Flashcards in Final Study Deck Deck (66):
Levels of Service
Based on the patient's condition and the needed level of care, used to identify and verify that the patient is receiving care at the appropriate level.
A process used to ensure that care is being delivered at or above acceptable
quality standards and as identified by the organization or national guidelines.
Effectiveness of Care
The extent to which care is provided correctly (i.e., to meet the patient's needs, improve quality of care, and resolve the patient's problems), given the current state of
knowledge, and the desired outcome is achieved.
A predetermined measure for assessing quality; a metric.
The process of determining specific objectives, goals, and actions designed to meet the client’s needs as identified through the assessment process. The plan should be action-oriented and time-specific.
An array of techniques and methods used for the collection and analysis of data gathered in the course of current healthcare practices in a defined care setting to identify and
resolve problems in the system and improve the processes and outcomes of care.
Case Management Plan (CMP)
Multidisciplinary Action PLan (MAP)
A timeline of patient care activities and expected outcomes of care that
address the plan of care of each discipline involved in the care of a particular patient. It is usually developed prospectively by an interdisciplinary healthcare team in relation to a patient's diagnosis, health problem, or surgical procedure.
Intensity of Service
An acuity of illness criteria based on the evaluation/treatment plan, interventions, and anticipated outcomes.
The ongoing process of gathering sufficient information from all relevant sources about
the case management plan and its activities and/or services to enable the case manager to determine the plan’s effectiveness.
Conducted while the patient is in the hospital, care is reviewed for its appropriateness.
A state of healthcare delivery in which a large number of consumers choose among health plans that offer similar benefits. In theory, competition would be based on cost and
quality and ideally would limit high prices and improve quality of care.
A measure or metric that can be used to monitor and assess quality and outcomes of
important aspects of care or services. It measures the performance of functions, processes, and outcomes of an organization.
The systematic, quantitative observation, at a point in time, of outcome indicators.
Efficiency of Care
The extent to which care is provided to meet the desired effects/outcomes to improve quality of care and prevent the use of unnecessary resources.
Measures of quality and cost of care. Metrics used to examine and evaluate the results of the care delivered.
The result of an illness or injury which prevents an insured from performing one or
more of the functions of his/her regular job.
Level of Care
he intensity of effort required to diagnose, treat, preserve or maintain an individual's
physical or emotional status.
The course of action adopted to care for a patient or to prevent disease.
The use of activities and programs to ensure the quality of patient care. These
activities and programs are designed to monitor, prevent, and correct quality deficiencies and noncompliance with the standards of care and practice.
Management Service Organization
A management entity owned by a hospital, physician organization, or third party. It contracts with payers and hospitals/physicians to provide certain
healthcare management services such as negotiating fee schedules and handling administrative functions, including utilization management, billing, and collections.
A formal and planned, systematic, organizationwide (or networkwide)
approach to the monitoring, analysis, and improvement of organization performance, thereby continually improving the extent to which providers conform to defined standards, the quality of patient care and services provided, and the likelihood of achieving desired patient outcomes.
The use of information and knowledge gained from outcomes monitoring to achieve optimal patient outcomes through improved clinical decision making and service delivery.
Continuous Quality Improvement (CQI)
A key component of total quality management that uses rigorous, systematic, organization-wide processes to achieve ongoing improvement in the quality of healthcare services and operations. It focuses on both outcomes and processes of care.
Severity of Illness
An acuity of illness criteria that identifies the presence of significant/debilitating
symptoms, deviations from the patient's normal values, or unstable/abnormal vital signs or laboratory findings.
The frequency with which a benefit is used during a 1-year period, usually expressed in
occurrences per 1000 covered lives.
A system of healthcare delivery that aims to provide a generalized structure and
focus when managing the use, access, cost, quality, and effectiveness of healthcare services. Links the patient to provider services.
Loss Expense Allocated
That part of expense paid by an insurance company in settling a particular claim, such as legal fees, by excluding the payments to the claimant.
Assignment of Benefits
Paying medical benefits directly to a provider of care rather than to a
member. This system generally requires either a contractual agreement between the health plan and
provider or written permission from the subscriber for the provider to bill the health plan.
A provision in most group policies for the return of premium to the policyholder
because of lower than anticipated claims.
Target Utilization Rates
Specific goals regarding the use of medical services, usually included in
risk-sharing arrangements between managed care organizations and healthcare providers.
A general class of insurance and workers' compensation insurance.
Efforts by the insurer and the insured to prevent accidents and reduce loss through
the maintenance and updating of health and safety procedures.
A legal duty, imposed by statute or otherwise, owing by defendant to the one
The application of the proper classification rate and possibly other factors to set the amount of premium for a policyholder. The three principle forms of rating are: 1) manual rating; 2) experience rating; and 3) retrospective rating.
