General Medical Definitions
One of the five stages of grief; acknowledgment of a situation whether it be an illness or death. The individual does not have to like what has happened they merely reach a point where they are no longer trying to change the situation through feelings of denial, anger, bargaining, or depression. They are acknowledging the reality of the situation or event
Activities of Daily Living (ADL)
Activities such as bathing, dressing, and meal preparation which you perform on a daily basis.
Second phase associated with a terminal illness. The individual now has a diagnosis (or name) to the symptoms and a plan of treatment may be discussed. The individual may experience the grief stages of anger and denial.
Acute Rehabilitation Facility
Hospital which provides moderate to intense rehabilitation services. Patients must be able to participate in 1-3 hours of rehabilitation per day and must show continued signs of improvement in order to qualify for ongoing treatment.
Advance Health Care Directives
Known by many names including health care proxy, advance directives, living will, is a document which has been written and signed by a competent individual with two witnesses signatures (is not notarized.) The document provides health care instructions and appoints a proxy (health care agent). In the event the individual is unable to speak for themselves the agent insures the health care decisions outlined in the document by the individual are carried out by the healthcare team. The document tends to be detailed instructions addressing wishes related to withdrawing food and fluids, ventilator support, dialysis and any other aggressive or “heroic” measures.
Care which is designed to preserve life. Aggressive care would include cardiopulmonary resuscitation (CPR), dialysis, chemotherapy, surgeries, etc.
Alternative Medicine/Alternative Therapy
Insurance carrier definition of any non-traditional form of healthcare. Common forms of alternative medicine include acupuncture, massage and chiropractic medicine. Insurance carriers consider you to be using alternative therapy when you choose to use only alternative therapies and do not combine them with traditional/conventional medicine.
One of Elisabeth Kubler-Ross’ five stages of grief. A feeling of rage with pain as the underlying emotion. An example would be “This is wrong! It isn’t fair!!!!”
Living expecting a loss to occur and experiencing the grief associated with that loss before it actually does occur. This is most common with terminal illnesses.
Administrative Service Only (ASO)
Employer insurance plans in which the employer takes on the full risk for financing the health care benefits it provides to its employees. Employers may contract with Third Party Administrators (TPA) such as insurance carriers, to provide certain administrative services such as the processing of claims. May also be referred to as Self-Funded HealthCare.
Foreign material such as vomit, food or fluids which enters the lungs causing inflammation and infection.
Attendant Care/Shift Care
Care provided in the home in shifts of 8 hours or more. The care may be considered skilled if it requires a licensed person to perform certain tasks or it could be considered custodial in nature (does not require the skills of a licensed person to perform).
May also be called Home Care or Domicile Care.
One of the five stages of grief identified by Elisabeth Kubler-Ross. In this stage, you may accept what is happening but you are bartering or negotiating for more time. For example: “If I could only stay long enough to see my child’s wedding.”
Pain that is not controlled by the normally scheduled pain medication routine. It may feel like a pain spike or surge. Things which can cause pain spikes include an increase in activity.
Most benefits and the deductible fall within the time period between January 1 and December 31.
A nurse or social worker who acts as a point person for individuals with complex medical needs, to assist in coordinating services and evaluating treatment plans.
The change in the rhythm or breathing pattern noted in the end-phase of life. The irregular pattern is a shallow pant followed by periods of not breathing.
Long lasting or continuous illness such as diabetes or arthritis.
This third phase of a terminal illness may take days, weeks or years. Chronic does not refer to the period of time. The individual may or may not be receiving treatment. It refers to the “mental state” of adjusting to the diagnosis with all of its ramifications. The stages of grief the individual may experience are: bargaining, anger, depression, and, if the illness extends over several years, they may experience denial again.
Coordination of Benefits (COB)
Agreement among insurance carriers to prevent the same claim from being paid by two or more carriers resulting in overpayment of the claim. If an individual is insured by two or more insurance policies, one of the insurance policies will agree to be primary, making the initial payment on the claim while the other policy will be secondary covering the remaining portion of the claim. May also be referred to as coinsurance.
The existence of other illnesses/ diseases in the presence of a primary diagnosis/illness.
Complimentary Medicine/Alternative Medicine (CAM)
Also known as Alternative Medicine or Alternative Therapy. More and more often the acronym “CAM” is utilized to describe the combination of using both conservative/traditional medicine in combination with alternative medicine. Complimentary/alternative medicine is any practice which is outside of the traditional form of medicine. In addition to the most common forms of complimentary/alternative medicine of massage, chiropractic and acupuncture, biofeedback and spiritual healing are two of the many other forms of alternative medicine practices.
