Accreditation
The process by which a private or public agency evaluates and recognizes a program of study or an institution as fulfilling applicable standards. The determination that a program or institution meets these standards is also referred to as accreditation of the program or institution. For example, the Joint Commission on Accreditation of Health Care Organizations, a private organization, evaluates whether hospitals, nursing homes and managed care organizations meet certain specified requirements; the Accreditation Association for Ambulatory Health Care and the National Committee for Quality Assurance assess and award compliance certifications to managed care organizations, including HMOs (see definitions for these terms). Public agencies sometimes require accreditation by a private body as a condition of licensure or may accept accreditation as a substitute for their own inspection or certification programs.
 

Activities of Daily Living (ADLs)
Bathing, dressing and grooming, walking and moving about, eating, using the toilet, communicating and other similar tasks relating to personal care. In order to receive benefits under group adult foster care or long term care insurance (see definitions), an individual must require assistance with a specified number of ADLs.
 

Actual Charge
The amount that a health care provider actually bills a patient for medical services rendered to the patient. Compare allowable, customary, prevailing or reasonable charge.
 

Acupuncture
The practice of medicine based on traditional Chinese theories. Acupuncture consists primarily of the insertion of metal needles through the skin at certain points on the body in an attempt to relieve pain or improve bodily functions. Many states require the registration or licensing of acupuncturists.
 

Administratively Necessary Day
A day during which a patient remains in a health care facility (typically, an acute care hospital) at a level of care higher (and usually more expensive) than the level required by his or her medical condition. The term, often abbreviated to "AD" or "AND," is used in connection with third-party reimbursement calculations.
 

Admission Agreement
A written agreement between a patient and a hospital or other inpatient health care facility, specifying the rights and obligations of both parties in connection with admission to, residence at and discharge from the facility. The content of an admission agreement is increasingly regulated by both state and federal law, and may address such matters as payment obligations, patients' rights, policies regarding the protection of patients' property, procedures for applying for Medicare or Medicaid program benefits, instructions for contacting resident advocacy groups or the state ombudsman and other matters.
 

Adult Day Care
Indicates facility has a program that provides supervision, recreation and health care services during the day to elderly and disabled individuals living in the community so family caregivers can work or attend to other responsibilities.
 

Allied Health Professionals
Specially trained and/or licensed health care workers, other than physicians, dentists, podiatrists, chiropractors, optometrists and nurses. Although the term has no specific meaning, it typically includes such health care professionals as laboratory and radiologic technicians, physical and occupational therapists and athletic trainers.
 

Allowable Charge
The maximum amount that a provider of health care services may expect to receive for a particular service or product from a third-party payor (such as an insurance company, a preferred provider organization, the Medicare program or Blue Cross). An allowable charge may be less than the actual charge a provider has billed or would like to bill a patient, and may or may not reflect the actual cost to the provider of providing the service. Compare actual, customary, prevailing or reasonable charge.
 

Allowable Cost
A specialized accounting term used to refer to an expense, incurred by a provider of health care services, that will eventually be reimbursed by a third-party payor. Under both the Medicare and Medicaid programs, certain providers are required to report their costs to the agency, who will audit them and incorporate those costs that are "allowed" under the rules of the program into reimbursement paid to the provider. Allowable costs do not necessarily equal the actual costs incurred by a provider, and may exclude some expenses.
 

Alzheimer's Unit
Indicates facility has a unit that provides specialized care to Alzheimer's patients.
 

Ambulatory Care
Health care services rendered by a provider, such as a hospital or clinic, on an outpatient basis (as opposed to inpatient services).
 

Ancillary Service
A service, other than the provision of room and board, provided by a hospital or other care facility, such as X-ray, laboratory or professional services.
 

Balance Billing
The practice by a provider of charging a patient for unreimbursed costs associated with services for which the available third-party reimbursement is not sufficient to reimburse the provider for the actual charge (see definition). Balance billing with respect to covered services is prohibited under some reimbursement systems, such as Medicare, Medicaid and Blue Cross/Blue Shield.
 

Beneficiary
A person who is receiving or is eligible to receive benefits from a private health insurance plan, a health maintenance organization or another payor of services. The term has the same meaning as "insured" or "subscriber" in the case of health insurance plans or "member" in the case of health maintenance organizations.
 

Best Interest of the Patient
A term, used in the context of cases involving terminally-ill, incompetent patients, to refer to the balancing of the patient's condition against the states interest in protecting the interests of innocent third parties, preventing suicide, preserving life and maintaining the ethical integrity of the medical profession. Compare substituted judgment.
 

