340B Drug Pricing Program

Mandates to drug manufactures to provide outpatient drugs at a lower cost to hospitals and other healthcare providers the treat a significantly large population of low-income patients

340B ID Number

Identification number assigned by CMS for facilities participating the 340B discounted pharmaceuticals program

AAMC/COTH Member: Association of American Medical Colleges/Council of Teaching Hospitals and Health Systems

A group of individual leaders who represent approximately 400 of the nation’s leading teaching hospitals and health systems. Membership is recognized throughout the world as a benchmark for excellence in patient care, research, and medical education.

ACO: Accountable Care Organization

Group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients; Coordinate care and avoid unnecessary duplication of services/prevent medical errors

ANCC Magnet Facility:  American Nurses Credentialing Center

certification body for nursing board certification and the largest certification body for advanced practice registered nurses in the United States,[1] as of 2011 certifying over 75,000 APRNs, including nurse practitioners and clinical nurse specialists. ANCC’s nursing board certification program is one of the oldest in the USA.

ASC: Ambulatory Surgery Centers

Known as outpatient surgery centers or same day surgery centers, are health care facilities where surgical procedures not requiring an overnight hospital stay are performed. Such surgery is commonly less complicated than that requiring hospitalization.

BPCI: Bundled Payment for Care Improvement

Initiative: General Information. Share. The Bundled Payments for Care Improvement (BPCI) initiative is comprised of four broadly defined models of care, which link payments for the multiple services beneficiaries receive during an episode of care.

CBSA: Core Based Statistical Area

U.S. geographic area defined by the Office of Management and Budget (OMB) that consists of one or more counties (or equivalents) anchored by an urban center of at least 10,000 people plus adjacent counties that are socioeconomically tied to the urban center by commuting

CHIP: Childrens Health Insurance Program

Medicaid program that provides health insurance coverage to eligible children. It is administered by states according to federal requirements, and is jointly funded by state and federal governments.

 CIN: Clinically Integrated Network

A Clinically Integrated Network is a collection of healthcare providers, such as physicians, hospitals, and post-acute care treatment providers, that come together to improve patient care and reduce overall healthcare cost.

 CJR: Comprehensive Care for Joint Replacement

The Comprehensive Care for Joint Replacement (CJR) model aims to support better and more efficient care for beneficiaries undergoing the most common inpatient surgeries for Medicare beneficiaries: hip and knee replacements (also called lower extremity joint replacements or LEJR). This model tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery.

CMS:  Centers for Medicare and Medicaid Services

Previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards.

 CON:  Certificate of Need

An endorsement required by numerous states before the construction of a new health care facility will be approved. The central idea of Certificate of Need legislation is the assertion that overbuilding and redundancy in health care facilities leads to higher health care costs.

Coordinated Care Reward Program: Beneficiaries receiving care from a Next Generation ACO are eligible to receive payments of up to $25 by going to an annual wellness visit with a primary care physician.

 CPT: Current Procedural Terminology

A medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations

CRM (Integration): Customer Relationship Management software

A category of software that covers a broad set of applications designed to help businesses manage many of the following business processes: customer data, customer interaction, business information, automate sales. (Example:  Access, Salesforce, Dynamic, NetSuite

Est.: Proprietary estimations of all-payor payments, charges, and procedures coming from Definitive Healthcare algorithms

FFS: Fee-for-Service

In FFS, providers are paid separately for each service.  Alternative for FFP, Episode-based payments are an alternative to fee-for-service (FFS) reimbursement

PAC: Post-acute care

FQHC: Federally Qualified Health Center

More commonly known as a Community Health Center(CHC) and is a primary care center that is community-based and patient-directed. By mission and design, CHCs exist to serve those who have limited access to health care although all are welcome.

GLN:  Global Location Number

Used to identify physical locations; facilities can have multiple (main hospital, laboratory, storage warehouse)

GPO: Group Purchasing Organization

Organization helps healthcare providers such as hospitals, nursing homes and home health agencies realize savings and efficiencies by aggregating purchasing volume and using that leverage to negotiate discounts with manufacturers, distributors and other vendors.

 HCPCS Code: Healthcare Common Procedure Coding System

A set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT).

HAC: Hospital Acquired Condition (Penalty)

Program to Reduce hospital-acquired conditions by penalizing the hospitals that rank among the lowest-performing 25 percent.

HAI: Healthcare Associated Infections

Hospitals are required to report rates of Healthcare Associated Infections among their Medicare patients.  Eg.: catheter-associated urinary tract infections (CAUTI), surgical site infections from colon surgery (SSI: Colon)

HHA: Home Health Agency

A wide range of health care services that can be given in yourhome for an illness or injury. Home health care is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility (SNF).

HIE: Health Information Exchange

Organization that facilitates the exchange of health care information electronically across organizations within a region, community or hospital system

 HIN:  Health Industry Number

Used to identify hospitals and other locations in the supply chain

HRR: Hospital Readmission Reduction Program

The HRR Program provides financial incentives to hospitals to reduce costly and unnecessary hospital readmissions. CMS penalizes hospitals for having excess readmission ratios for common diagnoses.  All hospitals have potential to receive penalty; degree varies by readmission scores.

