Health Care Tools
Beneficiary
Someone who is qualified according to a plan for health benefits to obtain certain health benefits. This might also include any dependents who are registered with the same plan.
Clinical Practice Guidelines
General instructions typically advanced by physicians practicing in a certain specific field of medicine that outlines what is considered to be an agreeable scope of practice for distinct medical conditions or diseases.
Covered Entities (in the context of HIPPA Privacy Rule)
Concerning HIPPA Privacy Rules, how it applies to healthcare plans, clearing houses, and providers who electronically process certain transactions dealing with health care.
Employee Assistance Program (EAP)
EAP is a program that is purchased by employers on behalf of their employees, dependents, and members of their household to be used for evaluation and referral or short-term counseling. Usage under this program has no co-payment required and usage is not part of any health care behavioral benefit plan.
Extended Care Facility (ECF)
This type of health care service is usually for people with a long-term or chronic disease as well as the rehab or therapy work needed with certain long-term medical conditions that may include both assisted living and medical care.
Health Care Financing Administration (HCFA)
HCFA is the federal agency that both administers Medicare to eligible particupants and handles Medicaid federal participation.
Health Insurance Portability and Accountability Act of 1996 (HIPPA)
This is the Act passed by Congress requiring that employer-sponsored group insurance plans, managed care organizations, and insurance companies safeguard workers and their families health insurance coverage if they change or lose jobs, reduce the supervisory cost to provide and pay for health care, and keep an individual’s health information private.
Health Maintenance Organization (HMO)
This is a type of health care insurance plan that has made arrangements with many providers of health care services for the use of subscribers. Treatment must be received from participating providers of the plan except during an emergency. There is a strong emphasis on wellness and preventive care.
Independent Practice Association (IPA)
This is a group of individual doctors or small medical practices that contractually work through Managed Care Organizations (MCOs) to provide subscribers with necessary health care services.
Integrated Delivery System (IDS)
A network of heathcare organizations that provides a broad spectrum of health-care services through the integration of doctors, hospitals, and other medical services.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
A non-profit organization that strives to improve public health care quality by evaluating and accrediting health care organizations and hospitals. The JCAHO helps improve organizations that provide ambulatory care, behavioral health care, home care, lab work, long-term care and managed care that could include IDS, PPO’s, and HMO’s.
Managed Care
A system of health care that has been designed to handle the financing and delivery of health care that strives to effectively manage the quality, accessibility, and cost of such care.
Managed Care Organization (MCO)
An entity that uses specific methods or procedures to manage the quality, accessibility, and cost of health-care.
Management Services Organization (MSO)
An organization that has been formed to oversee the non-medical or business aspects of individual doctors and small healthcare group practices. Typically owned by a hospital or a group of investors, the organization allows physicians to focus on the clinical aspects of their practice rather than the business requirements.
Medicaid
A federal program that is operated by the individual states to provide hospital and medical care insurance assistance to certain low-income, elderly, and/or disabled people.
Medicare
Created by Title XVIII of the 1965 Social Security Act, this program is the Federal program that provides insurance for hospital and medical expenses to individuals 65 or older as well as qualifying disabled persons.
National Committee on Quality Assurance (NCQA)
A non-profit organization that works to improve health care quality through the review of managed and behavioral health care plans/organizations as well as credentials verification groups.
Physician-Hospital Organization (PHO)
An organization that may include doctors, a hospital, and other group practices that negotiate directly as one group with insurers. The groups may also provide the overseeing of credentialing, quality assurance, and utilization review.
Physician Practice Management (PPM) Company
This is a company that buys physicians’ practices and then offers management of the practices. It often includes doctors who have long term contracts to work in their practice and perhaps have a share of ownership with the purchasing company.
Preferred Provider Organization (PPO)
A PPO is a type of health care plan that encourages the use of network providers or healthcare services but does allow beneficiaries to access health care providers or services with the understanding that their cost will be higher.
Protected Health Information (PHI)
The type of patient health care, medical services, or procedures that is identified as information to be individually protected.
State Children’s Health Insurance Program (SCHIP)
The state-level of Children’s Health Insurance Program created by the Balanced Budget Act to provide uninsured and low-income children with health insurance. SCHIP may operative separately or through the expansion of Medicaid eligibility programs.
