Term
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Definition
| person who benefits from health or life insurance |
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Term
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Definition
| official publication of all "residential Documents," "Rules and Regulations," and "Notices"; government-instituted national changes are published in the Federal Register |
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Definition
| an organization of physicians who contract with a Health Maintenance Organization to provide service to the enrollees of the HMO |
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Definition
| computer used to input the principal diagnosis and other critical information about a patient and then provide the correct DRG code |
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Term
| Health Maintenance Organization Act |
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Definition
| requires any company with at least 25 employees to provide an HMO alternative to regular group insurance. |
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Term
| Individual Practice Association |
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Definition
| an organization of physicians who provide services for a set fee; Health Maintenance Organizations often contract with the IPA for services to their enrollees |
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Term
| Major Diagnostic Categories |
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Definition
| the division of all principal diagnoses into 25 mutually exclusive principal diagnosis areas within the DRG system |
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Term
| Managed Care Organization |
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Definition
| a group that is responsible for the health care services offered to an enrolled group of persons |
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Term
| Maximum Actual Allowable Charge |
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Definition
| limitation on the total amount that can be charged by physicians who are not participants in Medicate |
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Term
| Medical Volume Performance Standards |
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Definition
| government's estimate of how much growth is appropriate for nationwide physician expenditures paid by the Part B Medicare program |
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Term
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Definition
| government mandated index that ties increases in the Medicare prevailing charges to economic indicators |
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Definition
| schedule that listed the allowable charges for Medicare services; was replaced by the Medicare reasonable charge payment system |
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Term
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Definition
| a Medicare-funded alternative to the standard Medicare supplemental coverage |
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Term
| National Provider Identifier |
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Definition
| a 10-digit number assigned to a physician by Medicare |
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Term
| Omnibus Budget Reconciliation Act of 1989 |
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Definition
| act that established new rules for Medicare reimbursement |
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Term
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Definition
| Medicare's Hospital Insurance; covers hospital/facility care |
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Term
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Definition
| Medicare's Supplemental Medical Insurance; covers physician services and durable medical equipment that are not paid for under Part A |
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Term
| participating provider program |
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Definition
| Medicare providers who have agreed in advance to accept assignment on all Medicare claims, now termed Quality Improvement Organizations (QIO) |
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Term
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Definition
| groups established to review hospital admission and care |
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Term
| Preferred Provider Organization |
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Definition
| a group of providers who form a network and who have agreed to provide services to enrollees at a discounted rate |
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Term
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Definition
| physician who oversees a patient's care with a managed care organization |
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Term
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Definition
| also known as a prior authorization, the payer's approval of care |
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Term
| Professional Standards Review Organization |
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Definition
| voluntary physicians' organization designed to monitor the necessity of hospital admissions, treatment costs, and medical records of hospitals |
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Term
| Provider Identification Number |
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Definition
| assigned to physicians by payers for use in claims submission |
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Term
| Quality Improvement Organizations |
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Definition
| consists of a national network of 53 entities that work with consumers, physicians, hospitals, and caregivers to refine care delivery systems |
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Term
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Definition
| unit value that has been assigned for each service |
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Term
| Resource-Based Relative Value Scale |
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Definition
| scale designed to decrease Medicare expenditures, redistribute physician payment, and ensure quality health care at reasonable rates |
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Term
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Definition
| a Health Maintenance Organization that directly employs the physicians who provide services to enrollees |
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Term
| Tax Equity and Fiscal Responsibility Act |
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Definition
| act that contains language to reward cost-conscious healthcare providers |
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