Download NCHA Guide to Healthcare Terms and Acronyms_rev11/2016

North Carolina Hospital Association
Healthcare Terms
(last update Nov. 1, 2016)
A
Academic medical center (AMC)
An academic medical center teaching hospital serves as a primary teaching site for a school of
medicine and at least one other health professional school, providing undergraduate, graduate
and postgraduate education; houses extensive basic medical science and clinical research
programs, patients and equipment; and serves the treatment needs of patients from a broad
geographic area through multiple medical specialties.
Access
A patient's ability to obtain medical care. The ease of access is determined by components such
as the availability of medical services and their acceptability to the patient, availability of
insurance, the location of health care facilities, transportation, hours of operation, affordability and
cost of care.
Accountable Care Organization (ACO)
A group of providers or suppliers or a network of groups, often affiliated with a hospital, that are
jointly responsible for the cost and quality of health care provided to Medicare beneficiaries
because they receive bonuses when they provide exceptional or low-cost care and are penalized
for low-quality or high-cost care.
Accreditation
Approval by an authorizing agency for institutions and programs that meet or exceed a set of predetermined standards. Participation is voluntary.
Activities of daily living (ADLs)
Activities performed as part of a person's daily routine of self care such as bathing, dressing,
toileting, and eating.
Acute care
Hospital care given to patients who generally require a stay of several days that focuses on a
physical or mental condition requiring immediate intervention and constant medical attention,
equipment, and personnel.
Adjudication
The process of determining the reimbursement applicable to a particular claim.
Administrative costs
Costs related to activities such as utilization review, marketing, medical underwriting,
commissions, premium collection, claims processing, insurer profit, quality assurance, and risk
management for purposes of insurance.
Advance directive
A document that patients complete to direct their medical care when they are otherwise unable to
communicate their own wishes.
Advanced Practice Registered Nurse (APRN)
A registered nurse who is approved by the Board of Nursing to practice nursing in a specified
area of advanced nursing practice. APRN is an umbrella term given to a registered nurse who
has met advanced educational and clinical practice requirements beyond the two to four years of
basic nursing education required of all RNs. There are four types: 1) certified registered nurse
anesthetist (CRNA); 2) clinical nurse specialist (CNS); 3) certified nurse practitioner (CNP); and
4), certified nurse midwife (CNM).
Adverse drug event (error)
Any incident in which the use of medication (drug or biologic) at any dose, a medical device, or a
special nutritional product may have resulted in an adverse outcome in a patient.
Adverse event
An injury resulting from a medical intervention that is not due to the underlying condition of the
patient.
Advocacy Needs Data Initiative (ANDI)
The North Carolina Hospital Association’s Advocacy Needs Data Initiative or ANDI is an online
survey that collects financial and workforce advocacy-related data.
Aftercare
Services following hospitalization or rehabilitation, individualized for each patient's needs.
Aftercare gradually phases the patient out of treatment while providing follow-up attention to
prevent relapse.
Affiliation
A form of cooperative agreement in which organizations coordinate and integrate their activities
without completely merging or consolidating.
Affordable Care Act
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The health reform law enacted in March 2010. The law was enacted in two parts: The Patient
Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by
the Health Care and Education Reconciliation Act on March 30, 2010. The name, “Affordable
Care Act”, or ACA refers to the final, amended version of the law.
Agency for Healthcare Research and Quality (AHRQ)
A federal agency within the Public Health Service responsible for research on quality,
appropriateness, and cost of health care. AHRQ also centralizes access to state inpatient data.
www.ahrq.gov/
AHEC
The North Carolina Area Health Education Center Program. The mission of the North Carolina
AHEC Program is to meet the state’s health and health workforce needs by providing educational
programs in partnership with academic institutions, health care agencies, and other organizations
committed to improving the health of the people of North Carolina. http://www.ncahec.net/
Alliance
A formal organization usually owned by shareholders/members that works on behalf of its
individual members in the provision of services and products and in the promotion of activities
and ventures.
Allied health personnel
Specially trained and often licensed health workers other than physicians, dentists, optometrists,
chiropractors, podiatrists, and nurses. They do not usually engage in independent practice.
Examples are respiratory therapists, physical therapists, radiologic technologists, etc.
Allowable charge
The maximum fee that a health plan will reimburse a provider for a given service.
Allowable costs
Charges for services rendered or supplies furnished by a health provider that qualify as covered
expenses for insurance purposes.
Alternative delivery
An alternative to traditional inpatient care, such as ambulatory care, home health care, and sameday surgery.
Alternative medicine
Treatment procedures that are not a usual component of mainstream medicine, often due to lack
of supporting experimental data.
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Alternative Payment Model/Mechanisms (APM)
A method of paying for services in which providers can voluntary choose to participate that is
different from the standard payment method used to pay those providers.
Ambulatory care
Care given to patients who do not require overnight hospitalization.
Ambulatory patient group (APG)
The Medicare program's prospective payment system for outpatient services and procedures.
Each APG is a classified medical service or procedure. Unlike diagnosis related group (DRG)
reimbursement for inpatient care, where medical events are condensed into one diagnostic
related group, an outpatient visit can combine several different APGs.
Ambulatory payment classification (APC)
Groups or groupings of medical procedures and services used as a basis for reimbursement
under the Medicare outpatient prospective payment system (OPPS).
Ambulatory setting
An institutional health setting in which organized health services are provided on an outpatient
basis, such as a surgery center, clinic, or other outpatient facility. Ambulatory care settings also
may be mobile units of service (e.g., mobile mammography, MRI).
Ambulatory surgical facility
See freestanding outpatient surgical center
American College of Healthcare Executives (ACHE)
An international professional society of nearly 30,000 health care executives based in Chicago.
www.ache.org
American Health Care Association (AHCA)
A trade association representing nursing homes and long-term care facilities in the United States
based in Washington, D.C. www.ahca.org
American Hospital Association (AHA)
A national association that represents allopathic and osteopathic hospitals in the United States
based in Washington, D.C., with operational offices in Chicago. www.aha.org
American Medical Association (AMA)
A national association organized into local and regional societies that represent over 700,000
medical doctors in the United States. AMA is based in Chicago. www.ama-assn.org
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American Osteopathic Association (AOA)
A national association organized into local and regional societies that represent over 43,000
osteopathic physicians in the United States. AOA is based in Chicago and also provides
accreditation for hospitals and colleges of osteopathic medicine. www.aoa-net.org
American Recovery and Reinvestment Act of 2009 (ARRA)
A stimulus bill that was passed to primarily reserve and create jobs and promote economic
recovery. Includes investments needed to increase economic efficiency by spurring technological
advances in science and health.
Americans With Disabilities Act (ADA)
A federal law that prohibits employers of more than 25 employees from discriminating against any
individual with a disability who can perform the essential functions, with or without
accommodations, of the job that the individual holds or wants.
www.usdoj.gov/crt/ada/adahom1.htm
Ancillary
A term used to describe additional services performed related to care, such as lab work, X-ray,
and anesthesia.
Anti-kickback statute
A federal law that prohibits the paying or receiving of remuneration in exchange for the referral of
patients or business paid by a federal health care program.
Antitrust
A situation in which a single entity, such as an integrated delivery system, controls enough of the
practices in any one specialty in a relevant market to have monopoly power (e.g., the power to
increase prices).
Assign the benefit
The transfer of rights held by one party to another party. In health insurance, the payment for the
benefit (health care services) received by the patient is usually assigned to the hospital or
provider such that the provider receives payment directly from the insurance company.
Associate Degree in Nursing (ADN)
A two-year education program in the field of nursing. Nurses usually obtain the associate degree
at a junior or community college.
Average adjusted per capita cost (AAPCC)
Payment rates used by the Centers for Medicare and Medicaid Services (CMS) to reimburse
managed care organizations for care delivered to Medicare enrollees.
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Average length of stay (ALOS)
A standard hospital statistic used to determine the average amount of time between admission
and departure for patients in a diagnosis related group (DRG), an age group, a specific hospital,
or other factors.
B
Bachelor of Science in Nursing (BSN)
A four-year college or university program that educates registered nurses, granting a Bachelor of
Science degree upon graduation.
Bad Debts
An unpaid obligation by an individual who could pay for the health care service they received.
Currently accepted health care accounting practices, and the challenge at the time of a patient’s
admission to identify those who need care but do not have the ability to pay, tend to blur the lines
between bad debt and charity care.
Balance billing
A provider's billing of a covered person directly for charges above the amount reimbursed by the
health plan. This may or may not be allowed, depending upon the contractual arrangements
between the parties.
Balanced Budget Act of 1997 (BBA)
A federal law enacted by U.S. Congress that made numerous changes to various titles of the
Social Security Act, contained significant changes to the Medicare and Medicaid programs, and
created a new Title XXI, the State Children's Health Insurance Program (SCHIP). It cut Medicare
payments to doctors and hospitals, which were subsequently reduced.
Balanced Budget Refinement Act of 1999 (BBRA)
A federal law enacted by U.S. Congress that restored an estimated $17 billion to the Medicare
program.
Behavioral health care
Mental health services, including services for alcohol and substance abuse.
Bed size
The number of beds a hospital has been designed and constructed to contain. It may also refer to
the number of beds set up and staffed for use.
Bending the Curve
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Slowing the rate of growth in health care spending.
Benchmarking
A method of comparing the procedures and results of a process, system or, operation under
study with a similar process, system, or operation under study that is generally recognized as
outstanding.
Beneficiary
A person designated by an insuring organization as eligible to receive insurance benefits.
Benefits Improvement and Protection Act of 2000 (BIPA)
A federal law enacted by U.S. Congress that, among other provisions, restored an estimated
$11.5 billion over five years to hospitals under Medicare, Medicaid, and other federal and state
health care programs.
Best Practices
The most up-to-date patient care interventions, scientifically proven to result in the best patient
outcomes and minimize patients' risk of death or complications. A superior method or innovative
practice that contributes to the improved performance of an organization, usually recognized as
"best" by other peer organizations.
Blue Cross and Blue Shield Association (BCBSA)
An organization that offers information, consultation, representation and operational services for
the Blue Cross and Blue Shield plan members across the country for purposes of providing
insurance benefits. www.bluecares.com
Blue Cross Blue Shield of North Carolina (BCBSNC)
North Carolina’s Blue Cross Blue Shield insurance plan. www.bcbsnc.com
Board-certified
A clinician who has passed the national examination in a particular field. Board certification is
available for most physician specialties, as well as for many allied medical professions.
Bundled payments
A comprehensive payment covering the costs of all applicable services and other appropriate
services furnished to an individual during an episode of care.
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C
Capitation (CAP)
A stipulated dollar amount established to cover the cost of health care delivered for a person or
group of persons. The term usually refers to a negotiated per capita rate to be paid periodically,
usually monthly, to a health care provider. The provider is responsible for delivering or arranging
for the delivery of all health services required by the covered person(s) under the conditions of
the contract.
CareLearning
An online education service of more than 40 state hospital associations (including NCHA) along
with the American Hospital Association (AHA) for the purpose of delivering more cost-effective
education to hospitals. www.carelearning.com
Care Share Health Alliance
Care Share is a private/public partnership that helps develop community-based, integrated
networks of healthcare for low-income and uninsured North Carolinians.
www.caresharehealth.org
Case management
A program that is designed to assess the continuing needs of members with chronic health
problems.
Case manager
Assists physicians in meeting an individual’s health care needs through coordination of services
and utilization of resources in order to promote high quality, cost effective outcomes.
Case mix index
A measure of relative severity of medical conditions of a hospital's patients.
Catchment area
The specific geographic area for which a particular institution is responsible.
Centers for Disease Control and Prevention (CDC)
An agency within the U.S. Department of Health and Human Services (HHS) that serves as the
central point for consolidation of disease control data, health promotion, and public health
programs. CDC is based in Atlanta, Ga. www.cdc.gov
Center for Medicare & Medicaid Innovation (CMMI)
The Center for Medicare & Medicaid Innovation (the CMS Innovation Center) fosters health care
transformation by finding new ways to pay for and deliver care that improve care and health while
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lowering costs. The Center identifies, develops, supports, and evaluates innovative models of
payment and care service delivery for Medicare, Medicaid and CHIP. www.innovations.cms.gov/
Centers for Medicare and Medicaid Services (CMS)
An agency within the U.S. Department of Health and Human Services (HHS) that is responsible
for the administration of the Medicare and Medicaid programs. Formerly called the Health Care
Financing Administration (HCFA). www.cms.gov
Certificate of need (CON)
North Carolina hospitals and physicians have to obtain approval from the NC Division of Health
Service Regulation for activity such as constructing or modifying hospitals, purchasing certain
medical equipment or providing new health care services.
