Healthcare Terminology

Accreditation - The process of evaluation in which an agency or organization recognizes a healthcare facility or program for having met certain predetermined criteria or standards, e.g., accreditation by the Joint Commission on Accreditation of Health Care Organizations.

Acute Care - The provision of care to a person who is in the acute phase of an illness or injury and who will probably have a hospital stay of less than 30 days.

Admitting Privileges - The authorization given by a healthcare organization’s governing body to medical practitioners who request the privilege of admitting and/or treating patients. Privileges are based on a provider’s license, training, experience and education.

Ambulatory Care - Healthcare services provided on an outpatient basis to people who are able to move about and don’t need to be confined to a hospital bed.

Ambulatory Patient Classification (APC) - A method used by the Health Care Financing Administration (HCFA) to classify episodes of outpatient care. Hospitals are then reimbursed based on the APC.

Ancillary Services - Support services used in a hospital such as laboratory, radiology, etc.

Assignment - An agreement by which a physician will bill Medicare directly and accept the government payment as the total payment. A physician cannot bill the patient for the balance.

Average Daily Census (ADC) - The average number of inpatients per day, calculated by dividing the total number of days patients stay in a hospital by the total number of calendar days in that same period.

Average Length of Stay - How long, on average, patients stay in a hospital, calculated by dividing the total number of hospital bed days in a certain period by the admissions or discharges during the same period.

Beds, Licensed - The number of beds a hospital is licensed to operate.

Beds, Complement or Staffed - The number of beds a hospital actually operates.

Board of Medical Examiners - The group of physicians that investigate complaints against physicians.

Board Certified - Term for physicians who have passed a national certifying exam for a specific medical specialty.

Bundled Billing - The practice of combining all of the medical expenses for a certain procedure into one charge (e.g., hospitalization for maternity care).

Capitation - The practice in which a provider is paid a set amount (usually monthly) for each person enrolled in a plan to provide healthcare to the group. No additional money is paid to the provider based on the actual services received by the patient.

CARECoalition - In West Virginia, a group committed to supporting doctors, hospitals, healthcare providers and all state residents in the fight for medical liability reform.

CareLearning.com - In West Virginia, a premier, comprehensive, Internet-based learning and learner management system for health providers.

Case Management - A system of assessment, treatment planning, referral and follow-up that ensures the provision of services according to a patient’s needs. It can also include the coordination of payment and reimbursement for care.

Case Mix - A calculation that reveals the average acuity level of patients in a hospital. For example, a high case mix refers to a patient population that is more ill than the average.

Census - The number of patients, excluding newborns, receiving care each day during a reporting period.

Certificate of Need (CON) - The application a provider must complete and present to the State Health Planning Agency to justify the need for a new service, the replacement of expensive equipment or a new building project.

Children’s Health Insurance Program (CHIP) - A national program that provides matching federal money to states that expand health insurance coverage to children.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) - The health plan that serves the dependents of active-duty and retired military personnel.

Clinical Pathway, also called Critical Pathway - A treatment regimen agreed to by a group of providers as the best means of treating a specific illness.

Closed Staff - A hospital medical staff that will accept no new applicants or a physician group that exclusively provides, under contract, all the administrative and clinical services required for operation of a hospital department.

Coalition for a Tobacco-Free West Virginia - A project designed to educate the public about tobacco-related issues and advocate for policies that reduce, with the intent to eliminate, tobacco use in West Virginia.

Coalition for Quality Health Care - A grant funded, physician-driven organization dedicated to exploring clinical variation and improving healthcare in West Virginia.

Community Benefits - Activities initiated by not-for-profit hospitals to benefit the community. More frequently used by the Internal Revenue Service in reviewing tax-exempt status.

Community Health Needs Assessment - The ongoing process of evaluating the health needs of a community. Usually facilitates a prioritization of needs and a strategy to address them.

Community Rating - Method for calculating health insurance premiums based on the average cost of the actual or anticipated health services used by all subscribers in a specific geographic area or industry.

Co-Morbidity - A preexisting condition that, linked to a principal diagnosis, causes an increase in the length of stay by at least one day in approximately 75 percent of cases.

Contractual Adjustment - This is a bookkeeping adjustment to reflect non-collectible differences between hospital charges and third-party payments.

Credentialing, also called Privileging - The process by which a hospital determines the scope of practice a specific medical practitioner will have in the hospital.

Critical-Access Hospital (CAH) - A hospital that meets very specific HCFA criteria and thus gets special payments for Medicare patients. Hospital can only provide short-term, limited care and must have a referral agreement.