Board Eligible and Board Certified
The term board eligible refers to a physician who is eligible to take an examination in a medical specialty. The relevant medical specialty board specifies its own requirements for eligibility, including graduation from an approved school or a specific type and amount of hospital-based training. For example, a physician usually does not become board eligible until he or she has completed a three-to-five-year resident training program.

Board certified refers to a physician who has passed the examination in a particular medical specialty and has been certified by the relevant medical specialty board as a specialist in that area of practice. Some specialty boards also have periodic recertification requirements. See medical specialty board.
 

Boards of Registration
State-chartered agencies that regulate and license health care and other professionals, such as physicians, nurses, psychologists and social workers. Typically, a Board of Registration has investigative and punitive powers to monitor and enforce compliance with its regulations.
 

Capital Expenditure Review
The review of proposed capital expenditures by hospitals and other health care facilities to determine the appropriateness and reasonableness of such expenditures. This review takes place during the certificate of need (see definition) and rate-review processes.
 

Capitation
A method of payment for health care services in which an individual or institutional provider (or a combination of the two) is paid a fixed, per capita amount, without regard to the actual number or type of services rendered to each patient. This method of payment is most commonly followed by health maintenance organizations, but is also used by physician-hospital organizations (see definitions).
 

CARF Accredited
Indicates facility has chosen to be reviewed by the Commission on the Accreditation of Rehabilitation Facilities (CARF), a private accreditation agency, and been found to be in compliance with CARF quality standards.
 

Carrier
An entity, such as a private commercial health insurer, Blue Cross, Blue Shield or a government agency, that underwrites or operates a program of reimbursement for health care services. In this generic sense, the terms carrier, fiscal agent, intermediary and third-party payor are often used interchangeably. The term carrier is also specifically used to refer to entities that administer the Medicare Supplemental Medical Insurance Program (Part B) and the Federal Employees Health Benefits Program.
 

Catastrophic Health Insurance
A plan that provides insurance against lengthy and severe illnesses and disabilities. The term appears most frequently in discussions of proposed national health insurance programs. In general, this type of plan pays for all or a specified percentage of medical expenses above a certain fixed amount for which the beneficiary is responsible.
 

CCRC
Continuing Care Retirement Community (CCRC). A facility offers several levels of care and accommodation. The facility requires an entrance fee that guarantees that when funds are depleted you will be cared for without charge for ONE year. Entry fees are refundable under specific conditions only. In addition to the entry fee, you pay a monthly service fee based on the level of services and accommodations.
 

Certificate of Need (CON)
A certificate issued by a state agency authorizing the construction of a new health care facility, the commencement of a new or innovative health care service or a substantial capital expenditure related to the provision of health care. The National Health Planning and Resources Development Act of 1974 contain provisions relating to state certificate of need programs.
 

Certification
The process by which a state Medicaid agency evaluates and approves a provider for receipt of reimbursements from the Medicaid program. For example, a nursing facility may not receive Medicaid reimbursements or enter into a provider agreement with the state under which reimbursements are authorized unless it is certified. An institutional provider will usually receive certification for participation in the Medicaid program after its facility has been inspected and surveyed by state surveyors for compliance with applicable federal regulations.
The term is also used in connection with peer review programs to refer to the approval of particular services rendered to a patient for payment by third-party insurers and payors such as the Medicare and Medicaid programs. Services must be certified as being medically necessary and appropriate if the provider rendering the services is to be reimbursed.
 

Charge
A price assigned to a particular medical service. Charges are computed by a variety of methods. They may or may not reflect the actual costs incurred by the provider or be frilly reimbursed by third-party payors. See actual, allowable, customary, prevailing or reasonable charge.
 

Child Care Center
Indicates facility has a licensed child care center on its premises for employees and/or the community. These programs often provide an opportunity for residents to interact with the children during intergenerational activities
 

Chiropractor
A practitioner who treats illness and injuries through adjustment, manipulation and treatment of the spinal column. In most states, chiropractors must be registered or licensed.
 

Coinsurance
A type of cost-sharing under a health insurance plan. Under some policies, the beneficiary is required to pay a percentage of the charge for the health services received, while the insurer will pay for the remaining amount.
 

Community Health Center
A health care center providing ambulatory health care services in a federally-recognized, medically underserved area. The center may also provide some social services and assistance in arranging for health services not offered by the center. Community health centers receive funding from the U.S. Public Health Service. They are also referred to as family health centers, community health networks or neighborhood health centers.
 

