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Copyright© 1997 - 2011, Pam Pohly, All Rights Reserved.
This glossary can now also be purchased in printed book format!
Glossary of Terms in Managed Health Care
The following are definitions of commonly used terms in the medical provider, hospital and managed care industries. This dictionary is comprised of 26 individual pages, one for each letter of the alphabet. To find a certain word that starts with this letter of the alphabet, may we suggest that you please try the "find" or "search" function in your browser. Or you may simply scroll down the list. If your word starts with another letter, please use the alphabet index below.
This glossary can also be purchased in printed book format if you would like to have it accessible to you at all times.
HAI - See Hospital-Acquired Infection.
HCFA 1500 - The Health Care Finance Administration's standard form for submitting provider service claims to third party companies or insurance carriers. HCFA is now called CMS, see CMS. Also see UB-92.
HCQIA - See Health Care Quality Improvement Act.
HCQIP - See Health Care Quality Improvement Program.
Health - The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It is recognized, however, that health has many dimensions (anatomical, physiological, and mental) and is largely culturally defined. The relative importance of various disabilities will differ depending upon the cultural milieu and the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms or morbidity and mortality.
Health and Human Services (HHS) - The Department of Health and Human Services that is responsible for health-related programs and issues. Formerly HEW, the Department of Health, Education, and Welfare. The Office of Health Maintenance Organizations (OHMO) is part of HHS and detailed information on most companies is available here through the Freedom of Information Act.
Health Benefits Package - The services and products a health plan offers.
Health Care, Healthcare - Care, services, and supplies related to the health of an individual. Health care includes preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, among other services. Healthcare also includes the sale and dispensing of prescription drugs or devices.
Health Care Clearinghouse - A public or private entity that does either of the following (Entities, including but not limited to, billing services, repricing companies, community health management information systems or community health information systems, and “value-added” networks and switches are health care clearinghouses if they perform these functions): 1) Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction; 2) Receives a standard transaction from another entity and processes or facilitates the processing of information into nonstandard format or nonstandard data content for a receiving entity. This term is used in the HIPAA rules.
CMS (HCFA) - Now called CMS, CMS is the federal government agency within the Department of Health and Human Services which directs and oversees the Medicare and Medicaid programs (Titles XVIII and XIX of the Social Security Act) and conducts research to support those programs. It generally oversees the state's administrations of Medicaid, while directly administering Medicare. See CMS, or Center for Medicare and Medicaid Services.
Health Care Operations - Institutional activities that are necessary to maintain and monitor the operations of the institution. Examples include but are not limited to: conducting quality assessment and improvement activities; developing clinical guidelines; case management; reviewing the competence or qualifications of health care professionals; education and training of students, trainees and practitioners; fraud and abuse programs; business planning and management; and customer service. Under the HIPAA Privacy Rule, these are allowable uses and disclosures of identifiable information "without specific authorization." Research is not considered part of health care operations.
Health Care Provider - Providers of medical or health care or researchers who provide health care are health care providers. Normally health care providers are clinics, hospitals, doctors, dentists, psychologists and similar professionals.
Healthcare Provider Taxonomy Codes - An administrative code set that classifies health care providers by type and area of specialization. The code set will be used in certain adopted transactions. (Note: A given provider may have more than one Healthcare Provider Taxonomy Code.)
Healthcare Quality - According to the Institute of Medicine, "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." See also Quality Improvement.
Health Care Quality Improvement Act (HCQIA) - A federal act which exempts hospitals, group practices, and HMOs from certain antitrust provisions as they apply to credentialing and peer review so long as these entities adhere to due process standards that are outlined in the Act.
Health Care Quality Improvement Program (HCQIP) - A program initiated by the CMS to improve the quality of care delivered to Medicare enrollees in managed care plans. Also see Quality Improvement.
Health Data Network - See Health Information Network.