Current Procedural Terminology (CPT) - A system of classifying healthcare procedures to determine costs. Each procedure has a five-digit CPT code.

Day One - A project is designed to reach parents of newborns with educational information related to infant brain development and the need and opportunities for stimulation to enhance future learning ability. The West Virginia Hospital Association (WVHA) is the home for the project, with primary funding for the Day One project provided through a grant from the West Virginia Department of Health and Human Resources, Bureau for Children and Families.

Diagnostic Related Group (DRG) - Methodology developed by HCFA to group Medicare patients based on their clinical condition, age, other existing conditions, etc., into one of almost 500 DRGs. Providers are then paid a set fee based on the DRG assigned.

Directors’ and Officers’ Liability Coverage - Insurance designed to protect governing board members in lawsuits brought against them based on their service as board members.

Disproportionate Share (DSH) Adjustment - A payment adjustment under both Medicare and Medicaid that provides additional money for hospitals serving a large volume of low-income patients.

Emergency Medical Treatment and Active Labor Act (EMTALA) - A federal law mandating that all patients who come to a hospital’s emergency room must receive an appropriate medical screening regardless of their ability to pay. Also, the patient must first be stabilized before being transferred to another facility.

Ethics Committee - A multidisciplinary committee that develops hospital policy relative to the use and limitation of aggressive medical technology. It can also serve as a resource for patients and their families regarding options for terminally ill patients.

Exclusions - Medical conditions specified in an insurance policy for which the insurer will provide no benefits.

False Claims Act - A federal law sometimes used to charge hospitals with fraud and abuse.

Fiscal Intermediary (FI) - An organization that contracts with the federal government to handle claims processing for Medicare patients.

GAP in the Mountains - A quality improvement project to provide better care for heart attack patients in West Virginia.

Global Fee - A single fee that encompasses every procedure, test, etc., performed during a hospitalization.

Health Care Financing Administration (HCFA) - The federal agency that administers the Medicare and Medicaid programs.

Health Insurance Portability and Accountability Act (HIPAA) - The federal law that changed many insurance rules including giving people the right to change jobs without fear of losing coverage. It also contained some provisions regarding patient privacy.

Health Maintenance Organization (HMO) - A prepaid health plan that acts as both an insurer and provider of comprehensive health services.

Hospitalist - A physician who is hired by a hospital to work with staff physicians to cover their patients while they are hospitalized.

InsoSolutions - The database maintained by Blue Cross, which contains information compiled from physician/patient encounters. The information is only available to BCBA and to participating providers.

Integrated Delivery System (IDS) - Healthcare facilities and professionals organized and coordinated to provide comprehensive health services to a defined population group.

International Classification of Diseases, 10^th Revision (ICD-10) - A set of codes that assists providers in classifying patients by diagnosis and procedure for claims reporting.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) - The organization that provides a voluntary accreditation process for hospitals and other healthcare providers.

Licensure - The process hospitals and health professionals must go through in order to practice medicine, run a facility or provide a certain service.

Life Safety Code - Standards established by the National Fire Protection Association that give guidance in construction and operations to reduce the risk of fire loss.

Long-Term Care - Medical services provided to persons who have chronic physical and/or mental impairments. This care is provided in a variety of settings, including the home, specialty facilities and nursing homes.

Managed Care - A system of providing healthcare through which access, cost and quality are controlled.

Market Basket Index - A measure of the annual change in the prices of goods and services providers use in producing healthcare services.

Mediation - A form of conflict resolution that brings two parties together in a process conducted by an impartial third party (the mediator). It is not a binding arbitration and participation is voluntary.

Medicaid - The joint federal and state program that provides healthcare coverage to low-income persons less than 65 years of age.

Medicaid Alliance - Led by the WVHA and other organizations, the Alliance is a statewide effort to protect, maintain and improve West Virginia’s Medicaid program.

Medical Payment Assessment Commission (Med PAC) - A group of independent experts appointed by the federal government to give advice on issues related to Medicare payments to providers.

Medical Staff, Active - Physicians or other healthcare practitioners who have privileges at a hospital and regularly practice there.

Medical Staff, Courtesy - Physicians or other healthcare practitioners who are eligible for privileges, but may only admit patients occasionally or provide consultation as needed.

Medicare - The federal program that provides healthcare services to all persons 65 years of age and older, regardless of income.

Medicare, Part A- The portion of Medicare that covers hospital services.

Medicare, Part B - The portion of Medicare that covers outpatient services and physician visits and must be purchased by enrollees. (Enrollees pay a monthly premium for Part B.)

