocacy, psychological, vocational, social,
  936. and/or behavioral interventions.
  937. Functional Capacity Evaluation (FCEJ
    A systematic process of assessing an individual's physical
  938. capacities and functional abilities. The FCE matches human performance levels to the demands of a
  939. specific job or work activity or occupation. It establishes the physical level of work an individual can
  940. perform. The FCE is useful in determining job placement, job accommodation, or return to work after
  941. injury or illness. FCEs can provide objective information regarding functional work ability in the
  942. determination of occupational disability status.
  943. Habilitation
    The process by which a person with developmental disabilities is assisted in acquiring
  944. and maintaining life skills to
    1) cope more effectively with personal and developmental demands
  945. and 2) to increase the level of physical, mental, vocational and social ability through services.
  946. Persons with developmental disabilities include anyone whose development has been delayed,
  947. interrupted or stopped/fixed by injury or disease after an initial period of normal development, as well
  948. as those with congenital condition.
  949. Inclusive Education
    An educational model in which students with disabilities receive their
  950. education in a general educational setting with collaboration between general and special education
  951. teachers. Implementation may be through the total reorganization and redefinition of general and
  952. special education roles, or as one option in a continuum of available services.
  953. Inpatient Rehabilitation Facilities Patient Assessment Instrument (IRF·PAI)
    The Inpatient
  954. Rehabilitation Facilities Patient Assessment Instrument, used to classify patients into distinct groups
  955. based on clinical characteristics and expected resource needs. The PAl determines the Case Mix
  956. Group (CMG) classification.
  957. Rehabilitation
    (1) Restoration of form and function following an illness or injury
  958. an individual's capability to achieve the fullest possible life compatible with his abilities and
  959. disabilities
    (3) the development of a person to the fullest physical, psychological, social, vocational,
  960. avocational and educational potential consistent with his/her physiological or anatomical impairment
  961. and environmental limitations.
  962. Rehabilitation Counseling
    A specialty within the rehabilitation professions with counseling being at
  963. its core. It is a profession that assists individuals with disabilities in adapting to the environment,
  964. assists environments in accommodating the needs of the individual, and works toward full
  965. participation of persons with disabilities in all aspects of society, especially work
  966. Rehabilitation Counselor
    A counselor who possesses the specialized knowledge, skills, and
  967. attitudes needed to collaborate in a professional relationship with persons with disabilities to empower
  968. them to achieve their personal, social, psychological, and vocational goals.
  969. Rehabilitation Engineering
    The field of technology and engineering serving disabled individuals in
  970. their rehabilitation. Includes the construction and use of a great variety of devices and instruments
  971. designed to restore or replace function mostly of the locomotion and sensory systems.
  972. Rehabilitation Impairment Categories (RIC)
    Represent the primary cause of the rehabilitation
  973. stay. They are clinically homogeneous groupings that are then subdivided into Case Mix Groups
  974. (CMGs).
  975. Rehabilitation Team
    A group of health care workers with backgrounds in rehabilitation who work
  976. together to provide integrated, patient-oriented care. A variety of specialists and other providers who
  977. combine resources to address each client's physical, mental, emotional and spiritual needs in order to
  978. minimize disability and resulting handicaps.
  979. Universal Design
    The design of products and environments to be usable by all people, to the
  980. greatest extent possible, without the need for adaptation or specialized design.
  981. Vocational Evaluation
    The comprehensive assessment of vocational aptitudes and potential, using
  982. information about a person's past history, medical and psychological status, and information from
  983. appropriate vocational testing, which may use paper and pencil instruments, work samples, simulated
  984. work stations, or assessment in a real work environment.
  985. Vocational Rehabilitation
    Cost effective case management by a skilled professional who
  986. understands the implications of the medical and vocational services necessary to facilitate an injured
  987. worker's expedient return to suitable gainful employment with a minimal degree of disability.
  988. Vocational Rehabilitation Counselor
    A rehabilitation counselor, who specializes in vocational
  989. counseling, i.e. guiding handicapped persons in the selection of a vocation or occupation.
  990. Vocational Testing
    The measurement of vocational interests, aptitudes, and ability using
  991. standardized, professionally accepted psychomotor procedures.
  992. RETURN-To-WORK Employability
    Having the skills and training that are commonly necessary in the labor market to be
  993. gainfully employed on a reasonably continuous basis, when considering the person's age, education,
  994. experience, physical, and mental capacities due to industrial injury or disease.