Community Mental Health Center
A health care center providing inpatient, outpatient and emergency mental health services to individuals in a specific geographic area. The community mental health center program was organized tinder the federal Mental Health Systems Act of 1980.
 

Community Support Facility
Refers to rest homes licensed to provide care to individuals with mental health problems.
 

Condition of Participation
A standard that a health care provider must fulfill in order to be eligible to receive reimbursements under the Medicare and Medicaid programs. Special conditions are applicable to each type of health care facility, such as nursing facilities, hospitals and home health care agencies. The conditions of participation provide the basis on which state agencies inspect and evaluate health care providers to determine whether to certify them for participation in the Medicaid program or to renew or revoke such certification. Failure to fulfill licensure standards can lead to loss of both licensure and certification; similarly, failure to comply with a certification requirement may result in loss of licensure.
 

Conservator
An individual who has legal authority to manage and preserve another individual's assets, pursuant to appointment by a probate court. A conservator is typically appointed when an individual, by reason of advanced age, mental weakness or physical incapacity, is unable to properly care for his property. This individual (commonly referred to as "the ward~') need not be legally incompetent. A conservator does not have custody of the person for whose benefit the conservatorship is established. Compare guardian.
 

Continuum of Care
That the levels of service and/or accommodation offered by a facility provide the resident with care through two or more levels of health needs.
 

Continuing Care Retirement Community/Continuing Care Facility (CCRC/CCF)
A residential community designed to offer shelter, convenience, services and personal and medical care, including nursing facility services, to elderly persons who invest in the project. In principle, CCRCs and CCFs are designed to offer a continuum of care, ranging from independent living to assisted living and nursing home care, that reflects the changing needs of their residents. The financial a1Tangements for these communities vary from a guarantee of lifetime nursing care to an arrangement linking the community to a nursing facility but requiring the resident to pay separately for nursing home care. CCRCs and CCFs are regulated by statute in many states. See life care contract.
 

COP Therapies
Certified Out Patient Therapies
 

Cost-Related or Cost-Based Reimbursement
A principle of reimbursement under a program, either public or private, that reimburses providers for health care services rendered on the basis of the costs incurred in providing the service. Medicare, Medicaid, Blue Cross and Blue Shield have historically been cost-related or cost-based programs. This method does not necessarily provide for reimbursement of all costs actually incurred, but may instead reimburse only "allowable" or "reasonable" costs. (This system may be compared to a charge-based system under which reimbursement is based on a provider's charges rather than its costs, or a capitated system where the provider receives a periodic flat fee regardless of the volume of services provided.) A cost-related or cost-based system may be either retrospective (reimbursing for costs already actually incurred) or prospective (reimbursing for anticipated costs).
 

Cost Report
A financial statement prepared by hospitals, doctors' groups and other health care providers who request Medicare reimbursement for services rendered to patients. This report, which is submitted to the U.S. Department of Health and Human Services or its designated intermediary, contains a detailed statement of income and expenses, itemizing occupancy rates, capital equipment depreciation amounts and other relevant information. Filing a cost report is a precondition to receipt of Medicare reimbursement.
 

Customary Charge
The uniform amount that the individual physician or other practitioner charges in the majority of cases for a specific medical procedure or service. The customary charge is one factor used by Medicare carriers in determining the reasonable charge that a provider may bill to Medicare for a particular service (see definition).
 

Custodial Care
The provision of room, board and some supervision of activities for individuals on a long-term basis, frequently in an institution such as a boarding house, halfway house or rest home. Custodial care does not include medical services, such as the care provided in skilled nursing or intermediate care facilities. Reimbursement is not generally available under either private or governmental health insurance programs, unless the custodial care is provided incident to other covered care. Some long term care insurance policies cover custodial services by paying for care in connection with assistance with activities of daily living (see definition).
 

Date Bank
See National Practitioner Data Bank.
 

Decertification
The process for revoking the certification of a provider for participation in the Medicare or Medicaid programs. Revocation of certification leads inevitably to the termination of provider agreements and the receipt of reimbursements, since a provider must be properly certified to receive reimbursements. Where residents are found to be in jeopardy, decertification may take place very quickly.
 

Deficiency
A facility surveyor's official conclusion that a health care facility is out of compliance with one or more regulatory standards. Deficiencies are reported on an official form on which space is set aside for the facility to write the mandatory plan of correction. See survey.
 

