A system wherein reimbursement rates are set, for a given period of time, prior to the circumstances giving rise to actual reimbursement claims.

Economic aspects related to the management and operation of a hospital.

Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance (MEDICARE PART A) and supplementary medical insurance (MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976)

A system for classifying patient care by relating common characteristics such as diagnosis, treatment, and age to an expected consumption of hospital resources and length of stay. Its purpose is to provide a framework for specifying case mix and to reduce hospital costs and reimbursements and it forms the cornerstone of the prospective payment system.

Laws and regulations concerning hospitals, which are proposed for enactment or enacted by a legislative body.

A method of examining and setting levels of payments.

A component of the Department of Health and Human Services to oversee and direct the Medicare and Medicaid programs and related Federal medical care quality control staffs. Name was changed effective June 14, 2001.

In health care reimbursement, especially in the prospective payment system, those patients who require an unusually long hospital stay or whose stay generates unusually high costs.

Extended care facilities which provide skilled nursing care or rehabilitation services for inpatients on a daily basis.

The compulsory portion of Medicare that is known as the Hospital Insurance Program. All persons 65 years and older who are entitled to benefits under the Old Age, Survivors, Disability and Health Insurance Program or railroad retirement, persons under the age of 65 who have been eligible for disability for more than two years, and insured workers (and their dependents) requiring renal dialysis or kidney transplantation are automatically enrolled in Medicare Part A.

Facilities designed to serve patients who require surgical treatment exceeding the capabilities of usual physician's office yet not of such proportion as to require hospitalization.

Medical and skilled nursing services provided to patients who are not in an acute phase of an illness but who require a level of care higher than that provided in a long-term care setting. (JCAHO, Lexikon, 1994)

Devices which are very resistant to wear and may be used over a long period of time. They include items such as wheelchairs, hospital beds, artificial limbs, etc.

Processes or methods of reimbursement for services rendered or equipment.

The term "United States" in a medical context often refers to the country where a patient or study participant resides, and is not a medical term per se, but relevant for epidemiological studies, healthcare policies, and understanding differences in disease prevalence, treatment patterns, and health outcomes across various geographic locations.

An Act prohibiting a health plan from establishing lifetime limits or annual limits on the dollar value of benefits for any participant or beneficiary after January 1, 2014. It permits a restricted annual limit for plan years beginning prior to January 1, 2014. It provides that a health plan shall not be prevented from placing annual or lifetime per-beneficiary limits on covered benefits. The Act sets up a competitive health insurance market.

Hospitals which provide care to patients with long-term illnesses.

The obtaining and management of funds for hospital needs and responsibility for fiscal affairs.

Hospitals located in a rural area.

Restoration of human functions to the maximum degree possible in a person or persons suffering from disease or injury.

Purchasers are provided information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. The focus is on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. (from http://www.ahrq.gov/qual/meyerrpt.htm accessed 11/25/2011)

Facilities which provide programs for rehabilitating the mentally or physically disabled individuals.

Payment by a third-party payer in a sum equal to the amount expended by a health care provider or facility for health services rendered to an insured or program beneficiary. (From Facts on File Dictionary of Health Care Management, 1988)

Care over an extended period, usually for a chronic condition or disability, requiring periodic, intermittent, or continuous care.

Referral by physicians to testing or treatment facilities in which they have financial interest. The practice is regulated by the Ethics in Patient Referrals Act of 1989.

Persons admitted to health facilities which provide board and room, for the purpose of observation, care, diagnosis or treatment.

Short-term debt obligations and assets occurring in the regular course of operational transactions.

Payments that include adjustments to reflect the costs of uncompensated care and higher costs for inpatient care for certain populations receiving mandated services. MEDICARE and MEDICAID include provisions for this type of reimbursement.

A legal requirement that designated types of information acquired by professionals or institutions in the course of their work be reported to appropriate authorities.

A nursing specialty involved in the diagnosis and treatment of human responses of individuals and groups to actual or potential health problems with the characteristics of altered functional ability and altered life-style.

The containment, regulation, or restraint of costs. Costs are said to be contained when the value of resources committed to an activity is not considered excessive. This determination is frequently subjective and dependent upon the specific geographic area of the activity being measured. (From Dictionary of Health Services Management, 2d ed)

The physical space or dimensions of a facility. Size may be indicated by bed capacity.

Federal program, created by Public Law 89-97, Title XIX, a 1965 amendment to the Social Security Act, administered by the states, that provides health care benefits to indigent and medically indigent persons.

Community health and NURSING SERVICES providing coordinated multiple services to the patient at the patient's homes. These home-care services are provided by a visiting nurse, home health agencies, HOSPITALS, or organized community groups using professional staff for care delivery. It differs from HOME NURSING which is provided by non-professionals.