IDN: Integrated Delivery Network

IDNs were formed in reaction to a demand for providers to deliver high quality, low cost, and coordinated care by consolidating

J-Code: The HCPCS “J” codes include the majority of those drugs and biologicals that should be reported with infusions, injections, and supply codes that go hand in hand with CPT procedure based coding.

LOS: Length of Stay

A term to describe the duration of a single episode of hospitalization. Inpatient days are calculated by subtracting day of admission from day of discharge.

M&A: Merger/Acquisition

MAC/FI: Medicare Administrative Contracts/Fiscal Intermediaries)

MACs are private organizations of Traditional Medicare (Parts A and B). They also handle durable medical equipment, home health and hospice claims

MACRA: Medicare Access and CHIP Reauthorization Act (2015)

This bill created the Quality Payment Program, which altered the way Medicare rewards clinicians for value rather than volume, streamlined quality programs under a new Merit Based Incentive Payments System (MIPS), and gives bonus payments for participation in eligible alternative payment models.

MCR: Medicare Cost Report

The MCR is a report that healthcare facilities accepting Medicare must send to the Centers for Medicare & Medicaid Services on time each year.  Medicare cost reports are used to report expenses for different types of Medicare reimbursable facilities, such as Skilled Nursing Homes (SNFs), Home Health Agencies (HHAs), Home Offices, Hospices, Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and hospitals.

MIPS: Merit Based Incentive Payments System

Participating providers earn performance-based payment adjustments to Medicare payments.

MPN: Medicare Provider Number

An identifier assigned by CMS to classify the hospital type and location of the facility

MSSP: Medicare Shared Savings Program

According to the Centers for Medicare & Medicaid Services (CMS), the Medicare Shared Savings Program (MSSP) aims to encourage coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. Created to facilitate the coordination of care between providers to improve quality of care:

  • Better care for individuals
  • Better health for populations
  • Lowering growth in expenditures

MU: Meaningful Use

CMS incentive program to encourage providers to demonstrate meaningful use of electronic health technologies

Introduced through the Affordable Care Act.  The completion of each stage determines the payment amount to the hospital from CMS

Network Affiliations

Hospitals/providers that cooperate primarily to purchase together or negotiate managed care together

News & Intelligence

Nationwide news and information pertaining to the Healthcare industry

NPI Number:  National Provider Identifier

A unique 10 digit number assigned to each health care provider, health plans, and health care clearinghouses for administrative and financial purposes

NSQIP Member: National Surgical Quality Improvement Program

ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in the private sector.

Payer: also referred to as “Payor”

In healthcare, a “payer” refers to an entity responsible for the processing of patient eligibility, services, claims, enrollment, or payment. Entities considered to be healthcare payers include Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), healthcare service contractors, state insurance agencies, claim handlers, and more. There is some conflict regarding the use of “payer” versus “payor”. Though the spellings are used interchangeably, “payer” is the form preferred by the American Medical Association (AMA).

PG: Physician Group

Group medical practices are defined as “the practice of medicine by a group of physicians who share their premises and other resources.”

PUF: Public Use Files

Public use data files are data files prepared by investigators or data suppliers with the intent of making them available for public use. The data available to the public are not individually identified or maintained in a readily identifiable form.

RFP: Request for Proposal

A document that solicits proposal, often made through a bidding process, by an agency or company interested in procurement of a commodity, service, or valuable asset, to potential suppliers to submit business proposals.

RPC: Regional Purchasing Coalition

Similar to a GPO, it’s an organization that collaborates in a defined program to improve the quality of healthcare by aggregating purchasing volume, but for a specific geographical area

SAF:  Medicare Standard Analytics File

File released by CMS for all inpatient and outpatient Medicare claims. Previously released annually; currently released by CMS quarterly

SNF: Skilled Nursing Facility

A health-care institution that meets federal criteria for Medicaid and Medicare reimbursement for nursing care including especially the supervision of the care of every patient by a physician, the employment full-time of at least one registered nurse, the maintenance of records concerning the care and condition of every patient, the availability of nursing care 24 hours a day, the presence of facilities for storing and dispensing drugs, the implementation of a utilization review plan, and overall financial planning including an annual operating budget and a 3-year capital expenditures program.

TQIP Member: Total Quality Improvement Program

Consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.  Quality is directly linked to an organization’s service delivery approach or underlying systems of care.

YTD: Year-to-date claims from CMS based on the recently released quarterly updates

VBP: Value Based Purchasing Program

Transitioning from a fee-for-service healthcare system to one focused on the value of the patients’ experience as well as the quality of care that they receive.  The actual reimbursement amount earned by each hospital depends on the range and distribution of all of the participating hospitals’ Total Performance Score.  Adding up the 4 weighted domain scores generates the Total Performance Score.  The monetary adjustments are determined after the hospital is compared to the other hospitals participating in VBP program and placed in a specific percentile