Department of Health and Human Services (DHHS)
The federal agency responsible for a variety of health-related functions. One division of this agency, the Health Care Financing Administration (HCFA), is responsible for operation of the Medicare program.
 

DoN
Director of Nursing
 

Determination of Need (DON)
See certificate of need (CON).
 

Diagnosis Related Group (DRC)
Refers to classification categories utilized by the Medicare program as part of the prospective payment system applicable to most participating hospitals. DRGs are also used by other third party payors. Upon hospitalization, each beneficiary is assigned a DRG by reference to his or her primary diagnosis. For each individual DRG, the Medicare program determines the fixed amount to be paid for the beneficiary's spell of illness, regardless of length of stay or actual utilization of services. Note that certain hospitals are not included in the DRG prospective payment system, and that the Medicare program has recently implemented a trial DRG system for certain skilled nursing facilities.
 

Do Not Resuscitate (DNR) Order
A physician's order entered into a patient's medical record to indicate that, in the event of cardiac arrest or other life-threatening event, the patient is not to be resuscitated by the use of cardiopulmonary measures. Such order may also be referred to as "no-code" orders.
 

Federal Financial Participation
A term used in federal statutes and regulations to refer to the federal government's share of expenditures for the operation of state Medicaid programs. A state is required to develop a plan, acceptable to the federal Department of Health and Human Services (DHHS), specifying the benefits available under the state's Medicaid program and its method of operation. When an adequate state plan is submitted to and approved by DHHS, the federal government provides financial aid, pursuant to a formula, to assist the state in operating its Medicaid program.
 

Fee Schedule
A list of the charges that may be made by a provider for services rendered.
 

Fiscal Agent or Intermediary
A private contractor that processes and pays provider claims and provides other administrative and management services for a state Medicaid agency or an employer's self-insured group.
 

Fraud and Abuse
The federal fraud and abuse statute penalizes health care providers who receive "remuneration" in exchange for referring patients or ordering goods and services that are reimbursable by Medicare or Medicaid, Often referred to as the "anti-kickback statute,' this law prohibits any type of direct or indirect payments such as cash, below-market rent, preferential patient access or fee discounts in situations where one party is in a position to make referrals for Medicare or Medicaid goods, services, or patients to another party. The Office of the Inspector General has promulgated a series of regulatory safe harbors describing practices not subject to enforcement under the statute.
 

Group Insurance
An insurance plan under which a number of employees or members of a group, having similar characteristics, receive health insurance benefits under a single policy that covers all members of the group. These policies are frequently experience-rated: the insurer's prior experience with coverage for members of the group forms the basis for establishing fee and benefit schedules for the policy.
 

Group Practice Without Walls (GPWW)
A network of physicians or physician practices that comprise one legal entity but maintain their individual practices in separate locations. The GPWW may employ all physicians (the "integrated" model), or may acquire some or all of the assets of each practice or provide centralized administrative services only (the "associate" model).
 

Guardian
An individual appointed by a probate court to manage the legal, financial and day-to-day affairs of a legally-incompetent person (i.e., a minor or an individual suffering from a mental or physical disability). The guardian may also have personal custody of that individual, as authorized by statutory provisions. Compare conservator.
 

Health Care Financing Administration (HCFA)
The agency under the federal Department of Health and Human Services that manages the administration of the Medicare program (see definition). Now know as CMS.
 

Home Health Agency
An agency that coordinates and provides home maker and health care services to individuals in their homes, rather than in an institutional setting. A home health agency usually provides skilled nursing services, and perhaps other services such as physical and speech therapy, together with assistance with activities of daily living. These agencies may be certified to receive reimbursements under the Medicare and Medicaid programs.
 

Homeopathy
A system of therapy premised on the use of minute amounts of substances, call remedies, that in larger doses cause symptoms similar to those being treated.
 

Hospice
An organization that provided medical care and support services (such as counseling) to terminally ill patients and their families.
 

Hospital-Based Skilled Nursing Unit
Nursing facility beds located in or on the grounds of a hospital. Also called transitional care units.
 

Independent Practice Association (IPA)
An entity formed by physicians to negotiate and obtain managed care or risk-sharing contracts on behalf of its member physicians. An IPA typically serves a network of independent physician practices that treat both IPA and non-IPA patients. An IPA may offer certain centralized billing, administration, quality assurance or marketing services, but the operation of individual practices tends to remain independent.
 

