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Health Care - Test 1 Terms
Temple Pharmacy PY1
Terms in this set (66)
Medical treatment rendered to people whose illnesses or medical problems are short-term or don't require long-term continuing care. Acute care facilities are hospitals that mainly treat people with short-term health problems.
A proposed healthcare system in which, no matter who is paying, prices for health services and payment methods are the same. Federal or state government, a private insurance company, a self-insured employer plan, an individual, or any other payer would pay the same rates. Also called Multiple Payer system.
All health services that are provided on an out-patient basis, that don't require overnight care. Also called out-patient care.
Examples: Surgical Centers (same day surgery), Dialysis Centers
A person who is eligible for or receiving benefits under an insurance policy or plan.
Non-profit, tax-exempt insurance service plans that cover hospital care, physician care and related services. Blue Cross and Blue Shield are separate organizations that have different benefits, premiums and policies. These organizations are in all states, and The Blue Cross and Blue Shield Association of America is their national organization.
Blue Cross/Blue Shield
A fixed prepayment, per patient covered, to a healthcare provider to deliver medical services to a particular group of patients. The payment is the same no matter how many services or what type of services each patient actually gets. Under capitation, the provider is financially responsible.
Medical services that are separated out and contracted for independently from any other benefits.
Intended to improve health outcomes or control costs, services and education are tailored to a patient's needs, which are designed to improve health outcomes and/or control costs
Treatment given to people whose health problems are long-term and continuing. Nu nursing homes, mental hospitals and rehabilitation facilities are chronic care facilities.
A medical problem that will not improve, that lasts a lifetime, or recurs.
Bills for services. Doctors, hospitals, labs and other providers send billed claims to health insurance plans, and what the plans pay are called paid claims.
Centers for Medicare and Medicaid Services - US federal agency which administers Medicare, Medicaid, and the Children's Health Insurance Program. Provides information for health professionals, also regulations and guidance. (Formerly called HCFA - Health Care Financing Administration)
(Consolidated Omnibus Budget Reconciliation Act of 1985) Designed to provide health coverage to workers between jobs, this legal act lets workers who leave a company buy health insurance from that company at the employer's group rate rather than an individual rate.
HMOs that are managed by the members of the health plan or insurance purchasing arrangements in which businesses or other groups join together to gain the buying power of large employers or groups.
Flat fees or payments (usual range $5-20) that a patient pays for each doctor visit or prescription.
The method of preventing healthcare costs from increasing beyond a set level by controlling or reducing inefficiency and waste in the healthcare system.
Treatments or other services for which a health plan pays at least part of the charge.
The amount of money, or value of certain services (such as one physician visit), a patient or family must pay before costs (or percentages of costs) are covered by the health plan or insurance company, usually per year.
A system for classifying hospital stays according to the diagnosis of the medical problem being treated, for the purposes of payment.
Diagnostic related groups (DRGs)
Programs for people who have chronic illnesses, such as asthma or diabetes, that try to encourage them to have a healthy lifestyle, to take medications as prescribed, and that coordinate care.
The contribution is the money a company pays for its employees' healthcare. Exclusions- Health conditions that are explicitly not covered in an insurance package and that your insurance will not pay for.
Physicians or other providers bill separately for each patient encounter or service they provide. This method of billing means the insurance company pays all or some set percentage of the fees that hospitals and doctors set and charge. Expenditures increase if the increaseThis is still the main system of paying for healthcare services in the United States.
A list of medications that a managed care company encourages or requires physicians to prescribe as necessary in order to reduce costs.
Health insurance offered through business, union trusts or other groups and associations. The most common system of health insurance in the United States, in which the cost of insurance is based on the age, sex, health status and occupation of the people in the group.
Guarantees that people who lose their group health insurance will have access to individual insurance, regardless of pre-existing medical problems, and allows employees to secure health insurance from their new employer when they switch jobs even if they have a pre-existing medical condition. Also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data in the U.S. health care system.
Health Insurance Portability and Accountability Act (HIPAA)
A health plan provides comprehensive medical services to its members for a fixed, prepaid premium. Members must use participating providers and are enrolled for a fixed period of time. HMOs can do business either on a for-profit or not-for-profit basis.
Health Maintenance Organization (HMO)
Skilled nurses and trained aides who provide nursing services and related care to someone at home.
Care given to terminally ill patients. Hospital Alliances- Groups of hospitals that join together to cut their costs by purchasing services and equipment in volume.
A system of health insurance in which the insurer pays for the costs of covered services after care has been given, and which usually defines the maximum amounts which will be paid for covered services. This is the most common type of insurance in the United States.
Care provided, at no cost, to people who do not have health insurance or are not covered by Medicare, Medicaid, or other public programs.
Formally Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)- A national private, non-profit organization that accredits healthcare organizations and agencies and sets guidelines for operation for these facilities.
Healthcare, personal care and social services provided to people who have a chronic illness or disability and do not have full functional capacity. This care can take place in an institution or at home, on a long-term basis.
