The Emergency Medical Treatment and Active Labor Act (EMTALA) is an act of the United States Congress, passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospital Emergency Departments that accept payments from Medicare to provide an appropriate medical screening examination (MSE) to anyone seeking treatment for a medical condition, regardless of citizenship, legal status, or ability to pay. Participating hospitals may not transfer or discharge patients needing emergency treatment except with the informed consent or stabilization of the patient or when their condition requires transfer to a hospital better equipped to administer the treatment.
Medicare is a national health insurance program in the United States, begun in 1966 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 Social Security Administration, as well as people with end stage renal disease and amyotrophic lateral sclerosis.
The Health Insurance Portability and Accountability Act of 1996 is a United States federal statute enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1996. It was created primarily to modernize the flow of healthcare information, stipulate how personally identifiable information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and address limitations on healthcare insurance coverage.
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.
Medical practice management software (PMS) is a category of healthcare software that deals with the day-to-day operations of a medical practice including veterinarians. Such software frequently allows users to capture patient demographics, schedule appointments, maintain lists of insurance payors, perform billing tasks, and generate reports.
Outpatient surgery, also known as ambulatory surgery, day surgery, day case surgery, or same-day surgery, is surgery that does not require an overnight hospital stay. The term “outpatient” arises from the fact that surgery patients may enter and leave the facility on the same day. The advantages of outpatient surgery over inpatient surgery include greater convenience and reduced costs.
In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking. This model also penalizes health care providers for poor outcomes, medical errors, or increased costs. Integrated delivery systems where insurers and providers share in the cost are intended to help align incentives for value-based care.
In the insurance industry in the United States, an experience modifier or experience modification is an adjustment of an employer's premium for worker's compensation coverage based on the losses the insurer has experienced from that employer. An experience modifier of 1 would be applied for an employer that had demonstrated the actuarially expected performance. Poorer loss experience leads to a modifier greater than 1, and better experience to a modifier less than 1. The loss experience used in determining the modifier typically comprises three years but excluding the immediate past year. For instance, if a policy expired on January 1, 2018, the period reflected by the experience modifier would run from January 1, 2014 to January 1, 2017.
The AAPC, previously known by the full title of the American Academy of Professional Coders, is a professional association for people working in specific areas of administration within healthcare businesses in the United States. AAPC is one of a number of providers who offer services such as certification and training to medical coders, medical billers, auditors, compliance managers, and practice managers in the United States. As of April 2019, AAPC has over 190,000 worldwide members, of which nearly 155,000 are certified.
In 1997 the Balanced Budget Act established annual per-beneficiary Medicare spending limits, or therapy cap, for outpatient Physical Therapy, occupational therapy and speech language pathology services covered under Medicare Part B. Facilities affected by the therapy cap include: private practice, physician offices, skilled nursing facilities, rehabilitiations agencies, comprehensive outpatient rehabilitation facilities, critical access hospitals, and outpatient hospital departments. For 2014, the therapy cap amount is $1920 for physical therapy and speech pathology combined. A separate $1920 is allowed for occupational therapy services. Beneficiaries enrolled in Medicare Advantage plans are not subject to the therapy cap unless the plan chooses to apply the cap.
Medicare Advantage is a type of health insurance plan in the United States that provides Medicare benefits through a private-sector health insurer. In a Medicare Advantage plan, a Medicare beneficiary pays a monthly premium to a private insurance company and receives coverage for inpatient hospital and outpatient services. Typically, the plan also includes prescription drug coverage. Many plans also offer additional benefits, such as dental coverage or gym memberships. By contrast, under so-called "Original Medicare", a Medicare beneficiary pays a monthly premium to the federal government and receives coverage for Part A and Part B services, but must purchase other coverage separately.
An outpatient department or outpatient clinic is the part of a hospital designed for the treatment of outpatients, people with health problems who visit the hospital for diagnosis or treatment, but do not at this time require a bed or to be admitted for overnight care. Modern outpatient departments offer a wide range of treatment services, diagnostic tests and minor surgical procedures.
A Medically Unlikely Edit (MUE) is a US Medicare unit of service claim edit applied to Medical claims against a procedure code for medical services rendered by one provider/supplier to one patient on one day. Claim edits compare different values on medical claim to a set of defined criteria to check for irregularities, often in an automated claims processing system. MUE are designed to limit fraud and/or coding errors. They represent an upper limit that unquestionably requires further documentation to support. The ideal MUE is the maximum unit of service for a code on the majority of medical claims. MUE is part of the National Correct Coding Initiative (NCCI) to address coding methodologies. The NCCI policies are based on coding conventions by nationally recognized organizations and are updated annually or quarterly.
Bundled payment is the reimbursement of health care providers "on the basis of expected costs for clinically-defined episodes of care." It has been described as "a middle ground" between fee-for-service reimbursement and capitation, given that risk is shared between payer and provider. Bundled payments have been proposed in the health care reform debate in the United States as a strategy for reducing health care costs, especially during the Obama administration (2009–2016). Commercial payers have shown interest in bundled payments in order to reduce costs. In 2012, it was estimated that approximately one-third of the United States healthcare reimbursement used bundled methodology.
An accountable care organization (ACO) is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation. The organization is accountable to patients and third-party payers for the quality, appropriateness and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services, an ACO is "an organization of health care practitioners that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it".
The Healthcare Common Procedure Coding System is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).
The Philippine Health Insurance Corporation (PhilHealth) was created in 1995 to implement universal health coverage in the Philippines. It is a tax-exempt, government-owned and controlled corporation (GOCC) of the Philippines, and is attached to the Department of Health. Its stated goal is to "ensure a sustainable national health insurance program for all", according to the company. In 2010, it claimed to have achieved "universal" coverage at 86% of the population, although the 2008 National Demographic Health Survey showed that only 38 percent of respondents were aware of at least one household member being enrolled in PhilHealth. Nevertheless, this social insurance program provides a means for the healthy to pay for the care of the sick and for those who can afford medical care to subsidize those who cannot. Both local and national governments allocate funds to subsidize the indigent.
The 340B Drug Pricing Program is a US federal government program created in 1992 that requires drug manufacturers to provide outpatient drugs to eligible health care organizations and covered entities at significantly reduced prices. The intent of the program is to allow covered entities to "[s]tretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services." Maintaining services and lowering medication costs for patients is consistent with the purpose of the program, which is named for the section authorizing it in the Public Health Service Act (PHSA) It was enacted by Congress as part of a larger bill signed into law by President George H. W. Bush.
Deemed status is a hospital accreditation for hospitals in the United States.
Healthcare shortage areas are two types of designation within the United States determined by the Health Resources and Services Administration (HRSA). Health professional shortage areas (HPSAs) designate geographic areas or subgroups of the populations or specific facilities within them as lacking professionals in primary care, mental health, or dental care. Medically Underserved Areas and Populations only designate geographic areas or populations, and only for their lack of access to primary care services. Geographic areas can designate single or multiple counties, parts of cities, or other civil divisions depending on the state. Populations typically designate those subgroups which face barriers to healthcare access in an otherwise well-served population, such as homeless or low-income groups. Facilities designate specific healthcare locations such as clinics, mental hospitals, or prisons.