Hospitals which provide care to the patient for the period following an acute illness until health is restored.

Special hospitals which provide care to the mentally ill patient.

Organized services in a hospital which provide medical care on an outpatient basis.

Educational programs for medical graduates entering a specialty. They include formal specialty training as well as academic work in the clinical and basic medical sciences, and may lead to board certification or an advanced medical degree.

Hospital department responsible for the organization and administration of psychiatric services.

Coded listings of physician or other professional services using units that indicate the relative value of the various services they perform. They take into account time, skill, and overhead cost required for each service, but generally do not consider the relative cost-effectiveness. Appropriate conversion factors can be used to translate the abstract units of the relative value scales into dollar fees for each service based on work expended, practice costs, and training costs.

Persons who receive ambulatory care at an outpatient department or clinic without room and board being provided.

Public or private organizations that provide, either directly or through arrangements with other organizations, home health services in the patient's home. (Hospital Administration Terminology, 2d ed)

Method of charging whereby a physician or other practitioner bills for each encounter or service rendered. In addition to physicians, other health care professionals are reimbursed via this mechanism. Fee-for-service plans contrast with salary, per capita, and prepayment systems, where the payment does not change with the number of services actually used or if none are used. (From Discursive Dictionary of Health Care, 1976)

Uniform method for health care providers and medical suppliers to report professional services, procedures, and supplies. It consists of alphanumeric codes and modifiers for the use of all public and private health insurers. It is developed by the Centers for Medicare and Medicaid Services.

The integration of epidemiologic, sociological, economic, and other analytic sciences in the study of health services. Health services research is usually concerned with relationships between need, demand, supply, use, and outcome of health services. The aim of the research is evaluation, particularly in terms of structure, process, output, and outcome. (From Last, Dictionary of Epidemiology, 2d ed)

The expenses incurred by a hospital in providing care. The hospital costs attributed to a particular patient care episode include the direct costs plus an appropriate proportion of the overhead for administration, personnel, building maintenance, equipment, etc. Hospital costs are one of the factors which determine HOSPITAL CHARGES (the price the hospital sets for its services).

The voluntary portion of Medicare, known as the Supplementary Medical Insurance (SMI) Program, that includes physician's services, home health care, medical services, outpatient hospital services, and laboratory, pathology, and radiology services. All persons entitled to Medicare Part A may enroll in Medicare Part B on a monthly premium basis.

Health care services provided to patients on an ambulatory basis, rather than by admission to a hospital or other health care facility. The services may be a part of a hospital, augmenting its inpatient services, or may be provided at a free-standing facility.

A scheme which provides reimbursement for the health services rendered, generally by an institution, and which provides added financial rewards if certain conditions are met. Such a scheme is intended to promote and reward increased efficiency and cost containment, with better care, or at least without adverse effect on the quality of the care rendered.

Absolute, comparative, or differential costs pertaining to services, institutions, resources, etc., or the analysis and study of these costs.

The effort of two or more parties to secure the business of a third party by offering, usually under fair or equitable rules of business practice, the most favorable terms.

The legal relation between an entity (individual, group, corporation, or-profit, secular, government) and an object. The object may be corporeal, such as equipment, or completely a creature of law, such as a patent; it may be movable, such as an animal, or immovable, such as a building.

Facilities which provide nursing supervision and limited medical care to persons who do not require hospitalization.

A management function in which standards and guidelines are developed for the development, maintenance, and handling of forms and records.

Private, not-for-profit hospitals that are autonomous, self-established, and self-supported.

The commission charged with evaluating issues and factors which affect the implementation of the PROSPECTIVE PAYMENT SYSTEM.

Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.

A listing of established professional service charges, for specified dental and medical procedures.

A method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount without regard to the actual number or nature of services provided to each patient.

The amounts spent by individuals, groups, nations, or private or public organizations for total health care and/or its various components. These amounts may or may not be equivalent to the actual costs (HEALTH CARE COSTS) and may or may not be shared among the patient, insurers, and/or employers.

PL97-248. Title II of the Act specifies "provisions relating to savings in health and income security programs." This includes changes in payment for services, benefits and premiums of Medicare as well as changes in provisions under Medicaid and other specific programs covered by Social Security. Title II includes various revenue measures.

The actual costs of providing services related to the delivery of health care, including the costs of procedures, therapies, and medications. It is differentiated from HEALTH EXPENDITURES, which refers to the amount of money paid for the services, and from fees, which refers to the amount charged, regardless of cost.

The period of confinement of a patient to a hospital or other health facility.

The administrative process of discharging the patient, alive or dead, from hospitals or other health facilities.

