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Glossary
For Healthcare Professionals
Accountable Care Organization (ACO)
A group of healthcare providers who work together to improve patient care and reduce costs. They earn rewards for keeping patients healthy and lowering expenses.
Medical Risk Adjustment (MRA)
A method used by insurance companies to estimate healthcare costs based on patient conditions.
Value-Based Contracting
Agreements between healthcare providers and insurance companies that focus on paying for results, not just services.
Care Coordination
The process of organizing a patient’s healthcare services to ensure smooth communication between doctors, nurses, and specialists.
Centers for Disease Control and Prevention (CDC)
A U.S. government agency that works to prevent diseases, protect public health, and promote healthy living.
Chronic Care Management
Ongoing healthcare services provided to patients with long-term conditions, such as diabetes or heart disease, to help them stay healthy.
DME (Durable Medical Equipment)
Medical devices like wheelchairs, oxygen tanks, or walkers that help patients with long-term health needs.
HCC Coding (Hierarchical Condition Category)
A medical coding system used to predict healthcare costs based on patient diagnoses.
Health Equity
The goal of making sure everyone has fair access to healthcare, regardless of income, race, or background.
Medicaid
A government program that provides free or low-cost healthcare to low-income individuals and families.
Medicare
A federal health insurance program for people aged 65 and older or those with certain disabilities.
Medication Reconciliation
The process of reviewing and updating a patient’s medication list to prevent errors and ensure safe treatment.
Network Management
The process of organizing healthcare providers in an insurance plan to ensure quality care at the best cost.
Pay for Performance
A payment model where healthcare providers earn bonuses for meeting quality and efficiency goals.
Payor
A company or government program that pays for healthcare services, such as insurance companies, Medicare, or Medicaid.
Population Health
The study of health trends in groups of people to improve care and prevent disease.
Primary Care
The first point of contact for patients, usually provided by family doctors, pediatricians, or general practitioners.
Provider Incentive
A bonus or reward given to doctors and hospitals for meeting quality or cost-saving goals.
Social Determinants of Health
Non-medical factors like income, education, and housing that affect a person’s health.
Affordable Care Act (ACA)
A U.S. law that makes health insurance more affordable and available to more people, including protections for those with pre-existing conditions.
Behavioral Health Integration
The coordination of mental health and substance use treatment with primary care to improve overall patient well-being.
Center for Medicare and Medicaid Services (CMS)
A federal agency that manages Medicare, Medicaid, and health insurance regulations in the U.S.
Clinical Integrated Network (CIN)
A group of doctors and hospitals that work together to improve patient care while lowering costs.
Emergency Room (ER) Diversion
Programs that help patients get the right care outside of the ER, such as urgent care or telehealth, to reduce unnecessary hospital visits.
End-Stage Renal Disease (ESRD)
The final stage of kidney failure where dialysis or a transplant is needed to survive.
Federally Qualified Health Center (FQHC)
A community health clinic that provides affordable healthcare services, especially for underserved populations.
Formulary
A list of prescription drugs covered by a health insurance plan.
Health Resources and Services Administration (HRSA)
A U.S. agency that helps provide healthcare to underserved communities.
Healthcare Marketplace
A government-run website where people can compare and buy health insurance plans under the Affordable Care Act.
Medical College Admission Test (MCAT)
A standardized exam required for students applying to medical school.
Medical Loss Ratio (MLR)
The percentage of health insurance premiums that must be spent on patient care rather than administrative costs or profits.
Medicare Advantage
A private insurance alternative to Medicare that offers extra benefits like dental and vision coverage.
Patient-Centered Medical Home (PCMH)
A healthcare model that focuses on personalized, coordinated, and accessible care for patients.
Percent of Premium
The percentage of an insurance premium that goes toward covering medical care rather than administrative costs.
Preferred Provider List
A list of doctors, hospitals, and specialists covered by a health insurance plan.
Provider Scorecard
A report that measures a doctor or hospital’s performance based on quality, patient satisfaction, and efficiency.
Quality Improvement
Programs designed to make healthcare safer, more effective, and more patient-friendly.
Risk Management
The process of identifying and reducing potential risks in healthcare to protect patients and providers.
Specialty Care
Healthcare services provided by specialists, such as cardiologists, oncologists, or orthopedic surgeons.
Total Cost of Care (TCOC)
The total amount spent on a patient’s healthcare over a period of time, including doctor visits, hospital stays, and medications.
Transitional Care Management
Support services that help patients move from hospital care back to their home or another care setting safely.
Value-Based Care
A healthcare model that rewards doctors and hospitals for quality and patient outcomes rather than the number of services provided.
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