Informed Consent
The consent from a patient that a health care provider must secure, authorizing the provider to perform a particular medical procedure. The consent is frequently given in writing and is valid only when the proposed treatment and its risks have been identified and explained to the patient in an understandable fashion. In the case of a minor or other legally-incompetent patient, a guardian may give informed consent for medical treatment.
 

Integrated Health Delivery System (IDS)
A single organization that provides hospital, physician and other health care services to patients. Such systems may be a single entity, either for-profit or not-for-profit, or a parent company of diverse health care organizations, such as foundations, group practices, hospitals, management services organizations or subsidiaries. Many systems offer their own health maintenance organization or other managed care product. (See definitions.)
 

Interim Rate
In the context of health care rate-setting determinations, a tentative rate issued by a rate-setting body for a fiscal period, based on the estimated expenses a provider expects to incur during that period. Adjustments for over and underpayments occur at some later date.
 

Intermediary
A public or private entity that contracts with the federal Department of Health and Human Services to process claims and carry out other administrative functions in connection with the Hospital Insurance Program (Part A) of Medicare.
 

Intermediate Care Facility (ICF)
A state-licensed facility that provides health care services to individuals who require institutional care, but not hospitalization or skilled nursing services. ICFs are now grouped with skilled nursing facilities under the federal designation Nursing Facility (NF), and must meet a variety of regulatory requirements in order to operate as providers and receive Medicaid and Medicare reimbursements. See nursing facility.
 

IV Therapy
Indicates facility provides intravenous therapies.
 

Joint Commission on the Accreditation of Health Care Organizations (JCAHO)
The private, not-for-profit organization that inspects and accredits hospitals, nursing homes and managed care organizations, and has as its purpose the maintenance of uniform standards of care in hospitals. In theory, participation in its accreditation programs is voluntary; however, most hospitals participate because JCAHO accreditation will satisfy the conditions of participation for the Medicare and Medicaid programs.
 

Joint Underwriting Association
An association of insurers organized to issue a particular type of insurance. A joint underwriting association may be established pursuant to state legislation, as is frequently the case for medical malpractice insurance. These associations may perform many of the functions of an individual insurance program, such as issuing policies, establishing rates and adjusting claims. See ProMutual.
 

Licensed Practical Nurse
A nurse who has received a certificate from an approved school of practical nursing. In general, a licensed practical nurse does not have the degree of expertise and is not granted the level of responsibility that a registered nurse has (see definition).
 

Life Care Contract
An agreement between a health care facility and a patient or resident. Under these contracts, the facility agrees to provide room and board, medical care and a variety of related services in return for which the patient or resident pays a sum of money. Historically, this amount was all or most of the resident's assets, but is now more typically a stated sum. The terms of such contracts vary considerably, depending on the type of facility involved and the needs of the patient or resident. In an increasing number of states, including Massachusetts, statutes govern such contracts and impose a variety of fiduciary and disclosure requirements on the facilities. See continuing care retirement community/continuing care facility.
 

Life Safety Code
A fire safety code developed by the National Fire Protection Association. Hospitals and nursing homes must generally meet the requirements of the Code applicable to those types of facilities in order to receive certification for participation in the Medicare and Medicaid programs, although the requirements for certification may be waived in some instances.
 

Living Will
An instrument that sets forth an individual's views regarding life-sustaining treatment and heroic measures in the event of impending death. Using a living will, the individual may specify the types of care he or she wants during the process of dying. At present, living wills are not legally enforceable under Massachusetts law. Compare health care proxy.
 

Long Term Care
Medical care provided by a health care facility to a chronically-ill, aged, disabled or retarded patient on a continuing and lengthy basis. This term usually refers to institutional care, and is most frequently used to refer to nursing home care provided by nursing facilities and institutions caring for the mentally-ill and the mentally-retarded.
 

Long Term Care Facility
A general term for a skilled nursing facility or an intermediate care facility (see definitions).
 

LongTerm Care Insurance
Private insurance designed to cover all or a portion of the medical and custodial costs of a prolonged illness or disability. Benefit plans vary in their coverage of skilled, intermediate and custodial care, and typically pay a fixed per diem rate for care, regardless of the actual cost to the insured.
 

Managed Care
The process by which a health care insurer or other payor becomes involved in the delivery of health services with the goal of controlling the cost and/or quality of such services. This process may include utilization reviews, provider reviews, beneficiary co-payments and benefit caps. Managed care projects take many forms, including health maintenance and preferred provider organizations (see definitions), and have been adopted by many state Medicaid programs.
 