  995. RETURN-To-WORK Job Bank Service
    A computerized system, developed by the Department of Labor, which maintains
  996. an up-to-date listing of job vacancies available through the State Employment Service.
  997. Return to work Job Club
    An organization of individuals who are seeking work, who join together to share
  998. information about employers, interviewing strategies, job seeking skills, and work opportunities.
  999. RETURN-To-WoRK Job Coach
    An employment specialist who provides training and support to a person at the
  1000. workplace.
  1001. RETURN-TO-WORK Reasonable Accommodation
    Making existing facilities used by employees readily accessible and
  1002. usable by individuals with disabilities. This may include job restructuring, part-time or modified work
  1003. schedules, acquisition or modification of equipment or devices, and other similar accommodations for
  1004. individua~ s with disabilities.
  1005. RETURN-TO-WORK Supported Employment
    Paid employment for persons with developmental disabilities who, without
  1006. long-term support, are unlikely to succeed in a regular job. Supported employment facilitates provide
  1007. competitive work in integrated work settings for individuals with the most severe disabilities (i.e.
  1008. psychiatrac, mental retardation, learning disabilities, traumatic brain injury) for whom competitive
  1009. employment has not traditionally occurred, and who, because of the nature and severity of their
  1010. disability. need ongoing support services in order to perform their job. Supported employment
  1011. provides assistance such as job coaches, transportation, assistive technology, specialized job
  1012. training, and individually tailored supervision.
  1013. RETURN-TO-WORK Vocational Assessment
    Identifies the individual's strengths, skills, interests, abilities and
  1014. rehabilitation needs. Accomplished through on-site situational assessments at local businesses and
  1015. in community settings.
  1016. RETURN-To-WORK Work Adjustment
    The use of real or simulated work activity under close supervision at a
  1017. rehabilitation facility or other work setting to develop appropriate work behaviors, attitudes, or
  1018. personal characteristics.
  1019. RETURN-To-WORK Work Adjustment Training
    A program for persons whose disabilities limit them from obtaining
  1020. competitive employment. It typically includes a system of goal directed services focusing on
  1021. improving problem areas such as attendance, work stamina, punctuality, dress and hygiene and
  1022. interpersonal relationships with co-workers and supervisors. Services can continue until objectives
  1023. are met or until there has been noted progress. It may include practical work experience or extended
  1024. employment.
  1025. RETURN-To-WORK Work Conditioning
    An intensive, work-related, goal-oriented conditioning program designed
  1026. specifically to restore systemic neuromusculoskeletal functions (e.g., joint integrity and mobility,
  1027. muscle performance (including strength, power, and endurance), motor function (motor control and
  1028. motor learning), range of motion (including muscle length), and cardiovascular/pulmonary functions
  1029. (e.g., aerobic capacity/endurance, circulation, and ventilation and respiration/gas exchange). The
  1030. objective of the work conditioning program is to restore physical capacity and function to enable the
  1031. patient/cli
    ent to return to work.
  1032. RETURN-To-WORK Work Hardening
    A highly structured, goal-oriented, and individualized intervention program that
  1033. provides clients with a transition between the acute injury stage and a safe, productive return to work.
  1034. Treatment is designed to maximize each individual's ability to return to work safely with less likelihood
  1035. of repeat injury. Work hardening programs are multidisciplinary in nature and use real or simulated
  1036. work activities designed to restore physical, behavioral, and vocational functions. They address the
  1037. issues of productivity, safety, physical tolerances, and worker behaviors.
  1038. RETURN-To-WoRK Work Modification
    Altering the work environment to accommodate a person's physical or mental limitations by making changes in equipment, in the methods of completing tasks, or in job duties.
  1039. RETURN-To-WORK Work Rehabilitation
    A structured program of graded physical conditioning/strengthening exercises and functional tasks in conjunction with real or simulated job activities. Treatment is designed to improve the individual's cardiopulmonary, neuromusculoskeletal (strength, endurance, movement, flexibility, stability, and motor control) functions, biomechanical/human performance levels, and psychosocial aspects as they relate to the demands of work. Work rehabilitation provides a transition between acute care and return to work while addressing the issues of safety, physical tolerances,
  1040. work behaviors, and functional abilities.

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