Health Employer Data and Information Set (HEDIS) - A set of HMO performance measures that are maintained by the National Committee for Quality Assurance. HEDIS data is collected annually and provides an informational resource for the public on issues of health plan quality.
Health Information - Information in any form (oral, written or otherwise) that relates to the past, present or future physical or mental health of an individual. That information could be created or received by a health care provider, a health plan, a public health authority, an employer, a life insurer, a school, a university or a health care clearinghouse. All health information is protected by state and federal confidentiality laws and by HIPAA privacy rules.
Health Information Network (HIN) - A computer network that provides access to a database of medical information. Also known as a health data network.
Health Insurance - Financial protection against the health care costs of the insured person. May be obtained in a group or individual policy.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) - A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. This legislation sets a precedent for Federal involvement in insurance regulation. It sets minimum standards for regulation of the small group insurance market and for a set group in the individual insurance market in the area of portability and availability of health insurance. As a result of this law, hospitals, doctors and insurance companies are now required to share patient medical records and personal information on a wider basis. This wide-based sharing of medical records has led to privacy rules, greater computerization of records and consumer concerns about confidentiality. In addition, HIPAA required the creation of a federal law to protect personally identifiable health information; if that did not occur by a specific date (which it did not), HIPAA directed the Department of Health and Human Services (DHHS) to issue federal regulations with the same purpose. DHHS has issued HIPAA privacy regulations (the HIPAA Privacy Rule) as well as other regulations under HIPAA. HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191.
Health Insurance Purchasing Cooperatives (HIPC) - Public or private organizations that secure health insurance coverage for the workers of all member employers. The goal of these organizations is to consolidate purchasing responsibilities to obtain greater bargaining clout with health insurers, plans and providers, to reduce the administrative costs of buying, selling and managing insurance policies. Private cooperatives are usually voluntary associations of employers in a similar geographic region who band together to purchase insurance for their employees. Public cooperatives are established by state governments to purchase insurance for public employees, Medicaid beneficiaries, and other designated populations.
See Purchasing Alliances.
Health Insuring Organization (HIO) - An organization that contracts with a state Medicaid agency as a fiscal intermediary.
Health Level Seven (HL7) - A data interchange protocol for health care computer applications that simplifies the ability of different vendor-supplied IS systems to interconnect. Although not a software program in itself, HL7 requires that each healthcare software vendor program HL7 interfaces for its products.
Also see HIPAA.
Health Maintenance Organization (HMO) - An entity that provides, offers or arranges for coverage of designated health services needed by members for a fixed, prepaid premium. HMOs offer prepaid, comprehensive health coverage for both hospital and physician services. The HMO is paid monthly premiums or capitated rates by the payers, which include employers, insurance companies, government agencies, and other groups representing covered lives. The HMO must meet the specifications of the federal HMO act as well as meeting many rules and regulations required at the state level. There are 4 basic models: group model, individual practice association, network model and staff model. An HMO contracts with health care providers, e.g., physicians, hospitals, and other health professionals. The members of an HMO are required to use participating or approved providers for all health services and generally all services will need to meet further approval by the HMO through its utilization program. Members are enrolled for a specified period of time. HMOs may turn around and sub-capitate to other groups. For example, it may carve-out certain benefit categories, such as mental health, and subcapitate these to a mental health HMO. Or the HMO may subcapitate to a provider, provider group or provider network. HMOs are the most restrictive form of managed care benefit plans because they restrict the procedures, providers and benefits.
Health Manpower Shortage Area (HMSA) - An area or group that the U.S. Department of Health and Human Services designates as having an inadequate supply of health care providers. HMSAs can include: (1) an urban or rural geographic area, (2) a population group for which access barriers can be demonstrated to prevent members of the group from using local providers, or (3) medium and maximum-security correctional institutions and public or non-profit private residential facilities.
Health of Seniors Survey - A CMS survey that measures Medicare patients' functional status.