Charge
The amount a doctor or other healthcare provider bills a patient. Direct and indirect expenses
incurred by the hospital in providing the services, or hospital costs, are one factor in the
determination of hospital charges. Competition, profits, and the necessity of recouping the costs
of uncompensated care are also considered.
Charity care
Health care services provided free of charge or at a substantial discount. North Carolina hospitals
want their communities to know their financial assistance policies and what benefits they are
providing. The hospitals have voluntarily submitted their financial assistance policies along with
their community benefit reports online at www.ncha.org/issues/community-benefit.
Cherry-picking
A colloquial term for selecting only the patients least likely to require costly medical services or
only those patients with sufficient insurance coverage to pay for required services.
Chief Executive Officer (CEO)
Principal executive leader of an organization.
Chief Financial Officer (CFO)
An executive leader who oversees financial operations.
Chief Operating Officer (COO)
An executive leader who oversees day-to-day management and internal operations.
Children’s Health Insurance Program (CHIP)
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A state-administered program funded partly by the federal government that allows states to
expand health coverage to uninsured, low-income children not eligible for Medicaid. North
Carolina’s program is called NC Health Choice for Children. www.ncdhhs.gov/dma/healthchoice/
Claim
A request for payment for benefits received or services rendered.
Clinical Measures
Measures representing processes of care and patient outcomes widely accepted as important to
quality care, consistently and accurately tracked in order to determine quality performance in a
given clinical area, such as heart attack, pneumonia or hip and knee replacement.
Clinical Guideline
A treatment regime, agreed upon by consensus, which includes all the elements of care
regardless of the effect on patient outcomes. Also called a clinical pathway.
Clostridium difficile (C. diff)
A bacterium transferred to patients mainly through the hands of health care personnel who have
touched a contaminated surface or item and which causes diarrhea and more serious intestinal
conditions such as colitis.
Code of Federal Regulations (CFR)
A publication of the federal government that consists of all regulations of federal departments and
agencies. www.gpoaccess.gov/cfr/index.html
Co-insurance
The percentage of the allowed amounts for covered services that the insurer will pay after a
covered person’s deductible is met.
Co-payment
The fixed-dollar amount paid for a covered health care service, usually when you receive the
service. The amount can vary by the type of covered health care service. Also referred to as
‘copay.’
Community Benefit
Programs or services that address community health needs — particularly those of the poor,
minorities, and other underserved groups — and provide measurable improvement in health
access, health status and use of health care resources. IRS definition: activities associated with
community health needs assessments as well as community benefit planning and administration.
Community benefit operations also include the organization’s activities associated with fund
raising or grant-writing for community benefit programs.” North Carolina hospitals want their
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communities to know their financial assistance policies and what benefits they are providing. The
hospitals have voluntarily submitted their financial assistance policies along with their community
benefit reports. www.ncha.org/issues/community-benefit
Community Care of NC (CCNC)
The Community Care of North Carolina program is building community health networks organized
and operated by community physicians, hospitals, health departments, and departments of social
services. By establishing regional networks, the program is establishing the local systems that are
needed to achieve long-term quality, cost, access and utilization objectives in the management of
care for Medicaid recipients. www.communitycarenc.org/
Computerized physician order entry (CPOE)
A system that allows physicians to write medical orders for their hospitalized patients using a
clinical software application.
Conditions of Participation (CoP)
The federal regulations hospitals must comply with in order to qualify for Medicare reimbursement.
Conference committee
A bi-partisan committee made up of equal members from each chamber of the North Carolina
General Assembly or U.S. Congress that is responsible for working out differences between
House- and Senate-passed versions of a piece of legislation.
Congressional Budget Office (CBO)
A non-partisan office that provides U.S. Congress with cost estimates of legislative proposals and
calculates estimates related to the federal budget. www.cbo.gov/
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
The 1985 federal spending plan which included several health provisions and protections,
including protection against denial of emergency medical care to patients who are unable to pay
and the opportunity to extend employer insurance coverage following the termination of
employment.
Consumer Price Index (CPI)
Widely used as an indicator of changes in the cost of living, as a measure of inflation, and as a
means of studying price trends. Measures the change in cost of a constant bundle of goods and
services purchased by consumers.
Continuum of Care
The full array of services, from prevention to treatment to rehabilitation and maintenance,
required to support optimum health of a population.
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Continuing Medical Education (CME)
Provisions and procedures used by third-party payers to determine the amount payable when a
claimant is covered under two or more health plans.
Coordination of Benefits (COB)
Provisions and procedures of insurers used to avoid duplicate payments when claims are
covered by more than one insurance company.
Core Measures
Specific clinical measures that, when viewed together, permit a robust assessment of the quality
of care provided in a given focus area, such as acute myocardial infarction (AMI).
Cost
The expenses incurred by a hospital in providing care. The hospital costs attributed to a particular
episode of care include the direct costs plus an appropriate proportion of the overhead
(administration, personnel, building maintenance, and equipment, etc.)
Cost shifting
A situation in which a health care provider compensates for the effect of decreased revenue from
one payer by increasing charges to another payer.
Coverage
A person has coverage if all or part of his or her health care costs are paid either by insurance or
by the government.
Covered Lives
People who are insured, whether by commercial insurance carriers, Medicare, or Medicaid.
Covered Services
Specific health care benefits, services and products a health plan or insurer will provide
reimbursement for.
Credentialing
The process of reviewing a practitioner’s academic, clinical, and professional ability as
demonstrated in the past to determine if criteria for clinical privileges are met.
Critical access hospital (CAH)
A federal designation under which hospitals receive cost-based reimbursement for Medicare
services. Hospitals must meet certain criteria, such as size, length of stay, and proximity to other
facilities.
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Critical Care Unit (CCU)
Synonymous with intensive or special care unit. Service area of a hospital established to provide
continuous intensive care to critically ill patients.
Critical Pathway
A treatment protocol including only the vital components or items proved to affect patient
outcomes.
D
Deductible
Out-of-pocket expenses that must be paid by the health insurance subscriber before the insurer
will begin reimbursing the subscriber for additional medical expenses.
Department of Health and Human Services (DHHS)
The North Carolina Department of Health and Human Services is the largest agency in state
government, responsible for ensuring the health, safety and well being of all North Carolinians,
providing the human service needs for fragile populations like the mentally ill, deaf, blind and
developmentally disabled, and helping poor North Carolinians achieve economic independence.
The Department is divided into 30 divisions and offices. DHHS divisions and offices fall under four
broad service areas - health, human services, administrative, and support functions.
www.ncdhhs.gov
Diagnostic related group (DRG)
A classification system that groups patients by common characteristics requiring treatment.
Discharge planning
The evaluation of patients' health needs for appropriate care after discharge from an inpatient
setting.
Disproportionate share hospital (DSH)
A hospital that provides care to a very high number of uninsured or underinsured patients.
Diversion
The routing of patients to other hospitals because an emergency room is temporarily at maximum
capacity.
Division of Health Service Regulation (DHSR)
The mission of the Division of Health Service Regulation is to provide for the health, safety and
well being of individuals through effective regulatory and remedial activities including appropriate
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consultation and training opportunities and by improving access to health care delivery systems
through the rational allocation of needed facilities and services. www.ncdhhs.gov/dhsr/
Division of Medical Assistance (DMA)
DMA manages the Medicaid and Health Choice programs. The mission of DMA is to provide
access to high quality, medically necessary health care for eligible North Carolina residents
through cost-effective purchasing of health care services and products. www.ncdhhs.gov/dma/
Division of Mental Health/Developmental Disabilities/ Substance Abuse Services
(DMH/DD/SAS)
DMH/DD/SAS provides people with, or at risk of, mental illness, developmental disabilities and
substance abuse problems and their families the necessary, prevention, intervention, treatment,
services and supports they need to live successfully in communities of their choice.
www.ncdhhs.gov/mhddsas/index.htm
Division of Public Health (DPH)
North Carolina Public Health works to promote and contribute to the highest possible level of
health for the people of North Carolina. publichealth.nc.gov/
Doctor of osteopathy (DO)
A licensed physician who is a graduate from an accredited school of osteopathic medicine.
Do not resuscitate (DNR)
An advance directive that patients may make to forego cardiopulmonary resuscitation or other
resuscitative efforts. (See advance directive.)
Doughnut hole
A gap in prescription-drug coverage for some Medicare recipients. In 2012 these Medicare
beneficiaries have no drug coverage once their medication costs exceed $2,930 until they have
spent $4,700 out of their own pocket.
Drug formulary
A listing of prescription medications and appropriate dosages felt to be the most useful and cost
effective for patient care. Health plans that have adopted a “closed, select or mandatory”
formulary limit coverage to those drugs in the formulary.
(The) Duke Endowment
The Duke Endowment seeks to fulfill the legacy of James B. Duke by improving lives and
communities in the Carolinas through higher education, health care, rural churches and children’s
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services. Since its inception, the Endowment has awarded nearly $2.9 billion in
grants. www.dukeendowment.org/
Durable medical equipment (DME)
Equipment that can stand repeated use, is primarily and customarily used to serve a medical
purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate
for use at home, such as hospital beds, wheelchairs, and oxygen equipment.
Durable power of attorney
A document in which individuals select another person to act on their behalf in the event they
become incapacitated. The document may identify specific activities, such as managing the
incapacitated person's financial affairs. If the document allows the agent to make health care
decisions, it must be drafted in a manner that meets statutory requirements for a "health care
durable power of attorney." (See advance directive)
E
Electronic Medical Records (EMR)
The EMR can be defined as the legal patient record created in hospitals and ambulatory
environments that is the data source for the EHR.
Electronic Health Records (EHR)
An EHR is generated and maintained within an institution, such as a hospital, integrated delivery
network, clinic, or physician office, to give patients, physicians and other health care providers,
employers, and payers or insurers access to a patient's medical records across facilities.
Emergency Department (ED)
The unit in a health care facility that administers emergency medical services.
Emergency Medical Services (EMS)
A system of health care professionals, facilities, and equipment providing emergency care.
Emergency Medical Technician (EMT)
A person certified to provide pre-hospital emergency medical treatment.
Emergency Medical Treatment and Labor Act (EMTALA)
An act created by Congress as part of the Consolidated Omnibus Budget Reconciliation Act
(COBRA) of 1985. It is designed to prevent hospitals from refusing to treat patients or transferring
them to “charity” or “county” hospitals because they are unable to pay or are covered by Medicare
or Medicaid programs.
Employee Retirement Income Security Act (ERISA)
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A federal law that exempts self-insured health plans from state laws governing health insurance,
including contribution to risk pools, prohibitions against disease discrimination, and other state
health reforms.
Employer mandate
A requirement that employers provide health insurance for employees, or pay a financial penalty.
Employer-sponsored health insurance
Health insurance paid for, in whole or in part, by businesses on behalf of their employees as part
of an employee benefit package. Most large employers in America offer group health insurance
to employees.
Environmental Protection Agency (EPA)
A federal and state agency responsible for programs to control air, water and noise pollution,
solid waste disposal and other environmental concerns. www.epa.gov
Episode of care
An interval of care by a health care facility or provider for a specific medical problem or condition.
It may be continuous or it may consist of a series of intervals marked by one or more brief
separations from care.
Essential Health Benefits
A comprehensive package of benefits that insurance policies must cover in order to be certified
and offered in Exchanges. All Medicaid state plans must cover these services by 2014. Essential
health benefit packages include items and services within at least the following 10 categories:
ambulatory patient services, emergency services, hospitalization, maternity and newborn care,
mental health and substance use disorder services, prescription drugs, laboratory services,
pediatric services, rehabilitative and habilitative services and devices, preventive and wellness
services.