Management Services Organization (MSO)
An organization that contracts with physicians or other groups to provide administrative and other practice management services. An MSO may be a direct subsidiary of a hospital, owned by physician-investors, or a combination of the two. MSOs do not provide health care services to patients; rather, they provide space, equipment, furnishings, personnel and services, such as management, billing, purchasing and information systems, for physician practices.
 

Medicaid (Title XIX)
A program established pursuant to Title XIX of the Social Security Act to provide medical benefits for certain categories of low-income individuals. The program provides benefits to indigent and disabled individuals and members of families receiving Aid to Families with Dependent Children. States have the option to provide benefits to a broader range of individuals. The program is a cooperative arrangement between the federal government and the states, under which both the federal government and a participating state contribute financial support. The state, however, retains a considerable amount of discretion over the operation and administration of the program, and has the right to determine the benefits to be provided, rules for eligibility, rates of payment for services and other matters, as long as broad regulatory guidelines established by the federal government are followed.
 

Medical Assistance Program
Another name for the Medicaid program.
 

Medical Specialty Board
An organization recognized by the American Medical Association or American Osteopathic Association that certifies the educational and practical qualifications of physicians in particular specialty areas. See board eligible and board certified.
 

Medical and/or Biological Waste
Refers to infectious or physically dangerous wastes which may cause or contribute to serious illness or pose a substantial hazard to human health or the environment when improperly treated, stored, transported, disposed of or otherwise managed. The term medical waste includes blood and blood products, pathological wastes, cultures, stocks of infectious agents and associated biological, research animals that have been exposed to pathogens, sharps (i.e., discarded hypodermic needles, pipettes, scalpel blades, etc.), and discarded preparations associated with genetically altered living organisms.
 

Medically Necessary
A term used in the context of utilization reviews to refer to the medical services that are required for proper treatment of an illness.
 

Medically Needy
A term used by the Medicaid program to describe individuals who are entitled to benefits based on specified financial thresholds.
 

Medicare (Title XVIII)
A federal health insurance program established by Title XVIII of the Social Security Act to provide medical benefits to insured persons without regard to income. Benefits are available to persons aged 65 or more, persons eligible for Social Security disability programs for over two years and certain individuals with end stage renal disease. Funds for the Medicare program are derived from payroll taxes and premiums paid by beneficiaries. The program is based on two sub-programs: hospital insurance (Part A) and supplementary medical insurance (Part B), which pays for services provided by individual providers.
 

National Practitioner Data Bank
A federally-mandated, central repository of malpractice and disciplinary information, established by the Health Care Quality Improvement Act of 1986. The Act requires physicians, dentists, nurses, malpractice insurers, state licensing authorities, hospitals and other health care providers to report information about disciplinary actions against practitioners and malpractice claims for which a payment has been made. It also requires each hospital to consult the data bank at the time a physician first applies for staff privileges and every two years thereafter.
 

Naturopathy
A system of therapy focusing on the use of natural forces, such as light, colors, heat, water, aromas and massage, but not drugs or surgery. Some states, such as Connecticut, require naturopaths to be licensed.
 

"No-Code: Order
See do not resuscitate (DNR) order.
 

Nurse Practitioner
A registered nurse with special training and qualifications for assessing the physical, psychological and social needs of a patient. A typical nurse practitioner administers primary care to patients under the direction of a physician. Many states require at least one year of advanced education as well as certification and licensure.
 

Nursing Facility (NF)
A federal designation, from the Omnibus Budget Reconciliation Act of 1987, encompassing all facilities previously known as "skilled nursing facilities" and "intermediate care facilities." A nursing facility must meet a variety of federal regulatory requirements in order to operate as a provider and to receive Medicaid and Medicare reimbursements.
 

Ombudsman
A state official whose role is to advocate on behalf of long term care facility residents or assisted living facility residents. The ombudsman typically receives, investigates and resolves complaints against facilities that involve the health, safety, welfare or rights of residents.
 

Omnibus Budget Reconciliation Act of 1987 (OBRA-87)
Landmark federal legislation that made significant changes to the regulatory structure governing nursing homes. The Act changed many of the requirements for nursing homes participating in the Medicare and Medicaid programs, including the elimination of the distinction between skilled nursing facilities and intermediate care facilities, the institution of more thorough and frequent patient assessment routines, the improvement of nurse's aide training requirements and a declaration of residents' rights. OBRA-87 also imposed significant new requirements on states to survey and certify nursing homes, and instituted a number of sanctions and enforcement mechanisms.
 