Health Oversight Agency – Under HIPAA rules, this refers to a person or entity at any level of the federal, state, local or tribal government that oversees the health care system or requires health information to determine eligibility or compliance or to enforce civil rights laws.
Health Plan - An entity that assumes the risk of paying for medical treatments, i.e. uninsured patient, self-insured employer, payer, or HMO.
Health Plan Employer Data and Information Set (HEDIS) - A set of performance measures designed to standardize the way health plans report data to employers. HEDIS currently measures five major areas of health plan performance: quality, access and patient satisfaction, membership and utilization, finance, and descriptive information on health plan management.
HEDIS was initially developed in 1991 by the National Committee for Quality Assurance.
Health Plan Management System (HPMS) - A database of information on Medicare Part A and Part B recipients who are enrolled in coordinated care plans.
Health Professional Shortage Area (HPSA) - A geographic area, population group, or medical facility that HHS determines to be served by too few health professionals of particular specialties. Physicians who provide services in HPSAs qualify for the Medicare bonus payments. This may also include re-payment of medical school loans or other incentives. These reports are published annually by HHS and can be of assistance to providers or groups wishing to recruit physicians to particular areas.
Health Plan Employer Data and Information Set (HEDIS) - A set of performance measures developed to support health plan and Medicaid agency efforts to improve the health status of Medicaid beneficiaries, support the strengthening of health care delivery systems for the Medicaid population, promote standardization of managed care reporting across public and private sectors, and promote the application of performance measurement technology across Medicaid programs.
Health Promotion Programs - Preventive care programs designed to educate and motivate members to prevent illness and injury and to promote good health through lifestyle choices, such as smoking cessation and dietary changes. Also known as wellness programs.
Health Resources and Services Administration (HRSA) - HRSA is a component of the U.S. Department of Health and Human Services. Included in HRSA responsibilities is administration of the Ryan White Care funds with a budget of about $1 billion/year to support a continuum of care services for persons with HIV infection.
Health Service Agreement (HSA) - Detailed explanation of procedures and benefits provided to an employer by a health plan.
See also Statement of Benefits.
Health Status - The state of health of a specified individual, group, or population. It may be measured by obtaining proxies such as people's subjective assessments of their health; by one or more indicators of mortality and morbidity in the population, such as longevity or maternal and infant mortality; or by using the incidence or prevalence of major diseases (communicable, chronic, or nutritional). Conceptually, health status is the proper outcome measure for the effectiveness of a specific population's medical care system, although attempts to relate effects of available medical care to variations in health status have proved difficult.
Health Risk Appraisal or Health Risk Assessment (HRA) - A process by which an MCO uses information about a plan member's health status, personal and family health history, and health-related behaviors to predict the member's likelihood of experiencing specific illnesses or injuries. Also known as health risk appraisal.
HEDIS – See Health Plan Employer Data and Information Set.
HHS - See Health and Human Services, above.
High-Cost Case - A patient whose condition requires large financial expenditures or significant human and technological resources.
High-Risk Case - A patient who has a complex or catastrophic illness or injury or who requires extensive medical interventions or treatment plans.
HIN - See Health Information Network.
HIO - See Health Insuring Organization.
HIPAA - See Health Insurance Portability and Accountability Act of 1996, above.
HIPC - See Health Insurance Purchasing Cooperative.
HL7 - See Health Level Seven.
HMO - See Health Maintenance Organization.
HMSA - Health Manpower Shortage Area.
Hold Harmless Clause or Hold Harmless Provision - A contract clause which forbids providers from seeking compensation from patients if the health plan fails to compensate the providers because of insolvency or for any other reason. For example, it could be a clause frequently found in managed care contracts whereby the HMO and the physician hold each other not liable for malpractice or corporate malfeasance if either of the parties is found to be liable. Many insurance carriers exclude this type of liability from coverage. It may also refer to language that prohibits the provider from billing patients if their managed care company becomes insolvent. State and federal regulations may require this language.