Evidence-based medicine
The wise and careful use of the best available scientific research and practices with proven
effectiveness in daily medical decision-making, including individual clinical practice decisions, by
well-trained, experienced clinicians. Evidence-based medicine that is best practice integrates best
research evidence with clinical expertise and patient values.
Exclusions
Clauses in an insurance contract that deny coverage for select individuals, groups, locations,
properties or risks.
Explanation of Benefits (EOB)
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A statement sent by a health insurance company to covered individuals explaining what medical
treatment/services were paid for on their behalf.
F
Failure mode effect analysis (FMEA)
A systematic method of identifying and preventing problems (errors) before they occur.
False Claims Act
A federal law that imposes liability for treble damages and fines of $5,000 to $10,000 for
knowingly submitting to the federal government a false or fraudulent claim for payment.
Federal Employee Health Benefits Program (FEHBP)
A government program that allows some 8 million federal employees, including members of
Congress, to purchase private health insurance. The government provides a set amount of
money to employees, who can select from a variety of health plans.
Federal Financial Participation (FFP)
The portion paid by the federal government to states for their share of expenditures for providing
Medicaid services and for administering the Medicaid program and certain other human service
programs. Also called federal medical assistance percentage (FMAP).
Federal Fiscal Year (FFY)
The federal government's accounting year, which begins Oct. 1 and ends Sept. 30 (e.g., FFY
2011 begins Oct.1, 2010, and ends Sept. 30, 2011).
Federal Medical Assistance Percentage (FMAP)
The share of each state's Medicaid program paid by the federal government, based on the state's
per capita income.
Federal poverty guidelines
The official annual income level for poverty as defined by the federal government. Under the 2011
guidelines, the federal poverty level for a family of four is $22,350.
Federal Poverty Level (FPL)
A measure of income level issued annually by the Federal Department of Health and Human
Services and used to determine eligibility for certain programs and benefits. For 2012, the FPL
was an annual income of $23,050 for a family of four.
Federal Trade Commission (FTC)
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A federal agency created to protect consumers against unfair methods of competition and
deceptive business practices, such as sales fraud and price fixing. Investigates and applies
antitrust laws. www.ftc.gov
Federal Register
An official publication of the federal government that provides final and proposed regulations of
federal legislation. www.gpoaccess.gov/fr/index.html
Federally Qualified Health Center (FQHC)
A primary care clinic located in an underserved area that meets the health care needs of special
populations and receives special reimbursement for doing so.
Fee for service
A method in which physicians and other health care providers receive a fee for services
performed.
Fee schedule
A comprehensive listing of fees used by either a health care plan or the government to reimburse
providers on a fee-for-service basis.
Fellow of American College of Healthcare Executives (FACHE)
The highest credential awarded by the American College of Healthcare Executives (ACHE).
Financial Assistance Policy
The standard course of action a hospital requires for patients to receive free or reduced-cost care.
The Federal government requires hospitals to ‘charge’ all patients, including the uninsured, the
same price for each service. Patients must demonstrate need to prevent hospitals from using
charity care resources to cover the cost of care for patients that can afford to pay for the services
they received.
Fiscal intermediary
The Medicare Part A claims processing contractor. North Carolina’s is Palmetto GBA.
Fiscal Year (FY)
Any entity's accounting year.
Food and Drug Administration (FDA)
An agency within the federal government that is responsible for regulations pertaining to food and
drugs sold in the United States. www.fda.gov
Freestanding emergency medical service center
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A health care facility, physically separate from a hospital, that provides immediate, short-term
medical care for minor but urgent medical conditions.
Freestanding outpatient surgical center
A health care facility, physically separate from a hospital, that provides pre-scheduled, outpatient
surgical services.
G
GAP Assessment and Payment Program (GAP)
Refers an individual insurance policy which can be purchased to cover certain health care
services and costs that are not provided by insurance.
General practitioner (GP)
A physician whose practice is based on a broad understanding of all illnesses and who does not
restrict his/her practice to any particular field of medicine.
Generic Drug
Pertaining to the descriptive or nontrade name of a drug or other product; for example, diazepam
is the generic name for Valium.
Government Accountability Office (GAO)
A non-partisan investigative arm of U.S. Congress that evaluates federal programs as an
oversight of federal spending, efficiency, and performance. www.gao.gov
Graduate medical education (GME)
Medical education as an intern, resident, or fellow after graduating from a medical school.
Group insurance
Any insurance policy or health services contract by which groups of employees (and often their
dependents) are covered under a single policy or contract, issued by their employer or other
group entity.
Group Practice
A formal association of three or more physicians, dentists, or other health professionals providing
services, with income from the medical practice distributed to the group members according to a
prearranged plan.
H
Health
19
A state of complete physical, mental and social well-being and not merely the absence of disease
of infirmity.
Health Benefits Exchanges
An insurance marketplace where individuals and small business can purchase qualified health
benefit plans starting in 2014. Individuals making between 100% and 400% of the Federal
Poverty Level (FPL) are eligible for subsidies to purchase insurance on the exchange.
Health and Humans Services (HHS)
The U.S. Department of Health and Human Services (HHS) is a department within the executive
branch of the federal government responsible for Social Security and federal health programs in
the civilian sector. www.dhhs.gov
Health care-acquired infection (HAI)
An infection acquired by an individual while receiving care or services in a hospital or other health
care facility.
Health care durable power of attorney
A document in which individuals select another individual to make health care decisions for them
in the event they become incapacitated. A health care durable power of attorney should be
distinguished from a living will, a document drafted by an individual that provides direction
regarding medical care if the individual becomes incapacitated by terminal illness or permanent
unconsciousness. (See "advance directive")
Healthcare Failure Mode and Effect Analysis (HFMEA)
A prospective assessment that identifies and improves steps in a process, thereby reasonably
ensuring a safe and clinically desirable outcome. A systematic approach to identify and prevent
product and process problems before they occur.
Healthcare Financial Management Association (HFMA)
A professional association of health care finance managers. www.hfma.org
Health care system
A corporate body that owns and/or manages multiple entities including hospitals, long-term care
facilities, other institutional providers and programs, physician practices, and/or insurance
functions. Also called health system, multihospital system, or network.
Health Information Technology for Economic and Clinical Health Act (HITECH)
20
The Health Information Technology for Economic and Clinical Health Act (HITECH) portion of the
ARRA provides $17.2B in reimbursement payment incentives and $2B in competitive planning
and implementation grants to states.
Health insurance
A contract that requires a health insurer to pay some or all of a patient’s health care costs in
exchange for a premium.
Health insurance exchange
A government-administered marketplace or portal (website) where private or public insurance
policies are sold.
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 included a series of
"administrative simplification" provisions that required the Department of Health and Human
Services (HHS) to adopt national standards for electronic health care transactions including
regulations related to electronic health care transactions, health information privacy, and security
requirements. Regulations have in some cases expanded the scope of HIPAA to also include
non-electronic transactions.
Health maintenance organization (HMO)
An entity that offers prepaid, comprehensive health coverage for both hospital and physician
services with specific health care providers using a fixed fee structure or capitated rates.
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 measures five major areas of health plan performance: quality, access and
patient satisfaction, membership and utilization, finance, and descriptive information on health
plan management.
Health Resource Service Administration (HRSA)
A federal agency within the U.S. Department of Health and Human Services that provides health
care grant programs. www.hrsa.gov
Health savings account (HSA)
A tax-deductible personal savings account, usually offered by employers along with highdeductible health-insurance plans, used to pay for medical expenses.
High deductible health plan (HDHP)
A health insurance plan with lower premiums and higher deductibles than a traditional health plan.
Being covered by an HDHP is also a requirement for having a health savings account.
21
Hill-Burton Act
Following World War II, the federal government encouraged the building of hospitals and other
health care facilities by providing funds for expansion and development. These funds, made
available through the Hill- Burton Construction Act (Titles VI and XVI of the Public Health Service
[PHS] Act), spurred the development of community hospitals, nursing homes, public health
centers and rehabilitation facilities. In accepting Hill- Burton funds, public and nonprofit medical
facilities agreed to make services available to persons in the facilities’ service area without
discrimination on the basis of race, color, national origin, creed or ability to pay for 20 years
following the facilities’ completion. Hill-Burton facilities were required to participate in the
Medicare and Medicaid programs and they were required to post public notice of their community
service obligation.
Home health agency (HHA)
An organization that provides medical, therapeutic, or other health services in patients' homes.
HOSPAC
NCHA’s Political Action Committee. www.ncha.org/hospac
Hospice
A facility or program that is licensed, certified, or otherwise authorized by law, that provides
supportive care of the terminally ill.
Hospital-acquired condition (HAC)
Conditions that could reasonably have been prevented through the application of evidence-based
guidelines.
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Standardized survey instrument and data collection methodology for measuring patients’
perceptions of their hospital experience. www.hcahpsonline.org
Hospital Incident Command System (HICS)
An incident management system based on the Incident Command System that helps hospitals
improve emergency management response and recovery capabilities for planned and unplanned
events.
Hospital market basket
Components of the overall cost of health care used in determining the consumer price index.
Hospital Market Basket Index
An inflationary measure of the cost of goods and services purchased by health care facilities,
often used to determine growth in reimbursement rates.
22
Hospital Quality Alliance
A public-private collaboration to improve the quality of care provided by U.S. hospitals by
measuring and publicly reporting a set of measures. An element of the program is the Hospital
Compare Web-site, which debuted April 2005 at www.hospitalcompare.hhs.gov and
www.medicare.gov.
Hospitalist
Physician specialists in inpatient medicine who spend at least 25 percent of their professional
time serving as the physicians-of- record for inpatients, returning the patients back to the care of
their primary care providers at the time of hospital discharge.
I
Indicator
1. A measure used to determine, over time, performance of functions, processes and outcomes.
2. A statistical value that provides an indication of the condition or direction over time of
performance of a defined process or achievement of a defined outcome.
Indigent medical care
Care given by health care providers to patients who are unable to pay for it.
Individual mandate
A requirement that every American have health insurance, which would be enforced through
financial penalties.
Inpatient
An individual who has been admitted to a hospital for at least 24 hours.
Inpatient Admission
The formal acceptance of a patient who is provided with room, board, and continuous nursing
service in an area of the hospital where patients generally reside at least overnight.
Integrated delivery system
Collaboration between physicians and hospitals for a variety of purposes. Some models of
integration include physician-hospital organization, management-service organization, group
practice without walls, integrated provider organization, and medical foundation.
Intergovernmental Transfers (IGT)
23
Transfers of public funds between governmental entities. The transfer may take place from one
level of government to another (i.e. counties to states) or within the same level of government.
Integrated Payment and Reporting System (IPRS)
Tracks, pays, and reports on all claims submitted by providers for services rendered. The IPRS
system processes and pays claims for the Division of MH/DD/SA Services and Medicaid system.
Often, when one refers to ‘IPRS dollars’ or ‘IPRS funding’ one is referring to funding for services
provided with 100% state dollars.
Intermediate care facility
A facility providing a level of medical care that is less than the degree of care and treatment that a
hospital or skilled nursing facility is designed to provide but greater than the level of room and
board.
International Classification of Diseases (ICD)
The classification of morbidity and mortality information for statistical purposes and for the
indexing of hospital records by disease and operations for data storage and retrieval. Provides
codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints,
social circumstances, and external causes of injury or disease.
Intensive Care Unit (ICU)
The area of a hospital where patients with life-threatening illnesses are closely monitored. Also
called Critical Care Unit.
IRS Form 990
The tax-exempt return most charitable organizations, including hospitals, file with the IRS each
year. It includes income, expenditures and activities, as well as compensation of high-level
employees and lobbying expenditures and certain other activities.
J
The Joint Commission
Founded in 1951 by doctors and hospitals, The Joint Commission (formerly Joint Commission
on Accreditation of Healthcare Organizations or JCAHO) evaluates and accredits health care
organizations in the U.S., including hospitals, health plans, and other care organizations that
provide home care, mental health care, laboratory, ambulatory care, and long-term services.
www.jointcommission.org/
Joint Commission Resources (JCR)
A subsidiary of the Joint Commission designed to distribute consulting and publication services.
www.jcrinc.com
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K
Kate B. Reynolds Charitable Trust
The Kate B. Reynolds Charitable Trust was established in 1947 with a mission to improve the
quality of life and the quality of health for the financially needy of North Carolina.
www.kbr.org/
L
Lean manufacturing
An Initiative focused on eliminating all waste in manufacturing processes. Principles of lean
include zero waiting time, zero inventory, scheduling (internal customer pull instead of push
system), batch to flow (cut batch sizes), line balancing and cutting actual process times.
