Medicare is a government national health insurance program in the United States, begun in 1965 under the Social Security Administration (SSA) and now administered by the Centers for Medicare and Medicaid Services (CMS). It primarily provides health insurance for Americans aged 65 and older, but also for some younger people with disability status as determined by the SSA, including people with end stage renal disease and amyotrophic lateral sclerosis.
The healthcare industry is an aggregation and integration of sectors within the economic system that provides goods and services to treat patients with curative, preventive, rehabilitative, and palliative care. It encompasses the creation and commercialization of products and services conducive to the preservation and restoration of well-being. The contemporary healthcare sector comprises three fundamental facets, namely services, products, and finance. It can be further subdivided into numerous sectors and categories and relies on interdisciplinary teams of highly skilled professionals and paraprofessionals to address the healthcare requirements of both individuals and communities.
Medical billing is a payment practice within the United States healthcare system. The process involves the systematic submission and processing of healthcare claims for reimbursement. Once the services are provided, the healthcare provider creates a detailed record of the patient's visit, including the diagnoses, procedures performed, and any medications prescribed. This information is translated into standardized codes using the appropriate coding system, such as ICD-10-CM or Current Procedural Terminology codes—this part of the process is known as medical coding. These coded records are submitted by medical billing to the health insurance company or the payer, along with the patient's demographic and insurance information. Most insurance companies use a similar process, whether they are private companies or government sponsored programs. The insurance company reviews the claim, verifying the medical necessity and coverage eligibility based on the patient's insurance plan. If the claim is approved, the insurance company processes the payment, either directly to the healthcare provider or as a reimbursement to the patient. The healthcare provider may need to following up on and appealing claims.
Stark Law is a set of United States federal laws that prohibit physician self-referral, specifically a referral by a physician of a Medicare or Medicaid patient to an entity for the provision of designated health services ("DHS") if the physician has a financial relationship with that entity.
The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care. It has become the predominant system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.
Health care prices in the United States of America describe market and non-market factors that determine pricing, along with possible causes as to why prices are higher than in other countries.
Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately.
Case management is a managed care technique within the health care coverage system of the United States. It involves an integrated system that manages the delivery of comprehensive healthcare services for enrolled patients. Case managers are employed in almost every aspect of health care and these employ different approaches in the control of clinical actions.
In the US a certificate of medical necessity is a document required by Centers for Medicare and Medicaid Services to substantiate in detail the medical necessity of an item of durable medical equipment or a service to a Medicare beneficiary. There are different types of CMN for different requirements, e.g., insulin pumps, home health and private duty nursing services, etc.
Durable medical equipment is any medical equipment used in the home to aid in a better quality of living. It is a benefit included in many insurance policies and in some cases covered by Medicare benefits. The item is defined by Title XIX for Medicaid:
This article discusses the definitions and types of home medical equipment (HME), also known as durable medical equipment (DME), and durable medical equipment and prosthetics and orthotics (DMEPOS).
In the United States, Medicare fraud is the claiming of Medicare health care reimbursement to which the claimant is not entitled. There are many different types of Medicare fraud, all of which have the same goal: to collect money from the Medicare program illegitimately.
First Databank (FDB) is a major provider of drug and medical device databases that help inform healthcare professionals to make decisions. FDB partners with information system developers to deliver useful medication- and medical device-related information to clinicians, business associates, and patients. FDB is part of Hearst and the Hearst Health network.
The Compliance Team Inc., is a US for-profit organization which runs the "Exemplary Provider" accreditation programs, a US-based alternative to the Joint Commission. It was set up in 1994 and is based in Philadelphia, Pennsylvania.
A standing wheelchair is assistive technology, similar to a standing frame, that allows a wheelchair user to raise the chair from a seated to a standing position. The standing wheelchair supports the person in a standing position and enables interaction with people and objects at eye level.
In the United States, hospice care is a type and philosophy of end-of-life care which focuses on the palliation of a terminally ill patient's symptoms. These symptoms can be physical, emotional, spiritual or social in nature. The concept of hospice as a place to treat the incurably ill has been evolving since the 11th century. Hospice care was introduced to the United States in the 1970s in response to the work of Cicely Saunders in the United Kingdom. This part of health care has expanded as people face a variety of issues with terminal illness. In the United States, it is distinguished by extensive use of volunteers and a greater emphasis on the patient's psychological needs in coming to terms with dying.
A wheelchair is a mobilized form of chair using 2 or more wheels, a footrest and armrest usually cushioned. It is used when walking is difficult or impossible to do due to illnesses, injury, disabilities, or age related health conditions.
A rural health clinic (RHC) is a clinic located in a rural, medically under-served area in the United States that has a separate reimbursement structure from the standard medical office under the Medicare and Medicaid programs. RHCs were established by the Rural Health Clinic Services Act of 1977, . The RHC program increases access to health care in rural areas by
- creating special reimbursement mechanisms that allow clinicians to practice in rural, under-served areas
- increasing utilization of physician assistants (PA) and nurse practitioners (NP)
Healthgrades Operating Company Inc., known as Healthgrades, is a US company that provides information about physicians, hospitals, and healthcare providers. Healthgrades has amassed information on over three million U.S. health care providers. The company was founded by Kerry Hicks, David Hicks, Peter Fatianow, John Neal, and Sarah Lochran, and is based in Denver, Colorado. Rob Draughon serves as the company's CEO. According to USA Today, Healthgrades is the first comprehensive physician rating and comparison database. The application is part of a trend in health technology in the United States towards consumer-driven healthcare.
The Medicare Physician Group Practice (PGP) demonstration was Medicare's first physician pay-for-performance (P4P) initiative. The demonstration established incentives for quality improvement and cost efficiency. Ten large physician groups participated in the demonstration, which started on April 1, 2005, and ran for 5 years. Previous funding arrangements, like the volume performance standard (VPS) and the sustainable growth rate (SGR) did not provide incentives to slow the growth of services. The Medicare PGP demonstration was intended to overcome that limitation in previous funding arrangements.