Omnibus Budget Reconciliation Act of 1990 (OBRA-90)
Certain provisions of this federal legislation modified the requirements of OBRA-87, with a particular focus on residents' rights and the standards of care nursing facilities must meet in the delivery of services.
 

Osteopathy
A school of medicine and surgery that utilizes traditional methods of diagnosis and treatment, including prescribing and administering drugs, surgery, obstetrics and radiology, but places special emphasis on the interrelationship of the musculoskeletal system with all other body systems. In many states, osteopaths are regulated as physicians and must be licensed by the Board of Registration in Medicine.
 

Participating
A term used to refer to a provider who agrees to accept an insurance plan's established fee as reimbursement in frill for its services or receives reimbursement under the Medicaid or Medicare programs.
 

Patients' Rights Bill
A statute, enacted in many states, that specifies in detail the rights a patient has in dealing with a health care facility (e.g., the right to privacy in treatment or to confidentiality of medical information). The federal rules governing the Medicare and Medicaid programs also contain a patients' bill of rights.
 

Peer Review Organization (PRO)
A not-for-profit professional association established for the purpose of reviewing health services provider to patients under Medicare, Medicaid and other governmental health programs with respect to the medical necessity, quality and appropriateness of such care. PROs contract with the Health Care Financing Administration and the state Medicaid programs to conduct reviews of providers and suppliers. Their decisions may be appealed before an administrative law judge. A PRO may also be referred to as a Quality Improvement Organization.
 

Pediatric Care
Indicates facility provides care to children and young adults with severe developmental disabilities caused by genetic conditions or devastating illnesses or accidents.
 

Per Diem Cost
The cost per day for inpatient medical care, derived by dividing the total cost of running a facility by the overall number of inpatient days care has been given.
 

Peritoneal Dialysis
An alternative to kidney dialysis.
 

Post-Acute Care
See Sub-Acute Care.
 

Prevailing Charge
A charge for a medical service that falls within the range of charges most often used in a particular locality for that particular service. The highest charge in this range is frequently used by a health insurance carrier as a ceiling for reasonable charges, above which any request for reimbursement may be disallowed. The prevailing charge for a particular medical service is also considered in determining reasonable charges for the purpose of Medicare reimbursement. See reasonable charge.
 

Primary Care
The general medical care provided to a patient by a physician, nurse practitioner or physician's assistant. Primary care most typically involves family medicine, internal medicine, pediatrics, obstetrics and gynecology and general medicine, as well as preventive health services. Compare secondary and tertiary care.
 

Prior Authorization
The requirement that a provider obtain approval from a health insurance carrier, peer review organization or another health care provider before rendering care to a patient.
 

Private Patient
A patient under the care of an individual health care professional who receives reimbursement for medical services directly from the patient, or from a third-party payor other than a public program or institution. These patients may also be referred to as "private-pay patients."
 

Prospective Reimbursement
A method for reimbursing health care facilities under which rates of reimbursement are established and paid to the relevant facilities on the basis of anticipated costs to be incurred in the coming year. Any actual costs greater than those previously estimated usually will not be reimbursed. The goal is to control increases in costs from year to year. Compare retrospective reimbursement.
 

Provider
A person or entity that provides health services to individuals under a system of third-party reimbursement. Providers include physicians, dentists, nurses, nursing homes, hospitals, home health agencies, clinics and other types of health care organizations.
 

Provider Agreement
A written agreement between a state Medicaid agency and a provider, specifying the terms under which the provider can participate in the Medicaid program and requiring the state to reimburse the provider at stated levels for services to Medicaid patients.
 

Psychiatric Care
Indicates facility has expertise in caring for individuals with psychiatric diagnoses.
 

PT/OT/SpT
Indicates facility provides physical, occupational and speech therapy services.
 

Reasonable Charge
A term used in connection with the Medicare program to refer to the lower of the customary charge by a physician for a particular type of medical service and the prevailing charge by physicians in the area, in general, for the service. Under the Medicare program, reimbursement is made for the lower amount. See customary and prevailing charge.
 

Receivership
The appointment by a court of a temporary operator of a nursing facility when the facility is in danger of delicensure, the health, safety or welfare of residents is in jeopardy or the operator is in severe financial distress. Although any court may invoke its equity powers to appoint a receiver, many states, like Massachusetts, have enacted statutes to regulate the goals, powers and duration of receiverships. See temporary manager.
 