Coverage for medical professionals which pays the costs of legal fees and/or any damages assessed by the court in a lawsuit brought against a professional who has been charged with negligence.
This term describes many types of health insurance, including HMOs and PPOs. They control the use of health services by their members so that they can contain healthcare costs and/or improve the quality of care.
An insurance program for people with low incomes who are unable to afford healthcare. Although funded by the federal government, Medicaid is administered by each state. Following very broad federal guidelines, states determine specific benefits and amounts of payment for providers.
A federal program of medical care benefits created in 1965 designed for those over age 65 or permanently disabled. Medicare consists of two separate programs: A and B. Medicare Part A, which is automatic at age 65, covers hospital costs and is financed largely by employer payroll taxes. Medicare Part B covers outpatient care and is financed through taxes and individual payments toward a premium.
A group of affiliated contracted healthcare providers (physicians, hospitals, testing centers, rehabilitation centers etc.), such as an HMO, PPO, or Point of Service plan.
A nurse specialist who provides primary and/or specialty care to patients. In some states nurse practitioners do not have to be supervised by a doctor.
A specified period of time during which people are allowed to change health plans.
Open Enrollment Period
The amount of money that a person must pay for his or her healthcare, including: deductibles, co-pays, payments for services that are not covered, and/or health insurance premiums that are not paid by his or her employer.
Out of Pocket costs
Measures of the effectiveness of particular kinds of medical treatment. This refers to what is quantified to determine if a specific treatment or type of service works.
Healthcare providers who have contracted with a managed care plan to provide eligible healthcare services to members of that plan.
Participating Physician or Provider
The organization responsible for the costs of healthcare services. A payer may be private insurance, the government, or an employer's self-funded plan.
A health professional who provides primary and/or specialty care to patients under the supervision of a physician.
A type of insurance where each time healthcare services are needed, the patient can choose from different types of provider systems (indemnity plan, PPO or HMO). Usually, members are required to pay more to see PPO or non-participating providers than to see HMO providers.
Point of Service (POS)
The process where, before a patient can be admitted to the hospital or receive other types of specialty services, the managed care company must approve of the proposed service in order to cover it.
A medical condition or diagnosis that began before coverage began under a current plan or insurance contract. The insurance company may provide coverage but will specifically exclude treatment for such a condition from that person's coverage for a certain period of time, often six months to a year.
A type of insurance in which the managed care company pays a higher percentage of the costs when a preferred (in-plan) provider is used. The participating providers have agreed to provide their services at negotiated discount fees.
Preferred Provider Organization (PPO)
The amount paid periodically to buy health insurance coverage. Employers and employees usually share the cost of premiums.
Prescription drug coverage associated with an insurance plan. e.g., everyone with Medicare, regardless of income, health status, or prescription drugs used, can get prescription drug coverage.
Prescription Drug Plan - PDP
Healthcare services that prevent disease or its consequences. It includes primary prevention to keep people from getting sick (such as immunizations), secondary prevention to detect early disease (such as Pap smears) and tertiary prevention to keep ill people or those at high risk of disease from getting sicker (such as helping someone with lung disease to quit smoking).
Basic or general routine office medical care, usually from an internist, obstetrician-gynecologist, family practitioner, or pediatrician.
The health professional who provides basic healthcare services. The PCP may control patients' access to the rest of the healthcare system through referrals.
Primary care provider (PCP)
Health insurance that is provided by insurance companies such as commercial insurers and Blue Cross plans, self-funded plans sponsored by employers, HMOs or other managed care arrangements.
An individual or institution who provides medical care, including a physician, hospital, skilled nursing facility, or intensive care facility.
A systematic process to improve quality of healthcare by monitoring quality, finding out what is not working, and fixing the problems of healthcare delivery.
Quality Assurance and Quality Improvement
How well health services result in desired health outcomes.
Quality of care
The amount paid to providers for services they provide to patients.
A type of insurance arrangement where employers, usually large employers, pay for medical claims out of their own funds rather than contracting with an insurance company for coverage. This puts the employer at risk for its employees' medical expenses rather than an insurance company.
A healthcare reform proposal in which healthcare costs are paid by taxes rather than by the employer and employee. All people would have coverage paid by the government.
Single Payer System
A healthcare system in which providers are paid by the government, and healthcare facilities are run by the government.
An organization other than the patient or healthcare provider involved in the financing of personal health services.
Third Party Payer
People who do not have health insurance of any type. Over 80 percent of the uninsured are working adults and their family members.
A program designed to help reduce unnecessary medical expenses by studying the appropriateness of when certain services are used and by how many patients they are used.
The amount of time a person must wait from the date he or she is accepted into a health plan (or from when he or she applies) until the insurance becomes effective and he or she can receive benefits.
States require employers to provide coverage to compensate employees for work-related injuries or disabilities.
Worker's Compensation Coverage
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