A predetermined all-inclusive fee for a specific set of related services, treated as a
single unit for billing or reimbursement purposes.
Organization of physicians and hospitals that is responsible for negotiating contractual agreements for healthcare provision with third-party payers such as managed
The percent relationship which losses bear to premiums for a given period.
The process of determining the premium rate for a group risk, wholly or partially
on the basis of that group's experience.
The uncertainty of loss with respect to person, liability, or the property of the insured OR
Probability that revenues of the insurer will not be sufficient to cover expenditures incurred in the delivery of contracted services.
Prepaid Health Plan
Health benefit plan in which a provider network delivers a specific complement
of health services to an enrolled population for a predetermined payment amount (see capitation).
Security against possible loss or damages. Reimbursement for loss that is paid in a
predetermined amount in the event of covered loss.
The legal requirement that a person responsible, or at fault, shall pay for the damages
and injuries caused.
The mental ability and capacity to make decisions, accomplish actions, and perform
tasks that another person of similar background and training, or any human being, would be
reasonably expected to perform adequately.
The right to pursue and lien upon claims for medical charges against another person
A decision by a judge or court that serves as a rule or guide to support other judges in
deciding future cases involving similar or analogous legal questions.
Legal responsibility for failure to act appropriately or for actions that do not meet the
standards of care, inflicting harm on another person.
The relinquishment of a right, claim, or privilege, by a person in whom it exists or to whom
it accrues, to the person against whom it might have been demanded or enforced.
An agreement between opposing parties that a particular fact or principle of law is true
Inability to understand the meaning of written, spoken or tactile speech symbols
because of disease or injury to the auditory and visual brain centers.
Case Mix Complexity
An indication of the severity of illness, prognosis, treatment difficulty, need
for intervention, or resource intensity of a group of patients.
Case Mix Group (CMG)
Has a relative weight that determines the base payment rate for
inpatient rehabilitation facilities under the Medicare system.
Any medical condition or illness that has heightened medical, social and
financial consequences that responds positively to the control offered through a systematic effort of
A general term indicating injury, deficiency or lessening of function.
A condition that is medically determined and relates to the loss or abnormality of psychological, physiological, or anatomical structure or function.
Disturbances at the level of the
organ and include defects or loss of limb, organ or other body structure or mental function, e.g. amputation, paralysis, mental retardation, psychiatric disturbances as assessed by a physical.
Basic therapy services provided by professionals on a rehabilitation unit. Usually
refers to nursing, physical therapy, occupational therapy, speech-language pathology,
neuropsychology, social work and therapeutic recreation.
Case Mix Index (CMI)
The sum of DRG-relative weights of all patients/cases seen during a 1-year
period in an organization, divided by the number of cases hospitalized and treated during the same
A counselor who possesses the specialized knowledge, skills, and
attitudes needed to collaborate in a professional relationship with persons with disabilities to empower
them to achieve their personal, social, psychological, and vocational goals.
The process by which a person with developmental disabilities is assisted in acquiring
and maintaining life skills to: 1) cope more effectively with personal and developmental demands;
and 2) to increase the level of physical, mental, vocational and social ability through services.
Persons with developmental disabilities include anyone whose development has been delayed,
interrupted or stopped/fixed by injury or disease after an initial period of normal development, as well
as those with congenital condition.
Inpatient Rehabilitation Facilities Patient Assessment Instrument (IRF-PAI)
s used to classify patients into distinct groups
based on clinical characteristics and expected resource needs. This determines the Case Mix
Group (CMG) classification.
The effectiveness and degree to which an individual meets standards of selfsufficiency
and social responsibility for his/her age-related cultural group.
Rehabilitation Impairment Categories (RIC)
Represent the primary cause of the rehabilitation
stay. They are clinically homogeneous groupings that are then subdivided into Case Mix Groups
The field of technology and engineering serving disabled individuals in
their rehabilitation. Includes the construction and use of a great variety of devices and instruments
designed to restore or replace function mostly of the locomotion and sensory systems.
Cost effective case management by a skilled professional who
understands the implications of the medical and vocational services necessary to facilitate an injured
worker’s expedient return to suitable gainful employment with a minimal degree of disability.
The use of real or simulated work activity under close supervision at a
rehabilitation facility or other work setting to develop appropriate work behaviors, attitudes, or
Work Adjustment Training
A program for persons whose disabilities limit them from obtaining
competitive employment. It typically includes a system of goal directed services focusing on improving problem areas such as attendance, work stamina, punctuality, dress and hygiene and interpersonal relationships with co-workers and supervisors. Services can continue until objectives
are met or until there has been noted progress. It may include practical work experience or extended employment.
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.