Home Health Care - Full range of medical and other health related services such as physical therapy, nursing, counseling, and social services that are delivered in the home of a patient, by a provider.
Horizontal integration, Horizontal Consolidation - Merging of two or more firms at the same level of production in some formal, legal relationship. In hospital networks, this may refer to the grouping of several hospitals, the grouping of outpatient clinics with the hospital or a geographic network of various health care services. Integrated systems seek to integrate both vertically with some organizations and horizontally with others. When local health plans (or local hospitals) merge. This practice was popular in the late 1990s and was used to expand regional business presence. See vertical integration.
Hospice or Hospice Care - Facility or program providing care for the terminally ill.
Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver as well. Hospice care is covered under Medicare Part A (Hospital Insurance).
Hospital - Any institution duly licensed, certified, and operated as a Hospital. In no event shall the term "Hospital" include a convalescent facility, nursing home, or any institution or part thereof which is used principally as a convalescence facility, rest facility, nursing facility, or facility for the aged.
Hospital-Acquired Infection (HAI) - Hospital-acquired infections encompass almost all clinically evident infections that do not originate from patient's original admitting diagnosis. Within hours after admission, a patient's flora begins to acquire characteristics of the surrounding bacterial pool. Most infections that become clinically evident after 48 hours of hospitalization are considered hospital-acquired. Infections that occur after the patient's discharge from the hospital can be considered to have a nosocomial origin if the organisms were acquired during the hospital stay. Risk factors include pathogens that are present on medical personnel hands, invasive procedures (e.g., intubation, indwelling vascular lines, urine catheterization), and antibiotic use and prophylaxis. Organizational risk factors include contaminated air-conditioning systems, contaminated water systems, and staffing and physical layout of the facility (e.g., nurse-to-patient ratio, open beds close together). Patient risk factors include the severity of illness, underlying immunocompromised state, and length of stay. In the US, nosocomial infections are estimated to occur in 5% of all acute care hospitalizations. The estimated incidence is more than 2 million cases per year, resulting in an added expenditure in excess of $4.5 billion. Nosocomial infections are estimated to more than double the mortality and morbidity risks of any admitted patient, and they probably result in about 90,000 deaths a year in the United States. Also see Nosocomial Infection.
Hospital Affiliation - A contractual agreement between a health plan and one or more hospitals whereby the hospital provides the inpatient services offered by the health plan.
Hospital Alliances - Groups of hospitals joined together to share services and develop group-purchasing programs to reduce costs. May also refer to a spectrum of contracts, agreements or handshake arrangements for hospitals to work together in developing programs, serving covered lives or contracting with payers or health plans. See also Network, Integrated Delivery System, PHO, or Provider Health Plan.
Hospital Audit Companies - Retrospective audit providers that typically achieve a 15-20 percent savings of billed claims
Hospital Based Infection - Also called Hospital-Acquired Infection. See Nosocomial Infection
Hospital Days (expressed as per 1,000) - A measurement of the number of days of hospital care health plan enrollees use in a year. It is calculated as follows: Total Number Of Days Spent In A Hospital By Members divided by Total Members. This information is available through HHS, OHMO and a variety of state sources.
Hospitalists - Physicians who spend a substantial amount of their time in a hospital setting where they accept admissions to their inpatient services from local primary care providers. In most cases, hospitalists are employees of the hospital.
HPMS - See Health Plan Management System.
HPSA - See Health Professional Shortage Area.
HSA - See Health Service Agreement
HRA - See Health Risk Appraisal.Human Subject – Under HIPAA rules, this term refers to a living subject participating in research about whom directly or indirectly identifiable health information or data are obtained or created.
This glossary can also be purchased in printed book format if you would like to have a copy for your briefcase or desk.
Copyright© 1997 - Present Date, Pam Pohly, All Rights Reserved.