Leapfrog Group
A group of Fortune 500 employers and other purchasers of health care, sponsored by the
Business Roundtable, focused on patient safety issues. www.leapfroggroup.org
Length of stay (LOS)
The number of days a patient stays in a hospital or other health care facility.
Licensed Practical Nurse (LPN)
A nursing school graduate who has been licensed by a state.
Life Safety Code
Standards of construction, protection and occupancy necessary to minimize danger to life from
fire, smoke, fumes and panic. The Joint Commission and the Centers form Medicare and
Medicaid Services require compliance with the code.
Living will
A legal document generated by an individual to guide providers on the desired medical care in
cases when the individual is unable to articulate his or her own wishes. (See "advance directive")
Local Management Entities (LMEs)
Formerly known as Area Mental Health Programs, LMEs are regional authorities responsible for
managing, coordinating, facilitating, and monitoring the provision of mental health, developmental
disabilities, and substance abuse in the area that they serve. Functions of LMEs include ensuring
access to MH/DD/SA services for all North Carolinians, connecting consumers to appropriate
outpatient and inpatient services and others codified in §122C-115.4 of NCGS. In addition to their
statutory LME functions, all LMEs must also become capitated behavioral health managed care
organizations, responsible for all state and local behavioral health funds, including Medicaid, by
July 1, 2013.
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Long-term care (LTC)
Care given to patients with chronic illnesses who usually require a length of stay longer than 30
days.
Long-term care hospital (LTCH or LTACH)
A hospital that specializes in treating patients with serious and often complex medical conditions
requiring a longer length of stay than customarily provided by a traditional acute care hospital.
LTCHs provide care for such conditions as respiratory failure, non-healing wounds, and other
diseases that are medically complex.
Long-Term Care Facility (LTCF)
Any residential health care facility that administers health, rehabilitative or personal services for a
prolonged period of time.
M
MACRA
see Medicare Access and CHIP Reauthorization Act of 2015
Magnet Hospital Recognition Program
A designation through the American Nurses Credentialing Center that recognizes those
institutions that act as a “magnet” by creating a work environment that recognizes and rewards
professional nursing. www.nursecredentialing.org/Magnet.aspx
Magnetic resonance imaging (MRI)
A diagnostic technique that uses radio and magnetic waves, rather than radiation, to create
images of body tissue and to monitor body chemistry.
Malpractice
The improper treatment of a patient, as by a physician or nurse, resulting in injury.
Managed care
A health care delivery system, comprising a spectrum of financial and structural relationships
among purchasers, insurers, providers and consumers designed to favorably affect the balance
of access, cost, and quality of health car for a defined population of subscribers and members.
Management Service Organization (MSO)
A legal entity that provides practice management, administrative and support services to
individual physicians or group practices. An MSO may be a direct subsidiary of a hospital, a joint
venture with physicians, a physician-owned organization or an investor-owned expertise.
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Master of Science in Nursing (MSN)
A person holding a master’s degree in nursing.
Medicaid
A state-administered health insurance program funded partly by the federal government that
provides health care services for certain low-income persons and certain aged, blind or disabled
individuals.
Medicaid Reimbursement Initiative/Gap Assessment Program (MRI/GAP Plan)
A plan designed to supplement losses incurred on providing care to Medicaid and uninsured
patients.
Medical Board
The entity that licenses physicians to practice in North Carolina and disciplines those who violate
state law and rules related to medical practice. www.ncmedboard.org
Medical Consumer Price Index
An inflationary statistic that measures the cost of all purchased health care services.
Medical doctor (MD)
A licensed physician who is a graduate of an accredited school and practices allopathic medicine.
Medical error
The failure of a planned action to be completed as intended (error of execution) or the use of a
wrong plan to achieve an aim (error of planning).
Medical malpractice insurance
Insurance purchased by a person or entity, such as a doctor or hospital, that pays up to the limits
of the policy for damages to a patient caused by malpractice.
Medical savings account (MSA)
A method of financing health care by giving tax advantages to individuals who establish and
maintain personal accounts for health care purposes; similar to an Individual Retirement Account
for retirement purposes.
Medical staff
The licensed physicians and other health care providers credentialed and privileged to provide
medical care to patients in a hospital.
Medicare
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A federally funded program that pays for medical services to residents over age 65 and the
permanently disabled. Coverage is divided into two components.
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Bipartisan federal legislation signed into law on April 16, 2015 that repealed the physician
sustainable growth rate (SGR) formula and encouraged the adoption of “alternative payment
mechanisms.”
Medicare Administrative Contractor (MAC)
Replaces Medicare Part A Fiscal Intermediaries (FIs) and Part B Carriers with 15 new regional
Medicare provider bill payment and cost report intermediaries. North Carolina is in MAC Region
11 (J11).
Medicare Advantage
Also referred to as “Medicare Part C,” or “Medicare+Choice,” a Medicare program under which
eligible Medicare enrollees can elect to receive benefits through a managed care program that
places providers at risk for those benefits.
Medicare Cost Reports
Reports submitted by hospitals that provide services to Medicare beneficiaries. These reports are
a condition of participation in the program and contain detailed hospital data, including financial
statements and utilization information.
Medicare Dependent
A Medicare reimbursement category for a hospital that is located in a rural area, has no more
than 100 beds, and has had at least 60 percent of its inpatient days or discharges attributed to
Medicare.
Medicare Modernization Act of 2003 (MMA)
A federal law that provided a prescription drug benefit under the Medicare program. MMA made
various other adjustments to the Medicare and Medicaid programs affecting providers, including
payment and regulatory improvements for hospitals. Also known as the Medicare Prescription
Drug Bill.
Medicare Part A
One of two parts of the Medicare program that covers inpatient hospital services and services
furnished by other health care providers such as nursing homes, home health agencies, and
hospices. Part A coverage is automatically provided for individuals entitled to Medicare.
Medicare Part B
One of two parts of the Medicare program that covers outpatient, physician, and medical supplier
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services. Part B coverage is optional and must be paid for separately through monthly premium
payments.
Medicare Part C
A Medicare program under which eligible Medicare enrollees can elect to receive benefits through
a managed care program that places providers at risk for those benefits.
Medicare Part D
The part of the Medicare program that covers prescription drug coverage. Since 2006,
beneficiaries have had access to partial prescription drug coverage paid mainly through state
payments, premiums and general revenue. Some assistance for low-income beneficiaries is
available for premiums and co-pays.
Medicare Payment Advisory Commission (MedPAC)
A non-partisan congressional advisory body charged with providing policy advice and technical
assistance concerning the Medicare program and other aspects of the health system. It conducts
independent research, analyzes legislation, and makes recommendations to U.S. Congress. The
Physician Payment Review Commission (PPRC) has been merged with the Prospective Payment
Assessment Commission (ProPAC) to create MedPAC. www.medpac.gov
Medigap
A policy guaranteeing to pay a Medicare beneficiary’s co- insurance, deductible, and copayments and provide additional health plan or non-Medicare coverage for services up to a
predefined benefit limit. In effect, the product pays for the portion of the cost of services not
covered by Medicare.
Merit-based Incentive Payment System (MIPS)
A new payment mechanism that will provide annual updates to physicians starting in 2019, based
on performance in four categories: quality, resource use, clinical practice improvement activities
and meaningful use of an electronic health record system.
Methicillin Resistant Staphylococcus Aureus (MRSA)
A type of staph infection that is resistant to certain antibiotics including methicillin and other more
common antibiotics such as oxacillin, penicillin and amoxicillin. MRSA is a hospital- and
community-acquired infection that is usually manifested as a skin infection, looking like a pimple
or boil, and can occur in otherwise healthy people.
Morbidity
Incidents of illness and accidents in a defined group of individuals.
Mortality
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Incidents of death in a defined group of individuals.
Most-favored-nation clause (MFN)
A provision requiring the contracting physician, hospital, or group to provide an insurer with the
lowest price it charges any other insurer.
N
National Cancer Registry
A unit within the National Institutes of Health (NIH) that provides updates on the latest cancer
diseases, research and diagnosis. www.ncri.ie
National Center for Health Statistics (NCHS)
A division within the U.S. Department of Health and Human Services that is responsible for
gathering data on illness and disability, producing the vital statistics of the nation and tracking the
use and availability of health services and resources. www.cdc.gov/nchs
National Committee for Quality Assurance (NCQA)
A nonprofit organization created to improve patient care quality and health plan performance in
partnership with managed care plans, purchasers, consumers, and the public sector.
www.ncqa.org/Pages/Main/index.htm
National Incident Management System (NIMS)
A standardized approach to incident management and response that establishes a uniform set of
processes and procedures that emergency responders at all levels of government use to conduct
response operations. There are 14 elements specific to hospitals and health care organizations.
National Information Center on Health Services Research and Health Care Technology
(NICHSR)
A division within the U.S. Department of Health and Human Services that supports analyses and
evaluations of the health care system and its financing, and underwrites the development and
testing of new approaches to improve the distribution, use and cost-effectiveness of services.
www.nlm.nih.gov/nichsr/
National Institutes of Health (NIH)
A division within the U.S. Department of Health and Human Services that is responsible for most
of the agency's medical research programs. www.nih.gov
National Quality Forum (NQF)
A not-for-profit membership organization created to develop and implement a national
30
strategy for health care quality measurement and reporting. www.qualityforum.org
National Provider Identifier (NPI)
The NPI is a unique identification number for covered health care providers. Covered health care
providers and all health plans and health care clearinghouses must use the NPIs in the
administrative and financial transactions adopted under HIPAA.
National Rural Health Association (NRHA)
A national trade association representing rural hospitals, rural health clinics and other rural health
care providers. www.ruralhealthweb.org/
NCHA Strategic Partners
NCHA Strategic Partners is a wholly owned subsidiary of the NC Hospital Association and is
committed to being the first resource healthcare providers turn to for access to cost-effective
solutions that work. www.nchastrategicpartners.org/
Network
A group of hospitals, physicians, other providers, insurers, and/or community agencies that work
together to coordinate and deliver a broad spectrum of services to their community.
Never event
An event that results in death, loss of a body part, disability, or loss of bodily function lasting more
than seven days or still present at the time of discharge from an inpatient health care facility. Also
referred to as preventable adverse events.
Nonprofit Hospital
A non-taxable hospital that operates on a not-for-profit basis under the ownership and control of a
private corporation. Usually owned by a community, church or other organization concerned with
community services and resources, nonprofit hospitals use earnings to improve their facilities and
services.
