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66 Cards in this Set

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Ambulatory Procedure Classifications (APCs):
Ambulatory Procedure Classifications (APCs): Enacted by the federal government in 2000, a prospective payment system for outpatient services, similar to DRGs, which reimburses a fixed amount for a bundled set of services
Cost-shifting:
Charging one group of patients more in order to make up for underpayment by others. Most commonly, charging some privately insured patients more in order to make up for underpayment by Medicaid or Medicare
Capitation
A system which pays providers a specific amount in advance to care for the health care needs of a population over a specific time period.
Care Mapping
A process which specifies in advance the preferred treatment regimen for patients with particular diagnoses. This is also referred to as a clinical pathway, clinical protocol, or practice guideline.
Compliance:
Compliance: The need to abide by governmental regulations, whether they be for the provision of care, billing, privacy, security, etc.
Cost-shifting:
Charging one group of patients more in order to make up for underpayment by others. Most commonly, charging some privately insured patients more in order to make up for underpayment by Medicaid or Medicare.
Defensive Medicine
The tendency of health care practitioners to do more testing and to provide more care for patients than might otherwise be necessary, simply to protect themselves against potential litigation.
DRGs:
DRGs: A patient classification scheme used by Medicare that clusters patients into categories on the basis of patients' illnesses, diseases and medical problems. These classifications are then used to pay providers a set amount based on the diagnosis related group in which the patient has been classified
Global Payments:
A system to pay providers whereby the fees for all providers (hospitals, physicians, home health care agencies) are included in a single negotiated amount. This is sometimes called "bundling" of services.
In non-global payment systems, each provider is paid separately.
Health Insurance Portability and Accountability Act (HIPAA):
A set of federal compliance regulations enacted in 1996 to ensure standardization of billing, privacy, and reporting as institutions enter a paperless age.
Prospective Payment System
The payment system used by Medicare to reimburse providers a predetermined amount. Several payment methods fall under the umbrella of PPS, including: DRGs (inpatient admissions); APCs (outpatient visits); RBRVS (professional services); and RUGs
Risk Pools
: A generally large population of individuals who are all simultaneously insured under the same arrangement, regardless of working status. Health care utilization - and therefore cost - is more stable for larger groups than it is for smaller groups, which makes larger groups' cost more predictable for insurers.
Accumulated Depreciation
The total amount of depreciation taken on an asset since it was put into use.
Amortization:
The allocation of the acquisition cost of debt to the period which it benefits
Assets:
Resources that the organization owns, typically recorded at their original costs
Basic Accounting Equation
Assets = Liabilities + Net Assets
Charity Care Discoun
Discounts from Gross Patients Accounts Receivable given to those who cannot pay their bills.
Current Assets
Assets which will be consumed (used up) within one year (or one time period).
Current Liabilities:
Financial obligations due within one year (or one time period).
Depreciation:
A measure of how much a tangible asset (such as plant or equipment) has been "used up" or consumed.
Fund Balance:
term used until 1996 for owners' equity by not-for-profit health care organizations. It was replaced with the present term, net assets, for non-governmental, not-for-profit organizations.
Liabilities
The financial obligations of the organization (i.e. debts).
Liquidity:
A measure of how quickly an asset can be converted into cash
Net Assets:
In not-for-profit organizations, the difference between assets and liabilities (assets minus liabilities).
Net Income:
: Excess of revenues over expenses
Non-current Assets:
The resources of the organization that will be used or consumed over periods longer than one year.
Non-current Liabilities
The financial obligations not due within one year.
Notes to Financial Statements
Additional key information written out in detail which is not presented in the body of the financial statement.
Operating Income
Income derived from the organization's main line of business
Owner's Equity:
In for-profit institutions, the difference between assets and liabilities (assets minus liabilities).
Operating Income:
Income derived from the organization's main line of business.
Owner's Equity
In for-profit institutions, the difference between assets and liabilities (assets minus liabilities).
Owner's Equity:
In for-profit institutions, the difference between assets and liabilities (assets minus liabilities).
Third Party Payors
Commonly referred to as third parties, these are organizations that pay on behalf of patients.
Allowable Costs
Costs which are allowable under the principles of reimbursement of government (Medicaid, Medicare) and other payors.
Ambulatory Procedure Classifications (APCs
Enacted by the federal government in 2000, a prospective payment system for outpatient services, similar to DRGs, which reimburses a fixed amount for a bundled set of services.
Capitation:
Capitation: 1) A system which pays providers a specific amount in advance to care for the health care needs of a population over a specific time period. Providers are usually paid on per member per month (PMPM) basis.
