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Reimbursement
Methodology
| Question | Answer |
|---|---|
| Accountable care organization (ACO) | Primary-care led physician and hospital organization that has voluntarily formed a network to provide coordinated care and to receive a share of the savings it produces whil meeting quality and cost targets |
| Affordable Care Act (ACA) | Brief name for Patient Protection and Affordable Care Act of 2010 PL 111-148 as amended by the Health Care and Education Reconciliation Act of 2010 PL 111-152 Collectively these two acts are known as the ACA occasionally the PPACA |
| Allowable fee or Allowable charge | Average or maximum amount the third-party payer will reimburse providers for the service. |
| Bad debt | Services for which healthcare organizations expected, but did not receive, payment. |
| Block grant | Fixed amount of money given or allocated for a specific purpose, such as a transfer of governmental funds to cover health services. |
| Bundling | Combination of supply and pharmaceutical costs or medical visits with associated procedures or services for one lump sum payment. |
| Capitated payment method or Capitation | Method of payment for health services in which an individual or nstitutional provider is paid a fixed, per capita amount for each person enrolled without regard to the actual number or nature of services provided or number of persons served. |
| Case | Patient, resident, or client with a given condition or disease. |
| Case-based payment | Type of prospective payment method in which the third-party payer reimburses the provider a fixed, preestablished payment for each case. |
| Charge | Price assigned to a unit of medical or health service, such as a visit to a physician or a day in a hospital. The charge for the service may be unrelated to the actual cost of providing the service. |
| Charity care | Services for which healthcare organizations did not expect payment because they had previously determined the patients' or clients' inablility to pay. |
| Claim | Request for payment, or itemized statement of healthcare services and their costs, provided by a hospital, physician's office, or other healthcare providere insurance plan by either the policy or certificate holder or the provider. |
| Copayment | Cost-sharing measure in which the policy or certificate holder pays a fixed dollar amount (flat fee) per service, supply, or procedure that is owed to the healthcare facility by the patient. The fixed amount policyholder pays may vary by type |
| Customary, prevailing, and reasonable (CPR) | Type of retrospective fee-for-service payment method in which the third-party pays for fees that are customary, prevailing, and reasonable. |
| Deductible | Annual amount of maney that the policyholder must incure (and pay) before the health insurance will assume liability for the remaining charges or covered expenses. |
| Dependent (family) coverage | Healthcare insurance benefits for spouses, children, or both of the member (enrollee, subscriber, certificate holder): coverage is dependent on relationship with member. |
| Discounted fee-for-service | Type of fee-for-service reimbursement in which the third-party payer has negotiated a reduced ("discounted") fee for its covered insureds. |
| Episode-of-care reimbursement | Healthcare payment method in which providers receive one-lump-sum for all the care they provide related to a condition or disease. |
| Fee | Price assigned to a unit of medical or health service, such as a visit to a physician or a day in a hospital. A fee for a service may be unrelated to the actual cost of providing the service. |
| Fee schedule | Third-party payer's predetermined list of maximum allowable fees for each healthcare service. |
| First mover | Initial innovators: other organizations follow trying to obtain success similar to first organization. |
| Fundamental healthcare reform | Implementation of policies that change key existing structure of the healthcare delivery system, such as unlinking employment and healthcare insurance or mandating universal coverage. |
| Global payment method | Method of payment in which the third-party payer makes one consolidated payment to cover the services of multiple providers who are treating a single episode of care. |
| Guarantor | Person who is responsible for paying the bill or guarantees payment for healthcare services. Patients who are adults are often their own guarantor. Parents guarantee payments for the healthcare costs of their children. |
| Health disparity | Population-specific difference in the presence of disease, health outcomes, quality of healthcare, and access to healthcare services that exists across racial and ethnic groups. |
| Health Insurance Portability and Accountability Act (HIPPA) of 1996 | Significant piece of legislation aimed at improving healthcare data transmission among providers and insurances; designated code sets to be used for electronic transmission of claims. |
| Incremental healthcare reform | Implementation of policies that make changes to existing structures, such as charging the structures. |
| Individual (single) coverage | Healthcare insurance benefits that cover only one individual, the member (enrollee, subscriber, certificate holder). |
| Insurance | Reduction of a person's (insured's) exposure to risk of loss by having another party (insurer) assume the risk. |
| Manager's amendment | Legislative mechanism in which a package of numerous individual amendments is added to a bill. The "managers" are the majority and minority members who led their respective legislative factions in the bill's debate. |
| Meaningful use | Providers' use of electronic health records to achieve significant improvement in health services. Included activities like entering basic patient data, using software apps to improve safety and quality exchanging health info, and submit clinical quality |
| Minimal creditable coverage | Minimum level of healthcare insurance that includes coverage for preventive and primary care, hospitalization, mental health benefits, and prescription drugs. |
| Payer | A payer is an entity that pays for health services, such as an insurance company, workers' compensation, Medicare, or an individual. |
| Policy | Binding contract issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to treat illness or injury (also known as health plan agreement and evidence of coverage). |
| Premium | Amount of money that policyholder or certificate holder must periodically pay a healthcare insurance plan in return for healthcare coverage. |
| Prospective payment method | Type of episode-of-care reimbursement in which the third-party payer establishes the payment rates for healthcare services in advance for a specific time period. |
| Provider | Physician, clinic, hospital, nursing home, or other healthcare entity (second party) rendering the care. |
| Regional health information organization (RHIO) | A health information organization that brings together healthcare stakeholders within a defined goegraphic area and governs health information exchange among them for the purpose of improving health and care in that community. |
| Reimbursement | Compensation or repayment for healthcare services already rendered. |
| Resource-based relative value scale (RBRVS) | Type of retorpective fee-for-service payment method that classifies health services based on the cost of providing physician services in terms of effort, practice expense (overhead), and malpractice insurance. |
| Risk pool | Group of people who will be covered by a healthcare insurance plan. |
| Self-insured plan | Method of insurance in which the employer or other association itself administers the health insurance benefits for its employees or their dependents, thereby assuming the risks for the costs of healthcare for the group. |
| Self-pay | Type of fee-for-service reimbursement in which the patients or their gurantors pay a specific amount for each service received. |
| Single-payer health system | Method financing health services. One entity acts as admin of single insurance pool. Entity collects all health fees (taxes or contributions) pays all health costs for an entire population. Single entity can be agency of govt or govt run organization. |
| Sliding scale | A method of billing in which the cost of healthcare services is based on the patient's income and ability to pay. |
| Third-party payer | Insurance co. or health agency pays physician, clinic, other healthcare provider(second party for care or services to patient(first party. Reimburses for vocered medical services. |
| Third-party payment | Payments for healthcare services made by an insurance company or health agency on behalf of the insured. |
| Uncompensated care | Overall measure of services provided for which no payments were received from the patient, client, or third-party payer. |
| Underserved area | Area or population designated by the federal Health Resources and Services Administration (HRSA) as having too few primary care provider high poverty high elderly high infant mortality |
| Universal healthcare coverage | Minimum level of healthcare insurance that includes coverage for preventative and primary care, hospitalization, mental health benefits, and prescription drugs. |
| Usual, customary and reasonable (UCR) | Type of retropspective fee-for-service payment method third party pays fees UCR wherein usual means for individ provid pract customary for community,reasonable for situation. |
Created by:
Lyn Slough
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