North Carolina Center for Rural Health Innovation and Performance
The NC Center for Rural Health was created by the North Carolina Hospital Association in 1996
as a rural health resource center, providing expert technical assistance and professional
consultation. The Center is dedicated to developing and spreading nation-leading improvements
in performance, leadership, quality and patient safety, operational management and community
health for rural hospitals and rural health organizations throughout North Carolina.
www.ncha.org/ruralhealth
North Carolina Hospital Association (NCHA)
The North Carolina Hospital Association is statewide trade association representing more than
31
130 hospitals and health systems. The association promotes improved delivery of quality
healthcare in North Carolina through leadership, advocacy, information and education, in its
members' interest and for public benefit. www.ncha.org/
North Carolina Hospital Quality Performance Report
The NC Quality Center's web-based transparent, hospital-specific performance report for North
Carolinians. www.NCHospitalQuality.org/
North Carolina Institute of Medicine (NCIOM)
The NC Institute of Medicine seeks constructive solutions to statewide problems that impede the
improvement of health and efficient and effective delivery of healthcare for all North Carolina
citizens. NCIOM serves an advisory function at the request of the Governor, the General
Assembly, and/or agencies of state government, and to assist in the formation of public policy on
complex and interrelated issues concerning health and healthcare for the people of North
Carolina. www.nciom.org/
North Carolina Office of Emergency Management Services (NC OMES)
The mission of the Office of Emergency Medical Services is to foster emergency medical systems,
trauma systems and credentialed EMS personnel to improve in providing responses to
emergencies and disasters which will result in higher quality emergency medical care being
delivered to the residents and visitors of North Carolina. www.ncems.org/
North Carolina Prevention Partners (NCPP)
NC Prevention Partners is a state and national leader in guiding schools, hospitals and
workplaces to improve their culture of wellness by improving policies and environments that
address tobacco use, physical inactivity, poor nutrition and obesity. The Healthy NC Hospitals
initiative is helping hospitals statewide establish quit-tobacco systems, healthy food and physical
activity policies to make NC hospitals even healthier for employees, patients and visitors.
www.ncpreventionpartners.org
North Carolina Quality Center
The North Carolina Hospital Association created the North Carolina Center for Hospital Quality
and Patient Safety (now called NC Quality Center) in 2004 to lead the state's hospitals to become
the safest and highest quality hospitals in the United States. www.ncqualitycenter.org/
North Carolina Quality Center Patient Safety Organization
North Carolina's first federal Patient Safety Organization (PSO) as certified by the Agency for
Healthcare Research and Quality (AHRQ). The NCQC PSO conducts activities that minimize
harm to patients by fostering a culture of quality and safety through learning and sharing among
healthcare organizations. www.ncqualitycenter.org/pso.lasso
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North Carolina-Virginia Hospital Engagement Network (NoCVA)
The North Carolina-Virginia Hospital Engagement Network (NoCVA HEN) is a group of 117
hospitals in North Carolina and Virginia working to meet the goals of the Partnership for Patients,
a national initiative which aims to reduce patient harm by 40 percent and reduce readmissions by
20 percent. www.ncqualitycenter.org/nocva/index.lasso
Nosocomial infections
An infection acquired by an individual while receiving care or services in a health care
organization.
Nuclear Regulatory Commission (NRC)
A federal commission created in 1974 to protect the public health and safety by regulating civilian
uses of nuclear materials. www.nrc.gov
Nurse Anesthetist
A registered nurse who is qualified by special training to administer anesthesia in collaboration
with a physician or dentist and who can assist in the care of patients who are in critical condition.
Nurse Midwife
A registered nurse that has received special training to examine expectant mothers and perform
or assist in routine labor and delivery of normal infants.
Nurse Practitioner
A registered nurse who has completed additional training beyond basic nursing education and
provides primary health care services in accordance with state nurse practice laws or statutes.
Nursing quality indicators
A set of 10 nursing-sensitive indicators that link nursing interventions to patient outcomes.
O
Occupational Safety and Health Administration (OSHA)
A federal agency within the U.S. Department of Labor that is responsible for setting standards to
promote and enforce employee safety in the workplace. www.osha.gov
Occupational therapist (OT)
A health care professional in rehabilitation who helps patients regain, develop and build skills for
independent functioning.
Office of the Assistant Secretary for Preparedness and Response (ASPR)
The federal agency within the U.S. Department of Health and Human Services (HHS) that
33
provides health care preparedness grants. www.hhs.gov/aspr
Office of Inspector General (OIG)
The enforcement arm within the U.S. Department of Health and Human Services (HHS) that
oversees investigations of alleged violations of Medicare and Medicaid laws and rules. (Most
federal agencies have their own OIG.) www.hhs.gov
Office of Management and Budget (OMB)
A federal agency responsible for providing fiscal accounting and budgeting services for the
federal government. www.whitehouse.gov/omb
Office of the National Coordinator for Health Information Technology (ONC)
ONC is the principal federal entity charged with coordination of nationwide efforts to implement
and use the most advanced health information technology and the electronic exchange of health
information. The position of National Coordinator was created in 2004, through an Executive
Order, and legislatively mandated in the Health Information Technology for Economic and Clinical
Health Act (HITECH Act) of 2009. healthit.hhs.gov
Office of Professional Standard Review Organizations
The health standards and quality bureau of the Centers for Medicare and Medicaid
Services.
Omnibus Budget Reconciliation Act (OBRA)
An amendment to the federal budget that outlines new federally funded programs or revisions to
existing programs.
Operating Margin
Operating margins reflect a surplus or deficit from operations. Through predominantly nonprofit in
Michigan, hospitals need positive margins to replace old equipment, recruit and retain
professional staff, and to demonstrate to lenders the ability to repay debt.
Operating Room (OR)
Hospital suite in which surgery requiring anesthesia is performed.
Optional Medicaid eligibility groups
Sub-sets of the population for whom the Federal government will provide the Federal Medical
Assistance Percentage (FMAP) of coverage.
Optional Medicaid services
34
Medical services, outside of the mandatory services prescribed by the Federal government, for
which the Federal government will provide the Federal Medical Assistance Percentage (FMAP) of
coverage.
Organ procurement organization (OPO)
A non-profit, federally funded organization that aids in the organ transplantation process.
ORYX
The integration of performance measurement into the Joint Commission’s accreditation process.
Each accredited facility must select vendors that have been approved by the Joint Commission
for the performance measurement system.
Osteopathic
One of two schools of medicine that uses manipulative measures in treating patients in addition to
the diagnostic and therapeutic measures of medicine. The other school is allopathic.
Outcome measures
Assessments to gauge the results of treatment for a particular disease or condition. Outcome
measures include the patient's perception of restoration of function, quality of life, and functional
status, as well as objective measures of mortality, morbidity, and health status.
Outlier
A patient case that falls outside of the established norm for diagnosis related groups.
Out-of-area benefits
The coverage allowed to HMO members for emergency and other situations outside of the
prescribed geographic area of the HMO.
Out-of-pocket maximum
The most an individual will have to pay for covered medical expenses in a plan year through
deductible and coinsurance before the insurance plan begins to pay 100 percent of covered
medical expenses.
Outpatient
A person who receives health care services without being admitted to a hospital.
Outpatient Prospective Payment System (OPPS)
A determined payment rate for a Medicaid outpatient procedure regardless of services rendered
or the intensity of the services.
35
P
Palliative care
Care for not only physical symptoms, but also for emotional, social, spiritual, psychological and
cultural symptoms to achieve the best possible quality of life. Palliative care is usually provided at
the end of life or to help deal with chronic conditions.
Palmetto GBA
Palmetto GBA, headquartered in Columbia, SC, administers the transaction process for Medicare
services in North Carolina. www.palmettogba.com
Participating provider
A health care provider who has a contractual arrangement with a health care service contractor,
HMO, PPO, IPA or other managed care organization.
Patient-Centered Care
Care that is respectful of and responsive to individual patient preferences, needs and values and
ensures patient values guide all clinical decisions; care that is coordinated, communicative and
supportive.
Partnership for Patients
The Partnership for Patients is a public-private partnership that will help improve the quality,
safety and affordability of health care for all Americans. With funding provided by the Affordable
Care Act and leveraging a number of ongoing programs, the Department of Health and Human
Services will work with public and private partners to achieve two core goals – keeping patients
from getting injured or sicker in the health care system and helping patients heal without
complication by improving transitions from acute-care hospitals to other care settings, like home
or a skilled nursing facility. Hospital Engagement Networks (HENs) will help identify solutions
already working to reduce health care acquired conditions, and work to spread them to other
hospitals and health care providers. www.healthcare.gov/compare/partnership-for-patients/
Patient Protection and Affordable Care Act (PPACA)
The Patient Protection and Affordable Care Act, also known as the Affordable Care Act (ACA) or
informally referred to as Obamacare, is a United States federal statute signed into law
by President Barack Obama on March 23, 2010. On June 28, 2012, the Supreme Court upheld
the constitutionality of much of PPACA. ACA represents the most significant regulatory overhaul
of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965. ACA is
aimed primarily at decreasing the number of uninsured Americans and reducing the overall costs
of health care. It provides a number of incentives, including subsidies, tax credits, and fees to
employers and uninsured individuals in order to increase insurance coverage. Additional reforms
are aimed at improving healthcare outcomes in the United States while updating and streamlining
the delivery of health care. ACA requires insurance companies to cover all applicants and offer
36
the same rates regardless of pre-existing conditions or gender.
Patient Safety Organization (PSO)
A PSO collects, aggregates and analyzes patient safety events that are confidentially reported by
hospitals and other healthcare providers. By encouraging voluntary and confidential reporting of
serious adverse events a PSO can facilitate a shared-learning approach that supports effective
improvements to reduce risk and harm in the delivery of health care. In 2008, the NC Center for
Hospital Quality & Patient Safety became North Carolina's first federal PSO as certified by the
Agency for Healthcare Research and Quality (AHRQ). www.ncqualitycenter.org/pso.lasso
Patient Self-Determination Act
A federal law that requires health care facilities to determine if new patients have a living will
and/or durable power of attorney for health care and take patients' wishes into consideration in
developing their treatment plans.
Pay for performance
A new movement in health insurance where providers are rewarded for quality of health care
services. Also called value-based purchasing.
Payment
Reimbursement a hospital receives for care provided; usually less than the standard charge and
sometimes less than the cost of providing care.
Payer
An organization (such as the federal government for Medicare or a commercial insurance
company) or person who directly reimburses health care providers for their services.
Peer review
Review of a health professional’s performance of clinical professional activities by peers through
formally adopted written procedures.
Peer Review Organization or Professional Review Organization (PRO)
An organization with which the Medicare program and hospitals contract for quality and utilization
review of services covered by the program.
Performance measure
A quantitative tool (for example, rate, ratio, index or percentage) that provides an indication of an
organization's performance in relation to a specified process or outcome.
Per member per month (PMPM)
The amount of money paid or received on a monthly basis for each individual enrolled in a
37
managed care plan, often referred to as capitation.
Physician-hospital organization (PHO)
A legal entity formed and owned by one or more hospitals and physician groups in order to obtain
payer contracts and to further mutual interests; one type of integrated delivery system.
Physical Therapist (PT)
An individual trained, licensed in, or practicing physical therapy.
Physician Assistant (PA)
A trained, licensed individual who performs tasks that might otherwise be performed by
physicians or under the direction of a supervising physician.
Point-of-service (POS)
An insurance plan in which members need not choose how to receive services until the time they
need them, also known as an open-ended HMO.
Point-of-Service Plan (POS)
A model that combines features of both HMOs and traditional insurance. Enrollees decide at the
time care is needed whether to use a doctor who is in the network or one who is not. Copayments
and fee schedules are typically larger when a doctor outside the network is chosen.
Political action committee (PAC)
A group of people organized to collect and distribute contributions to political candidates.
Pre-admission testing (PAT)
Patient tests performed on an outpatient basis prior to admission to the hospital.
Pre-existing condition
An illness or other medical condition that a patient has experienced before the effective date of
insurance coverage.
Preferred provider organization (PPO)
A panel of physicians, hospitals, and other health care providers of services to an enrolled group
for a fixed periodic payment.
Prenatal care
Services to pregnant women designed to ensure that both the expectant mother and the newborn
are in the best health. A lack of prenatal care early in the pregnancy is associated with low birth
weight and infant mortality.
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Present on Admission (POA)
A requirement the Centers for Medicare & Medicaid Services (CMS) has mandated which
requires that hospitals report if an infection was present when a patient was admitted to a facility
on all secondary claims to Medicare.
Preventive Care
Comprehensive care emphasizing priorities for prevention, early detection, and early treatment of
conditions, generally including routine physical examination, immunization, and well-person care.
Primary Care
Basic health care; a branch of medicine that accentuates the point when a patient first seeks
assistance in a health care system and the treatment of simpler, more common illnesses and
injuries.
Process improvement
The application of the plan-do-study-act (PDSA) philosophy to processes to produce positive
improvement and better meet the needs and expectations of customers.
Prospective Payment System (PPS)
A method of financing health care that mandates payments in advance for the provision of
services and is based on diagnostic related groups.
Provider
A hospital, physician, group practice, nursing home, pharmacy, or any individual or group of
individuals that provides a health care service.
Provider Reimbursement Review Board (PRRB)
A federal board responsible for making decisions regarding provider appeals on Medicare
reimbursement issues.