Charge-based:
A method of payment which is based on the charge of the provider.
Community Rating:
A rating methodology required of indemnity and HMO insurers that guarantees that there will be equivalent amounts collected from members of a specific group without regard to demographics such as age, sex, size of covered group, and industry type
Contact Capitation:
A method of capitation whereby each specialty has its own capitation pool and use of services by a physician only affects that physician's compensation, not the whole specialty network's compensation.
Contra-asset:
An asset which, when increased, decreases the value of a related asset on the books. Two primary examples are Accumulated Depreciation, which is the contra-asset to Properties and Equipment, and the Allowance for Uncollectibles, which is the contra-asset to Accounts Receivable.
Conversion Factor:
Actuarial based formulas developed to adjust rates allowing for differences in population demographics.
Copayment:
Requiring the patient to pay part of the health care bill. These payments are used to prevent overutilization of services.
Cost-based Reimbursement:
Using the provider's cost of providing services (supplies, staff salaries, space costs, etc.) as the basis for reimbursement.
Cost-shifting:
Charging one group of patients more in order to make up for underpayment by others. Most commonly, charging some privately insured patients more in order to make up for underpayment by Medicaid or Medicare
Deductibles:
When the patient covered is responsible for paying a certain base amount before coverage begins.
Experience Rating:
The method of setting premium rates based on the actual health care costs of a group of groups.
DRGs:
A patient classification scheme used by Medicare that clusters patients into categories on the basis of patients' illnesses, diseases and medical problems. These classifications are then used to pay providers a set amount based on the diagnosis related group in which the patient has been classified.
Gatekeepers:
Providers (typically the PCP) who must preapprove care received by a patient, such as a visit to the specialist. Gatekeepers are utilized in most POS plans and HMO plans.
HCFA:
The Health Care Financing Administration. The US government department that oversaw the provision of and payment for health care provided under its entitlement programs (Medicare, Medicaid) until 2001.
Health Maintenance Organization (HMO):
): A legal corporation that offers health insurance and medical care. HMOs typically offer a range of health care services at a fixed price. See Capitation.
Indemnity Insurance:
A plan which reimburses physicians for services performed, or beneficiaries for medical expenses incurred. Typically, the employer and/or patient pays a monthly premium to the plan for a predetermined set of healthcare benefits.
Managed Care:
Any of a number of arrangements designed to control health care costs through monitoring, prescribing, or proscribing the provision of health care to a patient or population.
Medicaid:
A federally mandated program, operated and partially funded by individual states (in conjunction with the federal government) to provide medical benefits to certain low-income people. The state, under broad federal guidelines, determines what benefits are covered, who is eligible, and how much
providers will be paid.
Medical Savings Accounts:
A limited amount of money an employee can take as pretaxed income to pay for medically related items such as physician visits, pharmaceuticals, eyewear, dental visits, etc. The pretax income is placed in an escrow account held by the employer. The employee must submit receipts
for care received to get reimbursed.
Medicare:
A nationwide, federally financed health insurance program for people age 65 and older. It also covers certain people under 65 who are disabled or have chronic kidney (end-stage renal) disease. Medicare Part A is the hospital insurance program; Part B covers physicians' services. Created by the 1965 amendment to the Social Security Act.
Payor:
An entity that is responsible for paying for the services of a health care provider. Typically, this is an insurance company or a government agency. Commonly referred to as third parties
Per Diem:
An amount a payor will pay for one day of care, which includes all hospital charges associated with the inpatient day (including nursing care, surgeries, medications, etc.).
Per Member Per Month (PMPM)
Generally used by HMOs and their medical providers as an indicator of revenue, expenses, or utilization of services per member per one-month period.
Preferred Provider Organization (PPO):
A network of independent providers preselected by the payor to provide a specific service or range of services at predetermined (usually discounted) rates to the payor's covered members.
Point of Service (POS)
A hybrid between a HMO and a PPO in which patients are given the incentive to see providers participating in a defined network, but may see non-network providers, though usually at some additional cost
RBRVS:
A system of paying physicians based upon the relative value of the services rendered.
RVU
Relative Value Unit
Staff Model HMO:
An HMO which owns its clinics and employs its doctors.
Subcapitation:
Where the primary care physician pays a portion of the total capitated dollars received to another provider (i.e. specialist).
Zero-based Budget (Capitation):
Dividing the entire amount of capitation (the "budget") among all the providers, essentially leaving nothing or "zero" left at the end of every accounting period.