Recertification
A term commonly used to refer to the process of regaining certification for participation in the Medicaid or Medicare programs after a previous decertification or revocation of certification. Usually, before recertification can occur, a provider must correct deficiencies in its compliance with regulatory provisions to the satisfaction of the agency responsible for inspecting health facilities.
 

Registered Nurse
A nurse who has graduated from a formal nursing education program and has received a license. Compared to a licensed practical nurse (see definition), a registered nurse has greater responsibility for patient assessments, planning and implementation of nursing care, coordination of health professionals and patient advocacy.
 

Related Party
A reimbursement concept under both the Medicaid and Medicare programs. Generally, reimbursement is prohibited for any amount in excess of actual cost whenever payment is made by a provider to a second entity, if the second entity is commonly owned or controlled by the provider. Although there are numerous exceptions to the related party prohibitions, the thrust of these regulations is to prevent excessive reimbursement.
 

Residential Health Care Facility
An institution (for example, a boarding house or rest home) that provides room and board, and sometimes social or other services, to individuals who reside at the facility for indefinite periods of time. A residential health care facility does not provide medical services or the type of intensive care delivered by nursing facilities (see definition).
 

Residents' Rights
The right to privacy, confidentiality, dignity and freedom of choice, to voice grievances and to receive full and complete information and communication about one's care and accommodations. Omnilius Budget Reconciliation Act regulations stipulate a range of rights applicable to residents of long term care facilities, while Massachusetts law promulgates a similar set of rights for residents of assisted living residences. (See definitions for these terms.)
 

Respite Care
Short-term placement of individuals to enable relatives caring for them at home to take some time off in their caregiving responsibilities.
 

Retrospective Reimbursement
A method of reimbursement for health care services that bases the rate of reimbursement on actual expenses incurred by a provider (or a group of similarly-situated providers) during some recent period. Compare prospective reimbursement.
 

Secondary Care
Medical care provided in an institutional setting, such as an inpatient hospital or nursing facility. Compare primary and tertiary care.
 

Self-Insurance
A mechanism whereby an employer directly pays the health care costs of its employees and their dependents, rather than purchasing insurance coverage from an insurance company, Blue Cross or HMO. Companies that self-insure frequently purchase stop loss insurance to limit their exposure (see definition).
 

Services for the Brain Injured
Indicates facility provides specialized services to individuals who have suffered traumatic brain injuries.
 

Subacute Care
Post-hospital care for patients who have suffered a serious illness or injury, but no longer require the intensity of services provided by acute care hospitals. Most subacute patients return home.
 

Suitability and Responsibility
When an entity or individual seeks to open or acquire a nursing home or hospital and to acquire a license, the state has significant concerns about the prospective owner's ability to operate the facility successfully and provide adequate care to patients. Accordingly, many states make inquiries into the backgrounds of prospective owners and operators. There are different names for this process (some states refer to "character and competence" while others, like Massachusetts, use 'suitability and responsibility"), but the facts that are considered generally involve the proposed licensee's financial stability and criminal record and the past performance of health facilities with which the prospective owner or operator has been affiliated.
 

Supplemental Health Insurance
A health insurance policy that provides coverage for medical expenses that are not covered by another health insurance plan the insured may already have in effect. For example, some private commercial insurers provide insurance, often known as "Medi-Gap" insurance, for services not covered by the Medicare program.
 

Supplemental Security Income (831)
A program created by the Social Security Act that provides monthly cash assistance to poor, aged, blind and disabled individuals. States may provide additional benefits if they choose.
 

Supplementary Medical Insurance Program (Part B)
A portion of the Medicare program in which persons entitled to Part A (hospital) insurance benefits may enroll by paying monthly premiums. This program is funded by premium payments and federal funding and covers medical expenses up to 80% of the reasonable charge for covered services, beyond a fixed annual deductible amount. Covered services include physician, outpatient hospital care and home health services, among other services. The program is organized by contracts with carriers to process claims and administer the program.
 

Supplementation
The former practice - now prohibited - of requiring a nursing home patient and/or his family to pay an amount for care above the established rate of Medicaid reimbursement for nursing home services. The Medicaid program now requires a participating nursing home to accept the Medicaid rate as reimbursement in full for covered services.
 

Survey
The process by which the Medicare and Medicaid programs evaluate the quality of care at health care facilities. Surveyors visit and evaluate each facility on both a regular and ad hoc basis and provide a written citation of any deficiencies from regulatory standards.
 

Skilled Nursing Facility (SNF)
A facility primarily engaged in providing intensive, 24-hour skilled nursing care and related services for inpatients