Ghost Busters - Who You Gonna Call
Payer
An entity responsible for the processing of patient eligibility, services, claims, enrollment, or payment. Entities considered to be healthcare payers include Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), healthcare service contractors, state insurance agencies, claim handlers, and more.
IPA
Independent Practice Association. An independent physician association (IPA) is a business entity organized and owned by a network of independent physician practices for the purpose of reducing overhead or pursuing business ventures such as contracts with employers, accountable care organizations (ACO) and/or managed care organizations (MCOs).
HIPAA
Health Insurance Portability and Accountability Act. United States legislation that provides data privacy and security provisions for safeguarding medical information.
FFS
Fee-For-Service. In FFS, providers are paid separately for each service. Alternative for FFP, Episode-based payments are an alternative to fee-for-service (FFS) reimbursement.
CMS
Centers Medicare and Medicaid Services. Previously known as the Health Care Financing Administration (HCFA), this is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards.
SNF
Skilled-Nursing Facility. A health-care institution that meets federal criteria for Medicaid and Medicare reimbursement for nursing care including especially the supervision of the care of every patient by a physician, the employment full-time of at least one registered nurse, the maintenance of records concerning the care and condition of every patient, the availability of nursing care 24 hours a day, the presence of facilities for storing and dispensing drugs, the implementation of a utilization review plan, and overall financial planning including an annual operating budget and a 3-year capital expenditures program.
MU
Meaningful Use. CMS incentive program to encourage providers to demonstrate meaningful use of electronic health technologies.
DRG
Diagnosis-Related Group. A patient classification system that standardizes prospective payment to hospitals and encourages cost containment initiatives. In general, a DRG payment covers all charges associated with an inpatient stay from the time of admission to discharge.
DHCS
Department of Health Care Services. A department within the California Health and Human Services Agency that finances and administers a number of individual health care service delivery programs, including Medi-Cal, which provides health care services to low-income people
ACO
Accountable Care Organization. Group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients; Coordinate care and avoid unnecessary duplication of services/prevent medical errors
CON
Certificate of Need. An endorsement required by numerous states before the construction of a new health care facility will be approved. The central idea of Certificate of Need legislation is the assertion that overbuilding and redundancy in health care facilities leads to higher health care costs.
DSH
Disproportionate-Share Hospital. The United States government provides funding to hospitals that treat indigent patients through the Disproportionate Share Hospital (DSH) programs, under which facilities are able to receive at least partial compensation.
DMHC
Department of Managed Healthcare. A regulatory body governing managed health care plans, sometimes referred to as Health Maintenance Organizations in California.
ASC
Ambulatory Surgery Centers. Known as outpatient surgery centers or same day surgery centers, these are health care facilities where surgical procedures not requiring an overnight hospital stay are performed. Such surgery is commonly less complicated than that requiring hospitalization.
Original name for the Stark Law
Ethics in Patient Referral Act of 1989. Initially designed to limit/prevent physicians from referring patients for clinical laboratory services under the Medicare Program to entities in which the physician or a relative had a financial interest.
CPT
Current Procedural Terminology. A medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations.