Glossary of Terms Flashcards by Rahel Hellebuyck

Contract between two parties where one party with stronger bargaining power sets the terms and conditions, the other party (weak) must adhere to contract as it is placed in a “take it or leave it” position

Adhesive Contract

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American Academy of Physical Medicine and Rehabilitation

AAPM&R

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The ability and ease of clients to obtain healthcare when they need it

Access to Care

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A term used to denote building facilities that are barrier-free thus enabling all members of society safe access including persons with physical disabilities

Accessible

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Set of healthcare providers that work together collaboratively and accept collective accountability for cost and quality of care delivered to a population of patients

Became popular in the medicare fee-for service benefit system as result of Affordable Care Act

Accountable Care Organization

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Standardized program for evaluating healthcare organizations to ensure a specified level of quality. Defined by set of national industry standards

entails a voluntary survey process that assesses the extent of a healthcare organizations compliance with the standards for the purpose of improving systems and processes of care –> improving client outcomes

Accreditation

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A legal duty, imposed by statute or otherwise, owing by defendants to the one injured

Actionable Tort

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structured way of communication and interacting where on is actively engaged with the speaker primarily through focused attention and suspension of ones bias/judgement

improves personal relationships, understanding and eliminates conflict

Active listening

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Routine actives an individual tends to do daily for self care and normal living

Assess to determine ability, independence, disability, limitations

Determines type of long term care/benefit coverage needed (nursing home, skilled care facility, home care)

Activities of Daily Livin (ADLs)

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Difficulties individual may have in executing activities

Activity limitations

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AKA real value

Measures the worth one derives from using or consuming a good, product, service or item and represents the utility of the good, product, service or item

Actual Value

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Statistical analysis of population based on utilization of healthcare services and demographic trend of population results used to estimate healthcare plan premiums or costs

Actuarial study

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A trained insurance professional who specializes in determining policy rates, calculating premiums, and conducting statistical studies

Actuary

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Complexity and severity of the clients health/medical condition

Acuity

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Delivery system focused on treating sudden and acute episodes of illness

Acute Care

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Americans with Disabilities Act of 1990

ADA

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Americans with Disabilities Act Amendment Act of 2008

ADA Amendments Act (ADAAA)

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The effectiveness and degree to which an individual meets standards of self sufficiency and social responsibility for his/her age related cultural group

Adaptive Behavior

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Extent to which a person’s behavior-taking meds, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider

Adherence

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Developed at John Hopkins University, system clusters clients into homogenous groups on a unique approach to measuring morbidity to improve accuracy and fairness in evaluating healthcare provider performance

System accounts for the burden of morbidity in a client population based on disease patterns, age, and gender and relies on dx and/or pharmaceutical code information found in insurance claims

Adjusted Clinical Group (ACG) System

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A person who handles claims

Adjuster

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Branch of public law that deals with the various organizations of federal, state, and local governments which prescribes in detail the manner of their activities

Administrative Law

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Insurance company or third party administrator that delivers administrative services to an employer group usually requires the employer to be at risk for the cost of healthcare services provided which the ASO processes and manages claims

Administrative Services Only (ASO)

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Form of utilization review in which an assessment is made of the medical necessity of a clients admission to a hospital or other IP facility

They ensure that clients requiring hospital based level of care and LOS appropriate for the admission dx are usually assigned and certified and payment for the services are approved

Admission Certification

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Occurs within 24hrs of patient admission to a healthcare facility or the timeframe required in contract agreement between provider and insurance company Ensures that patient care is necessary

Admission Review

Legally executed document that explains the clients healthcare related wishes and decisions Drawn up while the clients competent and used if client becomes incapacitated or incompetent **each state is different

Advanced Directive

Any untoward occurrences which under most conditions are not natural consequences of the clients disease process or treatment outcomes

Adverse Events

Act of recommending, pleading the cause of another; to speak or write in favor of

Advocacy

Person or agency who speaks on behalf of others and promotes their cause

Advocate

Observable emotional condition of an individual at any given time

Affect

Written statement of fact signed and sworn before a person authorized to administer an oath

Affidavit

Grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence in a clients health condition over time Individual diseases or conditions are placed into a single ADG based on set of criteria including likely persistence of dx, severity of illness, etiology dx certainty and need of special care interventions

Aggregated Diagnosis Groups (ADGs)

Evaluation conducted by a provider who is selected by agreement between an injured workers attorney and the insurance claims administrator and/or attorney Agree to conduct a medical exam and prepare medical-legal report to help with existing dispute help determine what portions of work-related injury have contributed to the disability and what resulted form other sources or causation

Agreed Medical Examination

American Heart Association

AHA

Agency for Healthcare Research and Quality

AHRQ

The chronological delineation of the steps in, or activities of, client care to be applied in the care of clients as they relate to specific conditions/situations

Algorithm

Level of care that can safely be used in place of the current level and determined based on the acuity and complexity of the clients condition and the type of needed services and resources

Alternate Level of Care

American Medical Association

AMA

Aggregate of reported cases forming a body of jurisprudence or the law of a particular subject as evidenced or formed by the adjudged cases, in distinction to statues and other sources of law

