Transition To The Registered Nurse Professional Role - Healthcare Financing

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Health Maintenance Organizations (HMOs)

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This is a prepaid, group managed care plan that allows subscribers to receive all the medical services they require through a group of affiliated providers.

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Managed care

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A system for financing and organizing the delivery of health care in which costs are contained by controlling the provision of services.

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Medicare

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Established under the Social Security Act to establish national and state health insurance programs for the elderly. Payment based on DRGs.

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Medicaid

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Established under the Social Security Act to provide funds for healthcare for those dependent on public assistance and certain other low-income individuals.

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Diagnosis-related groups (DRGs)

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A plan that pays the hospital a fixed amount that is predetermined by the medical diagnosis or specific procedure rather than the actual cost of care.

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Resource utilization groups (RUGs)

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These are the categories used to determine prospective payment for nursing home clients. Each group represents residents which require similar amounts of care and will have a similar cost to support that care each day.

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Fee-for-service

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Traditional method of healthcare payment based on generating a fee every time a service is provided. The more services provided, the more fees charged.

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Capitation

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A method of determining payment in which a fee is paid to a provider organization for each person signed up for the plan, regardless of whether or not that person uses any health care services.

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Independent practice associations (IPAs)

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An association that contracts with independent physicians, and provides services to managed care organizations at a negotiated rate

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Preferred Provider Organizations (PPOs)

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This plan allows a third-party payer to contact with a group of healthcare providers to provide services at a lower fee in return for prompt payment and a guaranteed volume of patients and services.

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The Joint Commission

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A nonprofit, voluntary organization which provides accreditation for hospitals, nursing homes, and related organizations and sets standards for hospital care.

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The National Committee for Quality Assurance (NCQA)

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This organization reviews and evaluates HMOs. Health Plan Employer Data and Information Set (HEDIS) was developed to standardize comparison and evaluation.

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Occupational Safety and Health Administration (OSHA)

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This administration mandates actions and prescribes safety equipment to improve the health and safety of the working environment.

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Equal Opportunity Commission (EEOC)

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This agency enforces laws prohibiting discrimination based on gender, age, race, religion etc.

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Centers for Medicare and Medicaid Services (CMS)

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Agency that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program, and health insurance portability standards