A fee-for-service plan which combines the covered benefits of the basic and major fee-for-service into one plan.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
1986 Federal legislation impacting health plans for businesses with twenty or more employees. COBRA allows you to continue to receive your health care insurance for up to 18 months, as long as you pay your own insurance premiums.
The discounted amount your insurance company and participating provider/par-provider have agreed upon for services.
Conventional Medicine/Traditional Medicine
A health care delivery system, in which medical doctors (MD’s) and other health care professionals treat symptoms and diseases. Another term used to describe this form of medicine is allopathic.
The set amount you are responsible for paying towards any healthcare services you access.
Covered Charges/Covered Expenses
Services which are included benefits in your insurance plan. Your insurance policy may exclude certain items such as prescription benefits. Medical expenses are only applied to services which are covered under the policy and your insurance carrier is only responsible for paying its share of cost on covered services.
the restoration of health. The absence of a disease activity over a period of time. With the greater passage of time, the statistics of the disease returning becomes less.
Care provided to assist the individual in performing activities of daily living such as bathing, dressing, or meal preparation. Typically not covered by standard insurance policies
A gurgling or rattling sound at the back of the throat noted when a person is breathing. This is present in the end-phase of life and caused by the collection of respiratory secretions.
The initial, specified amount you must pay before your insurance company begins to make payments towards your medical claims.
Grief which may occur months or even years after the event. This is often seen when the individual must address other responsibilities first (such as funeral preparations or financial issues.)
One of the five stages of grief identified by Elisabeth Kubler-Ross. It is the disbelief in what you are experiencing. For example: “I feel fine! The doctor must be wrong.”
One of the five stages of grief identified by Elisabeth Kubler-Ross. Feelings of sadness so severe that you are unable and have no desire to participate in the activities of daily living. In depression, you may not see the point of doing anything.
Name given to a group of signs and symptoms after obtaining a history, physical examination, evaluation of laboratory results and, test/procedures.
Durable Medical Equipment (DME)
Medical equipment which can withstand repeated use during a course of treatment. Examples of durable medical equipment include hospital beds, canes, and braces. Medicare also defines glucose test strips, glucose monitors and insulin pumps as durable medical equipment.
Durable Power for Health
Durable Power for Health is a document written by a mentally competent individual with the assistance of a lawyer or paralegal, with notarized signatures from the individual and witness. The document names an agent who will make medical decisions in the event the individual is incapacitated. Unlike the Living Will, this document may not be as detailed in outlining the wishes of the individual, leaving much in the way of interpretation on the part of the agent.
Employee Retirement Income Security Act (ERISA)
As it pertains to health insurance, federal law which regulates self-funded health plans. There are many parts to the ERISA law and recent amendments one of which includes the Health Insurance Portability and Privacy Act (HIPPA). Issues or concerns related to ERISA fall under the US Department of Labor (US DOL).
Evidence-Based Guidelines (EBG)
Guidelines based on research, which are used to help make medical decisions and standardize the practice of medicine for specific conditions. Milliman and Interqual are examples of evidence-based guidelines. Information to create the EBGs are obtained from the consensus of experts within a particular field, as well as clinical trial data. While EBGs may appear to be a great way of standardizing medical practices, they fail in several areas (see the section on “legal issues and laws”.)
With respect to your insurance coverage, exclusion is any service which is not considered part of your insurance plan. Custodial care is an example of a commonly excluded benefit.
Explanation of Benefits (EOB)
A statement provided by your insurance carrier detailing the activities or actions taken on claims submitted by healthcare providers for consideration of payment.
Insurance plan that allows you to receive services from any healthcare provider without restrictions. The policy is limited in what it covers. There are two types of FFS plans, a basic and major plan. The basic plan covers some physician visits, hospitalizations stays and prescriptions while the major plan covers serious, long-term illnesses. Some insurance carriers combine the basic and major plan into one comprehensive plan.
Fully Funded Plan
A health insurance plan which is completely managed by a medical insurance carrier. An example of a fully funded plan is an individual policy you may purchase for yourself.
With respect to medical insurance, the formulary is a list of drugs covered by a policy. The list is based on the cost, safety and effectiveness.
Medication whose ingredients are therapeutically the same as the manufacturer’s brand and can be offered at a lower cost.
The multifaceted emotional response to any loss. An individual may experience any of the five stages of: denial, anger, bargaining, depression and acceptance as outlined by Kubler-Ross.