Provider-sponsored organization (PSO)
A provider-owned entity that is certified by the Centers for Medicare and Medicaid Services to
participate in the Medicare+Choice program and to assume risk for benefits provided to Medicare
beneficiaries.
Public option
A government-run health-insurance plan that could offer coverage at a cost below that of private
insurance plans because of lower administrative costs and possibly lower reimbursements to
doctors and hospitals.
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Q
Quality assurance
A formal set of activities to review and improve the quality of services provided. Quality assurance
includes quality assessment and corrective actions to remedy any deficiencies identified in the
quality of direct patient, administrative, and support services.
Quality improvement
A continuous effort to provide services at the highest level of quality at the lowest level of cost.
Quality improvement organization (QIO)
QIOs hold contracts with CMS to make sure patients get the right care at the right time,
particularly among underserved populations. QIOs are directed to ensure that Medicare payment
is made only for medically necessary services and to investigate beneficiary complaints about
quality of care. The Carolinas Center for Medical Excellence (CCME) has been the designated
QIO in North Carolina since 1984 (formerly Medical Review of NC). www.thecarolinascenter.org/
R
Rate-setting
The determination by a government body of rates a health care provider may charge private-pay
patients.
Recovery Audit Contractors (RAC)
Recovery audit contractors review old Medicare claims to discover overpayments and
underpayments. RACs are paid on the basis of a percentage of the overpayments they recover.
Referring Physician
A physician who sends a patient to another source for examination, surgery, or to have specific
procedures performed, usually because the referring physician cannot adequately provide the
needed service.
Refined diagnosis related group (RDRG)
An expanded list of diagnosis related groups to take into account a patient's severity of illness.
Regional Advisory Committees (RACs)
Each county and hospital in NC is currently included in at least one of seven Regional Advisory
Committees. RACs were initially established for the purpose of regional trauma planning, to
include establishing and maintaining a coordinated trauma system. Following Sept. 11, 2001,
RAC responsibilities and members significantly expanded to account for increased disaster and
40
terrorism related activities. The NC Office of Emergency Medical Services (NCOEMS) oversees
the RACs in NC and works with them to coordinate their responsibilities regarding the state's
trauma/terrorism initiatives.
Registered Nurse (RN)
One who has graduated from a college or university program of nursing education and has been
licensed by the state.
Reinsurance
A type of insurance purchased by primary insurers from secondary insurers. A commercial or
captive insurance company purchases reinsurance to protect against part or all losses the
primary insurer might assume in honoring claims of its policyholders.
Rescission
Insurance companies' practice of dropping patients after they file expensive claims, on the
grounds that applicants misrepresented their health history when they signed up for coverage.
Resource-Based Relative Value Scale (RBRVS)
Medicare fee schedule for physician services that sets a uniform payment in each geographic
area for most of the approximately 7,000 medical procedures.
Resource Utilization Group (RUG)
A classification for nursing home patients whose resident information is similar and who have a
certain per diem reimbursement rate.
Return on investment (ROI)
A measure of a company’s ability to use its assets to generate additional value for shareholders.
It is calculated as net profit divided by net worth and is expressed as a percentage.
Risk
The chance or possibility of loss. Also used to refer to the insured or to the property coverage by
a policy. Risk is also defined in health insurance terms as the possibility of loss associated with a
given population. In an HMO setting, often employed as a utilization control mechanism.
Risk classification
The process by which a company decides how its premium rates should differ according to the
risk characteristics of individual insureds.
Risk management
The practice of identifying and analyzing loss exposures and taking steps to minimize the
financial impact of the risks they impose.
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Root cause
The most fundamental reason for the failure or inefficiency of a process. Also called underlying
cause.
Root Cause Analysis (RCA)
A process for identifying the basic or causal factor(s) that underlie variation in performance,
including the occurrence or possible occurrence of a sentinel event.
Rural Health Clinic (RHC)
A health care organization that is in compliance with the federal Rural Health Clinics Act. RHCs
must be located in a medically underserved area or a health professions shortage area, use
physician assistants and/or nurse practitioners to deliver services, provide preventive services,
and be licensed by the state.
Rural Referral Center
Hospitals located in rural areas that meet certain criteria to be paid the Medicare prospective
payment system’s urban rate, adjusted by the rural wage index. Qualifying criteria include such
things as having at least 275 beds and a minimum volume of discharges annually.
S
Safety net providers
Providers who have a mission or mandate to deliver large amounts of care to uninsured or other
vulnerable patients (e.g., public hospitals, teaching hospitals, community health centers or clinics).
Safe Practices
Practices that reduce the risk of harm from the processes, practices or systems of healthcare, the
standardization of which is likely to have significant benefit for patient safety if fully implemented.
Satisfaction Measures
Measures that address the extent to which the patients/enrollees, practitioners and/or purchasers
perceive their needs to be met.
Schedule H
A special section of IRS Form 990 for nonprofit entities that is required to be completed by
hospitals, providing details on community benefit and other activities.
Sentinel event
An unexpected occurrence involving death or serious physical or psychological injury, or the risk,
thereof.
Service Area
42
The geographical area in which a managed care plan is licensed to provide health care services
to its members; or the region served by a hospital or other health care provider.
Severity Adjustment
Classification of patients by severity-of-illness data to allow for meaningful comparison of
performance and quality among organizations and practitioners.
Single payer
A system in which a government insures all its citizens, paid for by tax dollars. It is used by Britain
and Canada.
Skilled nursing facility (SNF)
A facility, either freestanding or part of a hospital, that accepts patients in need of rehabilitation
and medical care that is of a lesser intensity than that received in the acute care setting of a
hospital.
Sole Community Provider
Health care facility located in an isolated area that serves as the only source of emergency,
outpatient, and inpatient care in the region. These facilities receive a special designation from the
Health Care Financing Administration and a different payment formula that provides for greater
reimbursement.
Specialty hospital
A limited-service hospital designed to provide one medical specialty such as orthopedic or
cardiac care.
Special Operations Response Team
SORT is a private non-profit organization located in Winston-Salem, is a federally supported
disaster medical team that responds nationwide.
Stark II
The commonly used name for federal laws and regulations that ban physician referral to entities
with which the physician has a financial relationship.
State Children’s Health Insurance Program (SCHIP)
See "Children’s Health Insurance Program (CHIP)"
State fiscal year
The state government's accounting year, which begins July 1 and ends June 30
State Health Coordinating Council (SHCC)
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Directs the development of the annual State Medical Facilities Plan (SMFP). Aims to promote
cost-effective approaches, expand health care services to the medically underserved, and
encourage quality health care services.
State Medical Facilities Plan (SMFP)
An annual document that contains policies/methodologies used in determining need for new
health care facilities and services.
State share
The cost, based on the state’s per capita income, of the Medicaid program less the Federal
Medical Assistance Percentage (FMAP) and any applicable block grants.
Stop loss
The point at which a third party has reinsurance to protect against the overly large single claim or
the excessively high aggregate claim during a given period of time. Large employers that selfinsure may purchase reinsurance for stop loss purposes.
Subacute care
Care given to patients who require less than a 30-day length of stay in a hospital and who have a
more stable condition than those receiving acute care.
Subsidies
In the context of health-care reform, these are financial credits from the government that are
distributed to Americans — calculated based on income — that Americans could use to purchase
health insurance.
Supplemental medical insurance
Private health insurance, also called medigap insurance, designed to supplement Medicare
benefits by covering certain health care costs that are not paid for by the Medicare program.
Supplemental Security Income (SSI)
A federal program of income support for low income, aged, blind and disabled persons
established by Title XVI of the Social Security Act. Qualification for SSI often is used to establish
Medicaid eligibility.
Sustainable Growth Rate (SGR)
A method used by the Centers for Medicare and Medicaid Services (CMS) in the United States to
control spending by Medicare on physician services.
Swing beds
Acute care hospital beds that can also be used for a different level of care.
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System error
An error that is not the result of an individual's action, but the predictable outcome of a series of
actions and factors that comprise a diagnostic or treatment process.
T
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
A federal law that authorizes health plans to enter into arrangements with the Centers for
Medicare & Medicaid Services for cost and risk contracts.
Teaching hospital
A hospital that has an accredited medical residency training program and is typically affiliated with
a medical school.
Telemedicine
Health care consultation and education using telecommunication networks to transmit information.
Tertiary care
Highly specialized care given to patients who are in danger of disability or death.
Third-party administrator
A person or organization that manages the payment, processing, and settlement of life, health,
dental, disability, and self-funded insurance claims for another person or organization.
TITLE XVIII
A section of the U.S. Social Security Act that authorizes and details the parameters of the
Medicare Program.
TITLE XIX
A section of the U.S. Social Security Act that authorizes and details the parameters of the
Medicaid Program.
TITLE XXI
A section of the U.S. Social Security Act that establishes the Children’s Health Insurance
Program (CHIP).
Tort
A negligent or intentional civil wrong not arising out of a contract or statute that injures someone
in some way and for which the injured person may sue the wrongdoer for damages.
Total margin
The ratio of total revenue to total costs or expenses, including non-patient care
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Transparency
A movement toward providing more information to the public on hospital operation costs and
quality.
Trauma center
Trauma center verification is the process by which the American College of Surgeons confirms
that a hospital is performing as a trauma center and meets the criteria contained in the ACS
Resources for Optimal Care of the Injured Patient document. The designation of a trauma facility
and its role in a trauma system is a political process enacted by local, regional, or state
government.
Triage
The process by which patients are sorted or classified according to the type and urgency of their
conditions.
TRICARE
A program that pays for care delivered by civilian health providers to retired members and
dependents of active and retired members of the seven uniformed services of the United States.
U
Uncompensated care
All health care services for which a provider is not compensated, including bad debt, charity care,
and other services that go unpaid. (See "charity care")
Underlying cause
The most fundamental reason for the failure or inefficiency of a process. Also called root cause.
Underinsured
People with some type of health insurance but not enough to cover all their health care needs.
Uniform Billing Code of 2004 (UB-04)
A federal directive requiring a hospital to follow specific billing procedures, itemizing all services
included and billed for on each invoice.
Uniform hospital discharge data set
A defined set of data that gives a minimum description of a hospital discharge. It includes data on
age, sex, race, residence of patient, length of stay, diagnosis, physicians, procedures, disposition
of the patient and sources of payment.
Uninsured
People who lack health insurance of any kind.
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Unpreventable Adverse Event
An adverse event resulting from a complication that cannot be prevented given the current state
of knowledge.
Upper Payment Limit (UPL)
The maximum amount states can pay providers for Medicaid services.
Urgent care
Medical care for illness or injury requiring attention at a level higher than for a physician office
visit but less than the level of emergency care.
U.S. Department of Health and Human Services (HHS)
A department within the executive branch of the federal government responsible for Social
Security and federal health programs in the civilian sector. www.dhhs.gov
U.S. House Energy and Commerce Committee
A congressional committee whose primary jurisdiction includes most hospital- and health carerelated issues. Members of this committee have significant influence over the development of
federal health care policy and funding. energycommerce.house.gov
U.S. House Committee on Ways and Means
A congressional committee with primary oversight of Medicare, Social Security and other public
welfare programs. Also responsible for legislation concerning taxes, bonded debt and tariffs.
waysandmeans.house.gov
U.S. Senate Committee on Finance
A congressional committee dealing with Medicare, Medicaid, federal bonds, the customs service
and related issues, public moneys, revenue sharing, health programs funded by specific taxes,
national social security and general revenue matters. Members of this committee have significant
influence over the development of federal health care policy and funding. finance.senate.gov
U.S Senate, Health Education, Labor, and Pensions Committee (HELP)
A congressional committee whose primary jurisdiction includes most hospital- and health carerelated issues. Members of this committee have significant influence over the development of
federal health care policy and funding. www.senate.gov/~labor/
Usual, customary and reasonable charges (UCR)
Charges for health care services in a geographical area that are consistent with the charges of
identical or similar providers in the same geographic area.
Utilization
The patterns of use of a service or type of service within a specified time, usually expressed in a
rate per unit of population- at-risk for a given period (e.g., the number of hospital admissions per
47
year per 1,000 persons in a geographic area).
Utilization review (UR)
An evaluation of the necessity and appropriateness of the use of health care services, procedures,
and facilities.