Hospitals owned and operated by a corporation or an individual that operate on a for-profit basis, also referred to as investor-owned hospitals.

The degree to which individuals are inhibited or facilitated in their ability to gain entry to and to receive care and services from the health care system. Factors influencing this ability include geographic, architectural, transportational, and financial considerations, among others.

The levels of excellence which characterize the health service or health care provided based on accepted standards of quality.

Concept referring to the standardized fees for services rendered by health care providers, e.g., laboratories and physicians, and reimbursement for those services under Medicare Part B. It includes acceptance by the physician.

Payments or services provided under stated circumstances under the terms of an insurance policy. In prepayment programs, benefits are the services the programs will provide at defined locations and to the extent needed.

A stand-alone drug plan offered by insurers and other private companies to beneficiaries that receive their Medicare Part A and/or B benefits through the Original Medicare Plan. It includes Medicare Private Fee-for-Service Plans that do not offer prescription drug coverage and Medicare Cost Plans offering Medicare prescription drug coverage. The plan was enacted as the Medicare Prescription Drug, Improvement and Modernization Act of 2003 with coverage beginning January 1, 2006.

The practice of nursing by licensed, non-registered persons qualified to provide routine care to the sick.

Descriptive terms and identifying codes for reporting medical services and procedures performed by PHYSICIANS. It is produced by the AMERICAN MEDICAL ASSOCIATION and used in insurance claim reporting for MEDICARE; MEDICAID; and private health insurance programs (From CPT 2002).

Innovation and improvement of the health care system by reappraisal, amendment of services, and removal of faults and abuses in providing and distributing health services to patients. It includes a re-alignment of health services and health insurance to maximum demographic elements (the unemployed, indigent, uninsured, elderly, inner cities, rural areas) with reference to coverage, hospitalization, pricing and cost containment, insurers' and employers' costs, pre-existing medical conditions, prescribed drugs, equipment, and services.

The Commission was created by the Balanced Budget Act of 1997 under Title XVIII. It is specifically charged to review the effect of Medicare+Choice under Medicare Part C and to review payment policies under Parts A and B. It is also generally charged to evaluate the effect of prospective payment policies and their impact on health care delivery in the US. The former Prospective Payment Assessment Commission (ProPAC) and the Physician Payment Review Commission (PPRC) were merged to form MEDPAC.

The Balanced Budget Act (BBA) of 1997 establishes a Medicare+Choice program under part C of Title XVIII, Section 4001, of the Social Security Act. Under this program, an eligible individual may elect to receive Medicare benefits through enrollment in a Medicare+Choice plan. Beneficiaries may choose to use private pay options, establish medical savings accounts, use managed care plans, or join provider-sponsored plans.

Insurance providing for payment of services rendered by the pharmacist. Services include the preparation and distribution of medical products.

Services for the diagnosis and treatment of disease and the maintenance of health.

Economic aspects of the field of medicine, the medical profession, and health care. It includes the economic and financial impact of disease in general on the patient, the physician, society, or government.

Amounts charged to the patient as payer for health care services.

Payment by individuals or their family for health care services which are not covered by a third-party payer, either insurance or medical assistance.

Review of claims by insurance companies to determine liability and amount of payment for various services. The review may also include determination of eligibility of the claimant or beneficiary or of the provider of the benefit; determination that the benefit is covered or not payable under another policy; or determination that the service was necessary and of reasonable cost and quality.

Detailed financial plans for carrying out specific activities for a certain period of time. They include proposed income and expenditures.

The assignment, to each of several particular cost-centers, of an equitable proportion of the costs of activities that serve all of them. Cost-center usually refers to institutional departments or services.

The number of beds which a hospital has been designed and constructed to contain. It may also refer to the number of beds set up and staffed for use.

Health services required by a population or community as well as the health services that the population or community is able and willing to pay for.

Criteria to determine eligibility of patients for medical care programs and services.

Provisions of an insurance policy that require the insured to pay some portion of covered expenses. Several forms of sharing are in use, e.g., deductibles, coinsurance, and copayments. Cost sharing does not refer to or include amounts paid in premiums for the coverage. (From Dictionary of Health Services Management, 2d ed)

Professional nurses who have completed postgraduate training in the administration of anesthetics and who function under the responsibility of the operating surgeon.

Reductions in all or any portion of the costs of providing goods or services. Savings may be incurred by the provider or the consumer.

Institutions with an organized medical staff which provide medical care to patients.

The use of severity-of-illness measures, such as age, to estimate the risk (measurable or predictable chance of loss, injury or death) to which a patient is subject before receiving some health care intervention. This adjustment allows comparison of performance and quality across organizations, practitioners, and communities. (from JCAHO, Lexikon, 1994)