Used in reference to the time it takes for half of a medication to become inactive in your body. The half-life is given as a reference. You should take into consideration any conditions which may slow the body’s ability to eliminate the medication including kidney or liver disease.
The perception that you are either hearing or seeing something that is not really there.
Health Insurance Portability and Accountability Act (HIPAA)
Act passed by Congress in 1996 which revised the previous Employee Retirement Income Act (ERISA) and Public Health Service Act. HIPAA was designed to protect the patient privacy and health insurance coverage.
Health Maintenance Organization (HMO)
A health care policy which is managed by a medical group (either a HMO or IPA group.) By requiring primary care physicians see large number of patients in a day, and restricting the number of referrals to specialists, the HMO’s are able to keep their costs down and pass on the savings to members in the form of affordable health care.
Non-sense. Foolishness or empty pretenses used to disguise deception. A form of trickery.
Home Health Care
Skilled care in the home setting. Unlike attendant/shift care, home health care is brief (lasting no more than 3-4 hours a day) and intermittent over a short course of time. Services provided in the home include, psychiatric nursing, social services, nursing care including the assistance of an aid, and rehabilitation services which include physical, occupational and speech therapy. Home care is created to provide assistance to the patient in their home setting.
In medical terms, hospice provides palliative/comfort care to an individual thought to have six months or less to live. The care provided is both on a physical and spiritual level and includes the individual’s family. The care is provided in the individual’s home or in a hospital setting.
Physician who specializes in providing care to hospitalized patients. Hospitalists often have a background in internal medicine or family practice. The position has been created to optimize time and curb costs for physicians who participate in a Health Maintenance Organization (HMO). By assigning a hospitalist to their hospitalized patients, physicians can focus on providing care to their office practice and less time making rounds to multiple hospitals.
The condition of having an illness or infection which has no chance of improvement despite treatment and will ultimately be fatal.
Independent Practice Associate (IPA)
A group of physicians who establish a contract to care for both HMO and PPO members.
When associated with a terminal diagnosis, it describes that period when testing begins to determine the cause of symptoms noted by the individual.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
An unbiased review organization which assesses healthcare organizations such as hospitals and home care organizations to insure quality, safety and standardization of care.
Lifetime Maximum (Lifetime Max)
The capped amount of money your insurance carrier will pay out for services during your lifetime.
Long Term Acute Care Hospital (LTACH)
Acute care hospital for patients who require intense care for thirty days or more. Examples of patients who may need LTACH include those who are trying to come off breathing machines (weaned from ventilators).
Long-Term Care Insurance
Insurance policies sold by life insurance companies which provide coverage for things which are generally not covered by medical/health insurance policies. Long-term care policies typically cover adult day care, assisted-living facilities, Alzheimer’s care, respite care, and attendant care.
Healthcare system which utilizes various methods to keep costs down and quality care up. Healthcare providers agree to contracted rates within the managed care system. By agreeing to accept lower fees for services, the contracted providers are promised referrals from the plan manager. Preferred Provider Organizations, Health Maintenance Organizations and Point of Service plans are examples of managed care plans.
Feelings of sadness which are buried or denied. Masked grief can be the result of religious, cultural or learned behavior. Repressing grief feelings can result in unexplained medical conditions which may or may not have a psychosomatic connection.
There are multiple applied definitions for the term “medical necessity.” Speaking generically, medical necessity is any treatment for an injury or illness which is considered necessary to improve or restore health. Each insurance carrier provides their own definition of medical necessity in the benefit booklet they provide their clients.
Federal- and state-aided medical insurance program for low-income United States citizens (in California, the Medicaid plan is called “Medi-Cal”.)This is the link to Medicaid’s site.
United States federally funded health insurance policy administered by the U.S. Social Security Administration; available to the permanently disabled, seniors over 65 who have been citizens for five years or more.
A blotchy discoloration of the skin noted during the end-phase of life as the result of shunting of oxygenated blood from the skin surface; usually seen first in the lower extremities.
National Committee of Quality Assurance (NCQA)
A non-profit organization which reviews health maintenance organizations and other managed care organizations.
A drug created by the original manufacturer of the drug and therefore goes by the manufacturer’s brand name.
Non-Participating Provider (Non-Par) Out-of-Network Provider
A healthcare provider who has not entered into a contract with your insurance provider and is therefore not part of the insurance network.
Amount you pay in the form of deductibles and co-payments for services you or your family receives within a calendar year.
