Health Informatics Flashcards
AAPCC - Adjusted Average Per Capita Cost
The basis for Health Maintenance Organization (HMO) or Competitive Medical Plan (CMP) reimbursement under Medicare-risk contracts. The average monthly amount received per enrollee is currently calculated as 95 percent of the average costs to deliver medical care in the fee-for-service sector. It is the Centers for Medicare & Medicaid Services’ (CMS’s) best estimate of the amount of money care costs for Medicare recipients under fee-for-service Medicare in a given area.
AAPPO
American Association of Preferred Provider Organizations
The leading national association of preferred provider organizations (PPOs) and affiliate organizations, and was established in 1983 to advance awareness of the benefits — greater access, choice and flexibility — that PPOs bring to American health care.
Access
A patient’s ability to obtain medical care determined by the availability of medical services, their acceptability to the patient, the location of health care facilities, transportation, hours of operation, and cost of care.
Accounts Receivable
The balance of money owed to a client by others.
Accreditation
The process by which an organization recognizes a program of study or an institution as meeting predetermined standards. Three organizations that accredit managed care plans are the National Committee for Quality Assurance (NCQA), URAC and the Joint Commission.
ACF - Ambulatory Care Facility
A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility. Also known as a medical clinic or medical center.
Actuary
A person trained in statistics, accounting and mathematics who conducts statistical studies such as determining insurance policy rates, dividend reserves and dividends, as well as conducts various other statistical studies.
Acute Care
Medical treatment rendered to people whose illnesses or medical problems are short-term or don’t require long-term continuing care. Unlike chronic care, acute care is often necessary for only a short time.
Adherence
The ability of a patient to take their medication or follow a treatment protocol according to the directions for which it was prescribed; a patient taking the prescribed dose of medication at the prescribed frequency for the prescribed length of time. Also referred to as compliance.
Adjudication
The process of completing all validity, process, and file edits necessary to prepare a claim for final payment or denial.
Adjustment
A credit or debit amount appearing at the carrier/group level on claims and administrative fee invoices sent to plan sponsors or at a claim level on adjustment advice sent to pharmacies. An adjustment can result from claims processing and/or billing errors (e.g., incorrect dispensing fee paid, incorrect pharmacy paid, incorrect administration fee billed, wrong carrier/group billed). An adjustment can also be processed against a general ledger account (e.g., bad debt or error).
Administrative Costs
The costs assumed by a managed care plan for administrative services such as claims processing, billing, and overhead costs.
Adverse Selection
The problem of attracting members who are sicker than the general population, specifically, members who are sicker than was anticipated when developing the budget for medical costs. A tendency for utilization of health services in a population group to be higher than average or the tendency for a person who is in poor health to be enrolled in a health plan where he or she is below the average risk of the group. From an insurance perspective, adverse selection occurs when persons with poorer-than-average health status apply for, or continue, insurance coverage to a greater extent than do persons with average or better health expectations.
Adverse Event
An unexpected medical problem that happens during treatment with a drug or other therapy. Adverse events do not have to be caused by the drug or therapy, and they may be mild, moderate, or severe.
Affiliated Provider
A health care provider or facility that is part of the Managed Care Organization’s (MCO’s) network, usually having formal arrangements to provide services to the MCO’s member.