Case Law

A multidisciplinary healthcare team meeting that is held to discuss a client or client's support system situation such as conflict in decision making between client/support system, clarification of plan of care and prognosis, end of life issues, or an ethical dilemma

Case Conference

Terminating the provision of CM services to a client/support system

Case Closure

Process of evaluating the quality and appropriateness of care based on the review of all individual med records to determine whether the care delivered is acceptable

Case-based review

Services excluded from a provider contract that may be covered through arrangements with other providers Providers are not financially responsible for services carved out of their contract

Carve Out

The insurance company or the one who agrees to pay the losses May be organized as a company, either stock, mutual, or reciprocal, or an association or underwriters

Carrier

Name given to the symptoms that occur when the nerves and tendons running through the carpal tunnel of the wrist are compressed by tissue or bone or become irritated and swell "cumulative trauma injury/disorder" "Repetitive motion injury" "Repetitive stress syndrome"

Carpal Tunnel Syndrome

Commission on Accreditation of Rehabilitation Facilities Non Profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehab facilities based on set of nationally recognized standards

CARF

Person responsible for caring for a client in the home setting Can be a family member, friend, volunteer, or assigned healthcare professional

Caregiver

Place across the continuum of health and human services where a client may recieve healthcare services dependent on need vary based on intensity and complexity of services provided to clients

Care setting

healthcare delivery process that helps achieve better health outcomes by anticipating and linking clients with the services they need more quickly helps avoid unnecessary services by preventing medical problems from escalating

Care Management

Nationally recognized and professionally supported plans of care recommended for the care management of clients with a specific diagnosis or health conditions and in a particular care setting

Care Guidelines

Deliberate organization of patient care activities between two or more participants involved in patients care to facilitate the appropriate delivery of health care services

Care Coordination

previously known as the Disease Management Association of America (DMAA)

Care Continuum alliance

Insurance company formed by an employer to assume its worker compensation and other risks and provide services

Captive

Fixed amount of money per-member per month (PMPM) paid to a care provider for covered services rather than based on specific services provided typical reimbursement method used by HMOs

Capitation

Construct that indicates the highest probable level of functioning a person may reach measured in uniform or standard environment

Capacity

Widely recognized information, standards, methods, tools, and practices about a specific field

Body of Knowledge (BOK)

"In good faith"

Bona Fide

Neurological disorder or syndrome indicating impairment or injury to brain tissue

Brain disorder

Models where healthcare resources, services, and CM are based externally to an acute care/hospital setting, thats in community

Beyond (outside)- the walls case management

CM that has earned CCM

Board certified CM

type of health and human service covered by an insurance company/health plan and as agreed upon between the plan/insurance company and independent enrollee or participants amount payable by insurance company to a claimant or beneficiary under the claimant specific coverage as stipulated in agreed health plan

Benefits

any damage to tissues of the brain that leads to impairment of the function of the central nervous system

Brain Injury

duty of producing evidence as the case progresses and/or the duty to establish the truth of the claim by a preponderance of the evidence

Burden of Proof

Sum of services for which a health plan, government agency, or employer contacts to provide basic physician/hospital service, prescriptions, dental, vision care

Benefit Package

Individual eligible for benefits under a particular plan HMO- members PPO- enrollees

Beneficiary

Act of comparing a work process with that of the best competitor through the process one is able to identify what performance measures levels must be surpassed helps assess strengths/weakness in organizations

Benchmarking

Burden Assessment Scale

BAS

Factors in persons environment that, if absent, or present, limits one's functioning and create disability

Barriers

Physical manmade environment or arrangement of structures that is safe and accessible to persons with disabilities

Barrier-Free

Generally involving actual or constructive fraud, or design to mislead or deceive another

Bad faith

Agreement to respect another right to self-determine a course of action; support of independent decision making

Autonomy

Approval of client care services, admission, or LOS by a health benefit plan based on information provided by healthcare provider

Authorization

assurance- term used in Canada/ Great Britain is the spreading of risk among many, among many, among who few are likely to suffer loss

Assurance/ Insurance

Doctrine based upon voluntary exposure to a known risk distinguished from contributory negligence which based on carelessness, in that it involves a comprehension that a peril is to be encountered and willingness to encounter it

Assumption of Risk

Any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive tech device

Assistive Technology services

Any item, piece of equipment, or product system, whether acquired commercially on or off shelf, modified or customized that is used to increase, maintain, or improve functional capabilities of individuals with disabilities

Assistive Technology

Any tool that is designed, made, or adapted to assist a person to perform a particular task

Assistive device

Paying medical benefits directly to a provider of care rather than to a member Generally requires either contract agreement between health plan and provider or written permission from subscriber for provider to bill health plan

Assignment of Benefits

Process of collecting in depth information about a persons situation and functioning to identify individual needs in order to develop a comprehensive CM plan that will address needs Information will be gathered by direct client and all other relevant sources

Assessment

Processing of collecting in-depth information about a client and his/her support system in order to identify the needs and decide upon the best CM service to address needs Greater depth that screening

Assessing

Amount medicare pays a physician based on medicare fee schedule Physicians may bill beneficiaries for an additional amount, subject to limiting charge allowed

Approved Charge

Glossary of Terms Flashcards

(81 cards)