Out-of-Pocket Maximum (or Maximum Out-of-Pocket Expense)
The maximum amount you will have to pay out between the deductible and co-payments for policy covered services before your insurance carrier covers your charges at 100%. Your policy will be divided into an individual out-of-pocket maximum, a family out-of-pocket maximum and a non-participating provider (non-par provider) maximum. If you choose to use an out-of-network provider, you will have to pay more towards your out-of-pocket maximum before your carrier picks up 100% of the amount allowed (100% of what is considered usual and customary.) Your insurance carrier will only apply the amount you have paid for services which are part of your policy benefit and only the amount which is allowed (usual and customary.) You will not be given credit for any payments for services which are not part of your policy or that are above what is considered usual and customary.
The pain scale is an assessment tool used to evaluate a person’s level of distress (whether physical or emotional). The scale may either be based on degrees ranging from 0-10 with “0” being the absence of distress and “10” being extreme distress, or a scale of 0-5 in which “0” is the absence of distress and “5” is extreme distress.
You can see that the 0-10 leaves a lot open for interpretation with respect to the “odd” numbers while the 0-5 scale consolidates your options.
Treatment provided to help relieve the symptoms or discomfort of an individual suffering from a terminal illness. This treatment is not designed to prolong one’s life. It is supported by hospice agencies.
Participating Provider (Par Provider)
Any healthcare provider who has a contract with an insurance plan and is therefore a member of that insurance plan network.
Participating Provider Organization Plan/Policy(PPO)
A form of managed care; a cross between a fee-for-service plan and a health maintenance organization; a group of physicians, healthcare agencies and facilities who have agreed to accept lower/contracted rates with an insurance company in exchange for client referrals. The manager of the plan is the insurance carrier. The plan manager keeps costs down and quality up by contracting services with healthcare providers. Although you are free to choose any healthcare provider you desire, you are given an incentive of lower payments if you choose one of the contracted/PPO providers.
Primary Care Physician(PCP)
a physician contracted by a health maintenance organization (HMO) to coordinate all of your medical care. Primary care physicians typically specialize in family medicine or internal medicine.
The course or outcome of a disease. The prognosis is a prediction of how an illness will progress, or the chance for recovery. It is based on symptoms, co-morbidities (other illnesses present), and past experience of how the primary disease has behaved.
In the case of terminal illness, the recovery phase does not deal with the person becoming well again. It deals with the individual reaching an acceptance of all aspects of your illness.
Being without disease activity for individuals diagnosed with a chronic or terminal illness.
1991 Congressional Act which allows an individual to make their own medical decisions. From this Act, the Advanced Healthcare Directive was created.
Employer insurance plans in which the employer takes on the full risk for financing the health care benefits it provides to its employees. Employers may contract with Third Party Administrators (TPA) such as insurance carriers, to provide certain administrative services such as the processing of claims. May also be referred to as an Administrative Service Only (ASO).
Skilled Nursing Facility (SNF)
A facility which provides long term care for chronically ill patients or patients who are not acutely ill but still require skilled services such as physical rehabilitation, or intravenous antibiotic therapy.
Stages of Grief
Originally introduced by Elisabeth Kubler-Ross in 1969; also known as the Five Stages of Grief. There is no set order or rule which governs the individual’s experience of the five stages outlined by Kubler-Ross. The stages are: denial, anger, bargaining, depression, and acceptance. Although she was referencing the stages in relation to her work with cancer patients in her book “On Death and Dying”, the stages can be applied to many aspects of life.
Death of a loved one may occur without warning, making the grieving process more difficult than if there had time to prepare for the loss.
A restlessness which maybe experienced in the end-phase of a terminal illness.
Terminal illness is an infection or a illness which, despite treatments, will result in death.
The final phase of a terminal illness. The individual experiences a life-threatening event, which may result in the recommendation of hospice care.
Third Party Administrator (TPA)
An independent organization which is contracted by employer groups to provide administrative services such as claims processing to an employer group. Health insurance carriers are one example of a TPA.
Traditional Medicine/Conventional Medicine
also referred to as Western Medicine. The form of medicine practiced by those holding a medical degree (MD) or doctor of osteopathy (DO) and other healthcare providers (nurses, physical therapists, speech therapists, occupational therapists, et. al.) based on applied science.
Usual and Customary Fees
The average rate paid in a geographical area for a particular medical service. Insurance companies may use an individual’s zip code to determine the geographical area then, based on statistical analysis of charges for services within that area, they are able to determine the usual and customary rate.
Utilization Review Accreditation Committee (URAC)
An impartial organization set up to review various healthcare organizations such as insurance carriers. URAC may review a part of an organization (such as case management or credentialing) or the entire organization for quality and standards.
Utilization Review Nurse
Nurse who monitors services provided for medical necessity.