V
Value-based purchasing (VBP)
A purchasing program designed to transform Medicare from a passive payer of claims to an
active purchaser of care. These programs make a portion of the hospital payment contingent on
actual performance of specified measures, rather than simply on the hospital’s reporting data.
Ventilator Associated Pneumonia (VAP)
A sub-type of hospital-acquired pneumonia (HAP) which occurs in people who are on mechanical
ventilation through an endotracheal or tracheotomy tube.
W
Wage index
A factor used to adjust the base Medicare reimbursement rates for an area to account for
geographic differences in wages paid to health care workers.
Weapon of mass destruction
Weapons capable of inflicting mass casualties and destruction; including nuclear, biological and
chemical weapons or the means to deliver them.
Well-baby care
Services provided in the first year of a newborn's life to identify, treat, and prevent health care
problems.
Workers’ Compensation (WC)
Provides state-mandated insurance coverage for work-related injuries and disabilities.
World Health Organization (WHO)
A specialized agency of the United Nations generally concerned with health and health care.
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Healthcare Acronyms
A
AA — Anesthesiologist Assistant
AACN — American Association of Colleges of Nursing
AAFP — American Academy of Family Physicians
AAP — American Academy of Pediatrics
AAPC — Adjusted Average Per Capita Cost
ABIM — American Board of Internal Medicine
ACHE — American College of Healthcare Executives
AAHP — American Association of Health Plans
AAP — American Academy of Pediatrics
AARP— American Association of Retired Persons
ACG — Ambulatory Care Group
ACO — Accountable Care Organization
ACP — American College of Physicians
ACPV — Average Cost per Visit
ACS — American College of Surgeons
ACU — Ambulatory Care Unit
ADA — Americans with Disabilities Act of 1990
ADATC — Alcohol and Drug Abuse Treatment Center
ADC— Average Daily Census
ADE — Adverse Drug Event
ADG — Ambulatory Diagnostic Group
ADL— Activities of Daily Living
ADJ —Adjusted Claim
ADR — Adverse Drug Reaction
ADS — Alternate Delivery System
ADT — Admission/Discharge Transfer
AHA — American Hospital Association
AHC — Academic Health Center
AHEC — Area Health Education Center
AHIMA — American Health Information Management Association
AHPA — American Health Planning Association
AHRQ — Agency for Healthcare Research and Quality
AIDS — Acquired immune deficiency syndrome
ALJ — Administrative Law Judge
ALOS — Average length of stay
AMA — American Medical Association
AMI — Acute Myocardial Infarction
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ANA — American Nurses Association
ANDI — NCHA’s Advocacy Needs Data Initiative
AoA — Administration of Aging
AONE — American Organization of Nurse Executives
A/P — Accounts Payable
APC — Ambulatory Payment Class
APD — Adjusted Patient Day
APM — Alternative Payment Model/Mechanisms
APR — Adjusted Payment Rate
APIC — Association for Professionals in Infection Control and Epidemiology
APRN — Advanced Practice Registered Nurse
A/R — Accounts Receivable
ARRA— American Recovery and Reinvestment Act of 2009
ASC — Ambulatory Surgical Center
ASHE — American Society for Healthcare Engineering
ASHMM — American Society for Healthcare Materials Management
ASHP — American Society of Health Systems Pharmacists
ASHPR — American Society for Hospital Public Relations
ASHRM — American Society for Hospital Risk Managers
AWI — Area Wage Index
B
BBA— Balanced Budget Act of 1997
BBRA — Balanced Budget Refinement Act of 1999
BCA — Blue Cross Association
BCBSNC — Blue Cross Blue Shield of NC
BHO — Behavioral Health Organization
BIPA — Benefits Improvement and Protection Act of 2000
BLS —Basic Life Support
BME — Board of Medical Examiners
BP — Blood Pressure
BSN — Bachelor of Science in Nursing
C
CABHA — Critical Access Behavioral Health Agency
CAE — Certified Association Executive CAH — Critical Access Hospital
CAH — Critical Access Hospital
CAHPS — Consumer Assessment of Healthcare Providers and Systems
CAP — Capitation
CAPS — Claims Automated Processing System (SSA MBR)
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CAT — Computerized Axial Tomography
CBO — Congressional Budget Office
CBO — Community-Based Organization
CC — Condition Code
CCNC— Community Care of North Carolina
CCME — Carolina Center for Medical Excellence
CCR — Cost-to-Charge Ratio
CCT — Comprehensive Crisis Treatment
CCTP — Community-based Care Transitions Program
CCU — Cardiac Care Unit
CDC — Centers for Disease Control and Prevention
C.diff — Clostridium Difficile
CE — Continuing Education
CEO — Chief Executive Officer
CFO — Chief Financial Officer
CME — Continuing Medical Education
CAUTI — Catheter Associated Urinary Tract Infection
CERT — Center for Emergency Response and Terrorism (DHSS)
CERT — (Medicare) Comprehensive Error Rate Testing
CHAMPUS — Civilian Health and Medical Program of the Uniformed Services (now TRICARE)
CHAMPVA — Civilian Health and Medical Program of the Veterans Administration
CHC — Community Health Center
CHE — Certified Healthcare Executive
CHIME — Center for Health Information Management and Evaluation
CHIP — Children’s Health Insurance Program (NC Health Choice)
CHNA — Community Health Needs Assessment
CICU — Cardiac Intensive Care Unit
CIO — Chief Information Officer
CLABSI — Central-line Associated Bloodstream Infection
CLASS — Community Living Assistance Services and Support
CLIA — Clinical Laboratory Improvement Act
CME — Continuing Medical Education
CMO — Chief Medical Officer
CMMI — Center for Medicare and Medicaid Innovation
CMI — Case Mix Indicator
CMR — Computerized Medical Record
CMS — Centers for Medicare and Medicaid Services
CN — Claim Number
CNO — Chief Nursing Officer
COA — Council on Accreditation
COB — Coordination of Benefits
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COBRA — Consolidated Omnibus Reconciliation Act of 1985
COC — Certificate of Coverage
COE — Center of Excellence
COLA — Cost of Living Adjustment
CON — Certificate of Need
COO — Chief Operating Officer
CoP — Conditions of Participation
COPD — Chronic Obstructive Pulmonary Disease
CPA — Certified Public Accountant
CPE — Certified Public Expenditure
CPHQ — Certified Professional in Healthcare Quality
CPI — Consumer Price Index
CPM — Clinical Performance Measure
CPOE — Computerized Physician Order Entry
CPR — Cardiopulmonary Resuscitation
CPT — Current Procedural Terminology
CQI — Continuous Quality Improvement
CQM — Clinical Quality Measure
CR — Change Request
CRNA — Certified Registered Nurse Anesthetist
CT — Computed Tomography
CWF — Common Working FIle
CY — Calendar Year
D
DA — Disability Assistance
DAW — Dispense as Written
DB — Deaf Blind
DD — Developmental Disability, Developmentally Delayed
DDS — Disability Determination Services
DDS — Doctor of Dental Surgery
DEA — Drug Enforcement Administration
DHHS — NC Department of Health and Human Services
DHSR — NC Division of Health Service Regulation
DHS — Department of Homeland Security
DMA — NC Division of Medical Assistance
DME — Durable Medical Equipment
DMH/DD/SAs — Division of Mental Health, Developmental Disabilities & Substance Abuse Services
DNR — Do-Not-Resuscitate
DoA — Division of Aging
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DO — Doctor of Osteopathy
DOA — Dead on Arrival
DOB — Date of Birth
DOC — Department of Correction
DOD — Department of Defense
DOE — Department of Education (federal)
DOJ — Department of Justice (federal)
DOL — Department of Labor
DOS — Date of Service
DOT — Department of Transportation
DPH— Division of Public Health
DPI — Department of Public Instruction
DRA — Deficit Reduction Act
DRG — Diagnosis Related Group
DSA — Digital Subtraction Angiography
DSB — Division of Services For The Blind
DSDHH — Division of Services For The Deaf And Hard of Hearing
DSH — Disproportionate Share Hospital
DSS — Department of Social Services (county) Division of Social Services (state)
DT — Day Treatment
DWAC — DHHS Waiver Advisory Committee
Dx — Diagnosis
E
EAP — Employee Assistance Program
EBP — Evidence-Based Practice
ECF — Extended Care Facility
ECG/EKG — Electrocardiogram
ECS — Electronic Claims Submission
ECU — Environmental Control Unit
ED — Emergency Department
EDI — Electronic Data Interchange
EDP — Electronic Data Processing
EDS — Electronic Data Systems
EEG — Electroencephalogram
EEOC — Equal Employment Opportunity Commission
EHR — Electronic Health Records
EKG/ECG — Electrocardiogram
EMG — Electromyogram
EMR — Electronic Medical Records
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EMS — Emergency Medical Systems
EMT — Emergency Medical Technologist
EMTALA — Emergency Medical Treatment and Active Labor Act
ENT — Ears, Nose and Throat
EOB — Explanation of Benefits
EOL — End of Life
EOMB — Explanation of Medicare Benefits
EOP — Emergency Operations Plan
EP — Emergency Preparedness
EPA — Environmental Protection Agency
EPSDT — Early Periodic Screening, Diagnosis and Treatment
ER — Emergency Room
ERISA — Employee Retirement Income Security Act
ESRD — End Stage Renal Disease
F
FACHE — Fellow of American College of Healthcare Executives
FAH – Federation of American Hospitals
FASB — Financial Accounting Standards Board
FCC — Federal Communications Commission
FCRA _ Fair Credit Reporting Act
FDA — Food and Drug Administration
FEC — Freestanding Emergency Center
FEMA — Federal Emergency Management Agency
FFP — Federal Financial Participation
FFS — Fee For Service
FFY — Federal Fiscal Year
FI — Fiscal Intermediary
FISS — Fiscal Intermediary Standard System
FLEX — Medicare Rural Hospital Flexibility Program
FMAP — Federal Medical Assistance Percentage rate
FMEA — Failure Modes and Effects Analysis
FMG — Foreign Medical Graduate
FMLA — Family Medical Leave Act
FNP— Family Nurse Practitioner
FOIA — Freedom of Information Act
FP — Family Practitioner
FPL — Federal Poverty Level
FQHC — Federally Qualified Health Center
FRA — Federal Reimbursement Allowance
54
FSA — Flexible Spending Account
FTC — Federal Trade Commission
FY — Fiscal year
FYE — Fiscal Year Ending
FTE — Full-Time Equivalent
FY — Fiscal Year
G
GAAP — Generally Accepted Accounting Principles
GAO — General Accounting Office
GAF — Geographic Adjustment Factor
GAP — Gap Assessment Program
GASB — Governmental Accounting Standards Board Financial Accounting
GDP — Gross Domestic Product
GI — Gastrointestinal
GME — Graduate Medical Education
GNP — Gross National Product
GP — General Practice
GPCI — Graduate Practice Cost Index
GPO — Group Purchasing Organization
H
HAI — Healthcare Associated Infections
HB — House Bill (state)
HCAP — Health Care Associated Pneumonia
HCAP — Hospital Care Assurance Program
HCBS — Home and Community-Based Services
HCFA — Health Care Financing Administration (renamed CMS in 2001)
HCPCS — Healthcare Common Procedure Coding System
HCPP — Health Care Prepayment Plan
HCQIA — Health Care Quality Improvement Act
HCW — Health Care Worker
HDHP — High Deductible Health Plan
HEBI — Hospital Employee Benefits, Inc
HEC — Hospital Engagement Contractor
HEDIS® — Health Plan Employer Data and Information Set
HEICS — Hospital Emergency Incident Command System
HEN — Hospital Engagement Network
HFMA — Healthcare Financial Management Association
HH — Home Health
55
HHA — Home Health Agency
HHS – US Department of Health and Human Services
HIAA — Health Insurance Association of America
HICS — Hospital Incident Command System
HIDI — Hospital Industry Data Institute
HIE — Health Information Exchange
HIM — Health Information Management
HINN — Hospital Issued Notice of Non-coverage
HIPAA — Health Insurance Portability and Accountability Act
HIS _ Hospital Information System
HIT — Health Information Technology
HITECH — Health Information Technology for Economic and Clinical Health Act
HIV — Human Immunodeficiency Virus
HMBI — Hospital Market Basket Index
HMO — Health Maintenance Organization
HMSA — Health Manpower Shortage Area
HOSPAC —Hospital Political Action Committee (NCHA’s PAC)
HPID — Health Plan Identifier
HPOE — Hospitals in Pursuit of Excellence (AHA)
HPS — Hospital Purchasing Service
HPSA — Health Professional Shortage Area
HQRM — Healthcare Quality and Resource Management
H.R. — House Resolution (federal legislation only. See HB for state legislation.)