Medicare Cost Report - The lengthy form hospitals must submit to HCFA each year showing the total costs and charges associated with providing care to all patients. In addition, it shows the portion of those costs allotted to Medicare patients and the payments made to a facility for Medicare patients.

Medigap Coverage - The private insurance Medicare beneficiaries can purchase that covers the portion of the bill not paid by Medicare (e.g., deductibles and copays).

Midlevel Practitioner (MLP) - Nurses, physician assistants, midwives and other health professionals who can operate somewhat independently, as long as they are under the sponsorship of a practicing physician and are licensed to do so by their respective state licensing authority.

National Practitioner Data Bank (NPDB) - A national database that contains claims and disciplinary actions filed against physicians and other medical practitioners.

Nosocomial Infection - An infection acquired by a patient while hospitalized.

Nurse Practitioner, Certified (CNP) - A registered nurse who has received advanced training and is able to provide primary care, including writing prescriptions under the supervision of a physician. CNPs are recognized and regulated by the State Board of Nursing.

Occupancy - The number of inpatients at any given time, usually expressed as a percentage (patients divided by total beds).

Occupational Safety and Health Administration (OSHA) - Federal agency responsible for reducing occupational injuries.

Outcomes - The results of the provision of healthcare, usually measured in terms of patient function, cost, mortality, etc.

Outliers - Cases that are substantially different, either clinically or economically, from the average case in a particular area.

Patient Days - Each calendar day of healthcare provided to a hospital inpatient under the terms of his insurance, usually beginning at midnight.

Per Diem Payment - Fixed payment for each day a patient is hospitalized that does not vary with the level of care provided.

Physician Assistant - A specially trained and licensed health professional who performs certain medical procedures under the supervision of a physician.

Preadmission Certification - The process by which a health professional uses pre-established guidelines to evaluate a physician’s request to hospitalize a patient.

Preferred Provider Organization (PPO) - A health plan that contracts with specific hospitals or physicians to provide care to a defined population using a negotiated fee schedule.

Primary Care - Basic healthcare that usually involves preventive care or treatment for minor illnesses.

Prospective Payment - A payment method in which the amount of payment is set in advance, and the hospital is at least partially at risk for either the losses or gains made in treating the patient.

Protocols - Standards or practices developed to assist healthcare providers and patients to make decisions about particular steps in the treatment process. (See clinical pathways.)

Qualified Medicare Beneficiary (QMB) - A Medicare beneficiary whose Part B premium and coinsurance is covered by Medicaid because he is at or below the poverty level.

Quality Improvement Program (QIP) – also called Continuous Quality Improvement  (CQI) - Constant evaluation of processes and procedures to try and improve quality by reducing waste and variables.

Quality Indicator - A measure of the quality of healthcare provided. For example, both length of stay and readmission rates are quality indicators.

Relative Value Scale (RVS) - An index HCFA uses to designate the degree of complexity for medical services provided by physicians to Medicare beneficiaries. The weights represent the amount to be paid for each service.

Resource-Based Relative Value Scale (RBRVS) - The fee schedule Medicare uses to pay physicians that reflects the value of one service relative to others in terms of the resources utilized.

Respite care - Relief available for people who care for others on a 24-hour basis, which can be provided in homes, assisted living facilities or hospitals.

Risk Management - The function of identifying and assessing problems that could cause legal, clinical or financial losses.

Sentinel Event - An unexpected incident resulting in injury or death to a patient, or an event that poses such a risk.

Skilled Nursing Facility (SNF), also called Extended Care Facility - A facility, usually a nursing home, that provides 24-hour medical care to people who are not in the acute stages of illness, but need rehabilitation, convalescent care, etc.

Staffing Ratio - The total number of employees divided by the average daily census.

Sub Acute Care - Medical and skilled nursing services provided to people who are not in the acute phase of care, but who require a higher level of service than is found at a long-term care facility.

Swing Beds - Hospital beds that can be used either for acute care or long-term care, depending on the needs of the community. These can only be used in smaller hospitals in rural areas where there is a shortage of long-term care beds.

Tertiary Care - High-level care provided in teaching hospitals or medical centers for patients who have severe, complicated or unusual problems.

Triage - The assessment and categorization of patients to determine the level of care needed and to prioritize who should be treated first.

Uniform Billing Code (UB-92) - A federal code that outlines the specific billing procedures hospitals must follow and list on each patient invoice.

Utilization Review (UR) - The concurrent or retrospective assessment of the care patients receive based on pre-established standards.

West Virginia Health Services - A wholly owned subsidiary of the WVHA that seeks to provide cost effective core related health services to healthcare providers and/or health-related support businesses.