An Accountable Care Organization (ACO) is a healthcare delivery model that aims to improve the quality of care and reduce costs by coordinating care across different providers and settings. ACOs bring together a group of healthcare providers, such as ...
ACO REACH is a program run by the Centers for Medicare and Medicaid Services (CMS) that aims to provide support and resources to Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP). The purpose of ACO ...
The term at-risk patient population is commonly used to refer to individuals who are more likely to develop health problems, require increased medical care, or have adverse outcomes due to factors such as age, underlying health conditions, lifestyle habits, ...
CMS STARs (Medicare’s Five-Star Quality Rating System) is a rating system used by the Centers for Medicare and Medicaid Services (CMS) to evaluate and compare the quality of healthcare services provided by Medicare- and Medicaid-participating facilities such as nursing ...
Coordinated care refers to a model of healthcare delivery that emphasizes collaboration and communication among all healthcare providers involved in a patient’s care. The goal of coordinated care is to ensure that patients receive comprehensive, high-quality care that is ...
Duplicate medical records refer to the occurrence of two or more identical or nearly identical copies of the same patient’s medical information in a healthcare system. Overlays are the additional information added to an existing medical record, which can ...
EHR (Electronic Health Record) integration refers to the process of connecting and combining different EHR systems within a healthcare organization or between multiple healthcare organizations to share patient information. The integration of EHR systems can improve the accuracy, efficiency, ...
Funding models refer to the methods used to finance healthcare services, treatments, and programs in the U.S.. Some common funding models include: Fee-for-service (FFS) – Healthcare providers are paid for each service or procedure they perform. Capitation – Healthcare ...
Gaps in care is similiar to quality gaps. Gaps in care refer to missed or delayed healthcare services or treatments that a patient needs to maintain or improve their health. These gaps can occur due to various reasons, such ...
Health Information Exchange (HIE) refers to the secure sharing of patient health information among healthcare organizations and providers. The goal of HIE is to improve patient care by ensuring that healthcare providers have access to a patient’s complete health ...
HCC (Hierarchical Condition Category) Coding is a method used in medical billing and reimbursement to categorize and group conditions and diseases of patients based on their impact on expected healthcare utilization and cost. The categories are hierarchical, meaning they ...
HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures used by healthcare organizations to assess and compare the quality of care they provide. Developed by the National Committee for Quality Assurance (NCQA), HEDIS measures ...
Health equity refers to the fair and equal distribution of health and healthcare resources, opportunities, and outcomes for all people, regardless of race, ethnicity, socioeconomic status, or other social determinants of health (SDOH). Health equity refers to an ideal ...
A Health Maintenance Organization (HMO) is a type of insurance that operates as a managed care organization that provides a network of healthcare providers for its members to choose from. This type of insurance is typically based on a ...
ICD 10 – (International Classification of Diseases, Tenth Revision)
ICD-10 (International Classification of Diseases, Tenth Revision) is a diagnostic classification system used by healthcare providers worldwide to code and classify diseases and health conditions. The ICD-10 is maintained by the World Health Organization (WHO) and is used for ...
Medicare is a national health insurance program in the United States, providing coverage to people who are 65 years of age or older, some people with disabilities, and people with End-Stage Renal Disease (ESRD). It was created in 1965 ...
Medicare Advantage (MA) is an alternative to traditional Medicare and is offered by private health insurance companies. It provides Medicare-covered benefits and may offer additional benefits such as vision, dental, and prescription drug coverage. People who are eligible for ...
The Medicare Shared Savings Program (MSSP) is a program under the Medicare program in the United States that incentivizes healthcare providers to coordinate care and reduce costs for Medicare beneficiaries. MSSP is an Accountable Care Organization (ACO) model that ...
Physician burnout is a state of physical, emotional, and mental exhaustion experienced by medical professionals as a result of prolonged exposure to work-related stress. It can result from a combination of factors such as long working hours, high workload, ...
A physician aggregator business is a type of company that brings together multiple physicians and medical practices under one umbrella organization. The aggregator typically provides a centralized platform or centralized services for managing the administrative and operational functions of ...
Physician enablement refers to the support and empowerment of doctors to deliver high-quality patient care efficiently and effectively. It aims to enhance their ability to diagnose and treat patients, manage their practices, and stay up-to-date with best practices and ...
Provider enablement refers to the processes, tools, and technologies used to support and empower healthcare providers in delivering high-quality patient care. It aims to enhance the provider’s ability to deliver care efficiently, effectively, and in a way that is ...
Procedure Codes HCPCS – Healthcare Common Procedure Coding System
Procedure Codes, also known as HCPCS (Healthcare Common Procedure Coding System) codes, are codes used to identify medical procedures and services provided to patients. They are used for billing purposes and for tracking healthcare utilization. Procedure codes are standardized ...
Point of care (POC) refers to the location where healthcare services are provided. This can include a variety of settings, such as a doctor’s office, clinic, hospital, or even a patient’s home. The term “point of care” is used ...
A Population-Based Risk Contract (PBRC) is a type of payment model used in healthcare that aims to incentivize providers to improve the health of a specific patient population and reduce the overall cost of care. Under a PBRC, a ...
Quality gaps refer to the difference between the current level of healthcare provided and the optimal level of healthcare that should be provided. These gaps can occur in various areas of healthcare, including access to care, preventive care, chronic ...
Referral guidance refers to the process of making recommendations or providing information on when and to whom a patient should be referred for specialized medical care. Referral guidance is typically provided by a primary care physician to ensure that ...
Risk sharing is a concept in healthcare financing that involves sharing the financial risk of providing healthcare services between payers (e.g. insurance companies, government programs) and providers (e.g. hospitals, doctors). In a risk-sharing arrangement, providers are incentivized to deliver ...
Risk adjustment is a method used in the health insurance industry to account for differences in the health status of enrollees in a health plan. The goal of risk adjustment is to ensure that health plans are not penalized ...
A risk-based contract is a type of agreement between a health insurer and a healthcare provider, in which the provider is financially responsible (or partially responsible) for the cost of providing care to a specific population of patients. The ...
Social Determinants of Health (SDOH) are the economic, social, and environmental factors that impact a person’s health and well-being. These factors include, but are not limited to, education, income, housing, transportation, and access to healthy food. SDOH have a ...
Value-based agreements (VBAs) are contracts between payers (such as insurance companies or government programs) and healthcare providers that tie payments for medical services to the quality and outcomes of patient care, rather than to the volume of services provided ...
