CBO

Congressional Budget Office - Since 1975, CBO has produced independent analyses of budgetary and economic issues to support the Congressional budget process. Each year, the agency’s economists and budget analysts produce dozens of reports and hundreds of cost estimates for proposed legislation.

CBO is strictly nonpartisan; conducts objective, impartial analysis; and hires its employees solely on the basis of professional competence without regard to political affiliation. CBO does not make policy recommendations, and each report and cost estimate summarizes the methodology underlying the analysis.

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CMS

Centers for Medicare and Medicaid Services - The Centers for Medicare & Medicaid Services (CMS) is part of the U.S. Department of Health and Human Services. CMS oversees many federal healthcare programs, including Medicare, Medicaid, Children's Health Insurance Program (CHIP), the meaningful use incentive program for electronic health records (EHR), HIPPA, and MACRA.

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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. CPT codes are used in conjunction with ICD-9-CM or ICD-10-CM numerical diagnostic coding during the electronic medical billing process.

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Cybersecurity

Cybersecurity is the protection of internet-connected systems, including hardware, software and data, from cyberattacks.

DRGs

Diagnosis Related Groups - A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the Inpatient Prospective Payment System (IPPS), hospitals are paid a set fee for treating patients in a single MS-DRG category, regardless of the actual cost of care for the individual. MS-DRGs allow an efficiently operated hospital to earn a reasonable rate of return on a per case basis.

MS-DRGs began fiscal year 2007.

EHR

Electronic Health Record - is an individual's official health document that is shared among multiple facilities and agencies. An EHR contains many data records including: contact information, past visits to providers, allergies, insurance information, family history, immunization status, list of medications, etc.

GDP

Gross Domestic Product - Gross domestic product is the total value of everything produced in the country. In the United States, the Bureau of Economic Analysis measures GDP quarterly.

Healthcare Economics

A branch of economics that is focused on issues related to efficiency, effectiveness, social determinants, value and behavior in the production and consumption of health and healthcare. Health economics is leveraged in measuring cost-effectiveness of new technologies, drugs, delivery, education and behavioral programs that guides design of policy with the intent of improving the general welfare.

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HIPPA

Health Insurance Portability and Accountability Act of 1996 - is United States legislation that provides data privacy and security provisions for safeguarding medical information.

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HIT

The Health Information Technology (HIT) policy committee is a federal committee created by the American Recovery and Reinvestment Act of 2009 (ARRA) that advises the National Coordinator for Health IT on the creation of a nationwide health IT infrastructure.

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HOPPS

Hospital Outpatient Prospective Payment System - Used by CMS to reimburse for hospital outpatient services. The CMS created HOPPS to reduce beneficiary copayments in response to rapidly growing Medicare expenditures for outpatient services and large copayments being made by Medicare beneficiaries.

All covered outpatient services belong to an Ambulatory Payment Classification (APC) group. Each group of procedure (i.e., codes) within an APC is supposed to be “similar clinically and with regard to resource consumption.”

IDTFs

An IDTF is a facility that is independent both of an attending or consulting physician’s office and of a hospital. When an IDTF furnishes diagnostic procedures in a physician’s office, IDTF general coverage and payment policy rules apply.

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IPPS

Inpatient Prospective Payment System - Payment system, defined the Social Security Act, for the operating costs of acute care hospital inpatient stays under Medicare Part A based on prospectively set rates. Under the IPPS, each case is categorized into a diagnosis-related group (DRG). Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG.

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Interoperability

Interoperability is the ability of different systems, devices, applications or products to connect and communicate in a coordinated way, without effort from the end user.

MACRA

Medicare Access and CHIP Reauthorization Act of 2015 - is U.S. healthcare legislation that provides a new framework for reimbursing clinicians who successfully demonstrate value over volume in patient care. The CHIP in the full MACRA name stands for the Children's Health Insurance Program, for which MACRA extends funding.

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Medicaid

Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources and offers benefits not normally covered by Medicare, like nursing home care and personal care services.

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Medicare

Medicare is the federal health insurance program for:

• People who are 65 or older
• Certain younger people with disabilities
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

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Medicare Part A (Hospital Insurance)

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

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Medicare Part B (Medical Insurance)

Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.

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Medicare Part D (Prescription drug coverage

Part D adds prescription drug coverage to:

• Original Medicare
• Some Medicare Cost Plans
• Some Medicare Private-Fee-for-Service Plans
• Medicare Medical Savings Account Plans

These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.

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MIPS

Merit-based Incentive Payment System - Under MIPS, clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule. Performance is measured through the data clinicians report in four areas - Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost.

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MIPS APMs

APM bases payment incentives on performance, cost/utilization, and quality measures. APM entities that participate must have an agreement with CMS and include one or more MIPS eligible clinicians.

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MPFS

Medicare Physician Fee Schedule - CMS uses the MPFS to reimburse physician services associated with: physician work, practictice expense, and professional liability insurance. Under the MPFS, each of these three elements is assigned a Relative Value Unit (RVU) for each Current Procedural Terminology (CPT®) code. These RVUs are then adjusted based on the Geographical Practice Cost Index associated with various geographic areas for different medical costs and wage differentials. The conversion factor is the national dollar amount that is multiplied by the total geographically adjusted RVU to determine the Medicare-allowed payment amount for a particular physician service.

OPPS

The Outpatient Prospective Payment System (OPPS) is the system through which Medicare decides how much money a hospital or community mental health center will get for outpatient care to patients with Medicare. The rate of reimbursement varies with the location of the hospital or clinic.

Per Capita

Per capita means the average per person and is often used in place of per person in statistical observances. The phrase is used with economic data or reporting.

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Price Transparency

Hospitals will have to disclose contracted rates on a set group of procedures and an additional grouping agreed upon with CMS.

RBRVS

Resource Based Relative Value Scale - Physician Fee Schedule payment source for hospital based radiologists (Professional Component), IDTFs, and physician office setting.

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RVU

Relative Value Unit - Rank the resources used to provide each physician service on a common scale. These resources include the physician’s work, the expenses of the physician’s practice, and professional liability insurance. To determine the Medicare fee, a service’s RVUs are multiplied by a dollar conversion factor. Estimating and updating the RVUs is a labor-intensive process because there are no readily available, up-to-date data on the resource requirements of each service.

SURPRISE BILLING

Also known as "Surprise Medical Bill" describes charges arising when an insured person unintentionally receives care from an out-of-network provider. Surprise billing can occur in emergency care where the patient might not choose the ambulance, hospital, etc. This can also occur when a patient receives care from a provider that is not in their network but operates out of an in-network facility.

TRICARE

TRICARE is the health care program for uniformed service members, retirees, and their families around the world. TRICARE provides comprehensive coverage to all beneficiaries, including: Health plans, Special programs, Prescriptions, and Dental plans. Most TRICARE health plans meet the requirements for minimum essential coverage under the Affordable Care Act. TRICARE is managed by the Defense Health Agency under leadership of the Assistant Secretary of Defense (Health Affairs).

Value-Based Healthcare

Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for. Value-based programs also support our three-part aim:

• Better care for individuals
• Better health for populations
• Lower cost

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Volume-Based Healthcare

Volume-based care refers to the payment a health care provider receives for services a patient might need. The type of service and quality of service does not really make a difference in the amount a provider might receive. This is volume-based care in a nutshell, which is sometimes referred to as a fee-for-service care.