HRA — Health Risk Assessment
HRET — Hospital Research and Educational Trust (AHA)
HRSA — Health Resources and Services Administration
HSA — Health Savings Account
HSA — Health Service Agency
HSR — Hospital Specific Rate
HSP — Health Service Plan
HVA — Hazard Vulnerability Assessment
I
IBNR — Incurred But Not Reported
ICD-9-CM — International Classification of Diseases, Ninth Revision, Clinical Modification
ICD-10-PCS — International Classification of Diseases, 10th Revision, Procedure Coding System
ICF — Intermediate Care Facility
ICN — Intermediate Care Nursery
ICU — Intensive Care Unit
IDD — Intellectual and Developmental Disabilities
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IDS — Integrated Delivery System
IG — Inspector General
IHI — Institute for Healthcare Improvement
IHN — Integrated Health Network
IJ — Immediate Jeopardy
ILC — Independent Living Center
IME — Indirect Medical Education
IOM — Institute of Medicine
IP — Inpatient
IPA — Independent Practice Association
IPAB — Independent Payment Advisory Board
IPF — Inpatient Psychiatric Facility
IPPS — Inpatient Prospective Payment System
IPRS — Integrated Payment and Reimbursement System
IRB — Institutional Review Board
IRF — Inpatient Rehabilitation Facility
IS — Information System
ISMP — Institute for Safe Medication Practices
IT — Information Technology
IV — Intravenous
IVC — Involuntary Commitment
J
J11 — Jurisdiction 11 Part B (NC)
JCAHO — The Joint Commission (formerly Joint Commission on Accreditation of Healthcare
Organizations)
JCC — Joint Conference Committee
JCR — Joint Commission Resources
K
KBR — Kate B. Reynolds Charitable Trust
L
LCD — Local Coverage Determinations
LCP — Licensed Clinical Psychologist
LCSW — Licensed Clinical Social Worker
LDR — Labor and Delivery Room
LME — Local Management Entity
LMRP — Local Medical Review Policy
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LOB — Legislative Office Building
LOC — Legislative Oversight Committee
LOS — Length of Stay
LPC — Licensed Professional Counselor
LPN — Licensed Practical Nurse
LTAC — Long-term Acute Care Hospital
LTC — Long-term Care
LTCF
— Long-term Care Facility
LVN — Licensed Vocational Nurse
M
MA — Medicare Advantage
MAC
— Medicare Administrative Contractor
MAC — Maximum Allowable Costs
MACRA — Medicare Access and CHIP Reauthorization Act of 2015
MACPAC — Medicaid and CHIP Payment Access Commission
MBI — Market Basket Index
MCAC — Medical Care Advisory Committee
MCC — Medical Care Commission
MCO — Managed Care Organization
MCT — Mobile Crisis Team
MD — Medical Doctor
MedPAC — Medicare Payment Advisory Commission
MFS — Medicare Fee Schedule
MGCRB — Medicare Geographic Classification Review Board
MHA — Master of Healthcare Administration
MI — Myocardial Infarction
MIC — Medicaid Integrity Contractor
MIG — Medicaid Integrity Group
MIP — Medicaid Integrity Program
MIPPA — Medicare Improvement for Patients and Provider Act
MIPS — Merit-based Incentive Payment System
MLP — Midlevel Practitioner
MLR — Medical Loss Ratio
MMA — Medicare Modernization Act
MMI — Maximum Medical Improvement
MMR — Measles, Mumps, and Rubella
MOA — Memorandum of Agreement
MPH — Master of Public Health
MRI — Magnetic Resonance Imaging
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MRI — Medicaid Reimbursement Initiative
MRSA — Methicillin-Resistant Staphylococcus Aureus
MSA — Medical Savings Account
MSA — Metropolitan Statistical Area
MSN — Master of Science in Nursing
MSO — Management Service Organization
MSP — Medicare Secondary Payer
MU — Meaningful Use
MUA — Medically Underserved Area
MUP — Medically Underserved Population
MUR – Monthly Utilization Report
MVPS —Medicare Volume Performance Standard
N
N3CN — NC Community Care Networks
NAPH — National Association of Public Hospitals
NB — Newborn
NCAFP — NC Academy of Family Physicians
NCBON — North Carolina Board of Nursing
NCD — National Coverage Determinations
NCHA — NC Hospital Association
NCHCFA — NC Health Care Facilities Association
NCHESS — NC Hospital Emergency Surveillance System
NCHEX — NC Healthcare Exchange
NCHS — National Center for Health Statistics
NCHV — NC Hospital Volunteers
NCIOM — NC Institute of Medicine
NCMS — NC Medical Society
NCNA — NC Nurses Association
NCONL — NC Organization of Nurse Leaders
NCPHP — NC Physician Health Plan
NCPP — NC Prevention Partners
NC SHIM — NC System for Hospital Infection Measurement
NCTN — NC Telehealth Network
NCAHP — NC Association of Health Plans
NCHA — NC Hospital Association
NCHF — NC Hospital Foundation
NCHS — National Center for Health Statistics
NCQA — National Committee for Quality Assurance
NCQC — The NC Center for Hospital Quality and Patient Safety (The NC Quality Center)
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NDC — National Drug Code
NHSN — National Healthcare Safety Network
NICU — Neonatal Intensive care unit
NIH — National Institutes of Health
NoCVA —North Carolina-Virginia Hospital Engagement Network
NP — Nurse Practitioner
NPI — National Provider Identifier
NPRM — Notice of Proposed Rulemaking
NPSF — National Patient Safety Foundation
NPSP — National Patient Safety Partnership
NQF — National Quality Forum
NUBC — National Uniform Billing Committee
O
OASIS — Outcome and Assessment Information Set
OB-GYN — Obstetrics and Gynecology
OBRA — Omnibus Budget Reconciliation Act
OEID — Other Entity Identifier
OIG — Office of Inspector General
OMB — Office of Management and Budget
ONC — Office of the National Coordinator
OP — Outpatient
OPHP — Office of Public Health Preparedness
OPO — Organ Procurement Organization
OPPS — Outpatient Prospective Payment System
OR — Operating Room
OSHA — Occupational Safety and Hazard Agency
OT — Occupational Therapy
OTC — Over-The-Counter
P
PA — Physician Assistant
PAC — Political Action Committee
P&L — Profit and Loss
PBH — LME formerly called Piedmont Behavioral Health
PBM — Pharmacy Benefit Management Company
PCCM — Primary Care Case Management
PCMH — Patient Centered Medical Home
PCN — Primary Care Network
PDL — Prescription Drug List
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PDP — Prescription Drug Plan
PDR — Physicians’ Desk Reference
PDC — Policy Development Committee (NCHA)
PET — Positron Emission Tomography
PFP — Partnership for Patients
PFS — Patient Financial Services
PHI — Protected Health Information
PHIX — Public Health Information Exchange
PHO — Physician Hospital Organization
PHR — Personal Health Record
PIP — Periodic Interim Payment (Medicare)
PML — Patient Monthly Liability
PMPM — Per Member Per Month
POA — Present On Admission
POS — Point-of-Service
PPACA — Patient Protection and Accountable Care Act
PPI — Provider Price Index
PPO — Preferred Provider Organization
PPRC — Physician Payment Review Commission
PPS — Prospective Payment System
PRO — Peer Review Organization
ProPAC — Prospective Payment Assessment Commission
PRRB — Provider Reimbursement Review Board
PSDA — Patient Self-Determination Act
PSN — Provider Sponsored Organization
PSO — Patient Safety Organization
PSRO — Professional Standards Review Organization
PS&R — Provider and Statistical Reimbursement System
PT — Physical Therapy
PTA — Physical Therapy Assistant
Q
QA — Quality Assurance
QAP — Quality Assurance Program
QHi — Quality Health Indicators
QI — Quality Improvement
QIO — Quality Improvement Organization
QIP — Quality Improvement Plan
QM — Quality Management
QMB — Qualified Medicare Beneficiary
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QOL — Quality of Life
R
RAB — Regional Advisory Board
RAC — Recovery Audit Contractor
RAC — Regional Advisory Committee (Disasters/Terrorism)
RAD — Radiation Absorbed Dose
R&D — Research and Development
RBRVS — Resource-Based Relative Value Scale
RCA — Root Cause Analysis
RCC — Ratio of Cost to Charge
RDRG — Refined Diagnosis Related Group
REC — Regional Extension Center
RFP — Request for Proposal
RHC — Rural Health Clinic
RHIO — Regional Health Information Organization
RN — Registered Nurse
ROA — Return on Assets
ROE — Return on Equity
ROI — Return on Investment
RPB — Regional Policy Board (AHA)
RPCH — Rural Primary Care Hospital
RPh — Registered Pharmacist
RPT — Registered Physical Therapist
RRA — Registered Record Administrator
RRT — Registered Respiratory Therapist
RRTs — Regional Response Teams
RT — Respiratory Therapist/Therapy
RUG — Resource Utilization Group
RV — Residual Volume
RVS — Relative Value Scale
RVU — Relative Value Unit
RWJ — Robert Wood Johnson Foundation
Rx — Prescription
RY — Rate Year
S
S. — Senate resolution (federal legislation only. See SB for state legislation.)
SAD — Self-Administered Drugs
SB — Senate Bill (state legislation only. See S. for federal legislation.)
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SBH — Swing-Bed Hospital
SCH — Sole Community Hospital
SCHIP — State Children's Health Insurance Program (NC Health Choice)
SCU — Special Care Unit
SEC — Securities and Exchange Commission
SGR — Sustainable Growth Rate
SHCC — State Health Coordinating Council
SHIM — System for Hospital Infection Measurement
SHSMD — Society for Healthcare Strategy and Market Development
SIC — Standard Industry Code
SICU — Surgical Intensive Care Unit
SIDS — Sudden Infant Death Syndrome
SLMB — Specified Low Income Medicare Beneficiaries
SLP — Speech Language Pathologist
SMDA — Safe Medical Devices Act of 1990
SMFP — State Medical Facilities Plan
SMI — Supplemental Medical Insurance
SMRS — State Medical Response System
SMSA — Standard Metropolitan Statistical Area
SNF — Skilled Nursing Facility
SORT — Special Operations Response Team
SPA — State Plan Amendment for Medicaid
SPECT — Single Photon Emission Computed Tomography
SSA — Social Security Administration
SSI — Supplemental Security Income
SSI — Surgical Site Infection
ST — Speech Therapist
T
TAC — Technical Advisory Committee
TANF — Temporary Assistance for Needy Families
TBI — Traumatic Brain Injury
TDE — The Duke Endowment
TEFRA — Tax Equity and Fiscal Responsibility Act of 1982
TJC— The Joint Commission
TOPS — Transitional Outpatient Payments
TPA — Third-Party Administrator
TPL — Third-Party Liability
TQI — Total Quality Improvement
TQM — Total Quality Management
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TRICARE — Formerly the Civilian Health and Medical Program of the Uniformed Services or
CHAMPUS
TTD — Temporary Total Disability
U
UB-04 — Uniform Billing Code of 2004
UB-92 — Uniform Billing Code of 1992
UDI — Unique Device Identifier
UHI — Universal Health Insurance
UPL — Upper Payment Limit
UR — Utilization Review
USPCC — US Per Capita Cost
V
VA — Veterans Administration
VAP — Ventilator-Associated Pneumonia
VBP — Value-Based Purchasing
VHA — Voluntary Hospitals of America (known now as VHA)
VR — Vocation Rehabilitation
W
WC — Workers’ Compensation
WHO — World Health Organization
WI — Wage Index
WIC — Women and Infant Children Program
Y
YTD — Year to Date
Z
ZPIC — Zone Program Integrity Contractor
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