Frequently Asked Questions
In the more recent past, a large percentage of CHSR work has focused
around government organizations. However, the CHSR has actively assisted
many industry for-profit and not-for-profit business in areas such
as practice, operations and strategic management, information systems,
and quality assurance and utilization review processes. As the CHSR
is housed within the auspices of the J. Mack Robinson College of Business,
the CHSR is able to stay abreast of the leading issues in the business
arena and assist companies and organizations in developing solutions
to the problems that many face.
Federal law and regulations require States to use an External Quality
Review Organization to review the care provided by capitated managed
care entities. EQRO's may be Peer Review Organizations (PROs), another
entity that meets PRO requirements, or a private accreditation body.
HEDIS is a collection of performance measures and their definitions/criteria
produced by the National Committee for Quality Assurance (NCQA).
HEDIS measures may be applied to both FFS and encounter data.
A Managed Care Organization (MCO) contracts with individuals, employers,
unions, and other purchasers to provide comprehensive health care
services to people who enroll in the plan. This contract is known
as the health insurance policy or subscriber agreement. The 'purchaser
pays the MCO a fixed fee each month per individual or family. The
enrolled individuals who become known as "members' or 'enrollees,"
may be responsible for paying all or a portion of the fixed fee,
depending on whether they have purchased the policy themselves or
whether h is offered by their employer or union as part of an employee
benefits package. Based on employment or contractual arrangements
with health care professionals, the MCO delivers or arranges for
the delivery of health care services using various mechanisms to
control the cost and use of health care services.
An IPA is a group of physicians who form a legal entity to deliver
medical care through contractual arrangements with MCOs or purchasers,
usually on a capitated basis. Physicians are generally required
to contribute dues or in-kind donations as a condition of participation
in the IPA, or are offered stock in the IPA and become its shareholders.
Hospitals involved in the development of many IPAs and provide initial
capital for start- up expenses, donate office space, and make financial
loans. Like any corporation, an IPA will create a board of directors
and various committees to oversee the operations of the organization.
Administrative Simplification is Subtitle II of HIPAA related to
patient information privacy, security, and confidentiality and health
data standardization.
BBA represents the Balanced Budget Act (I997).
CDC represents Centers for Disease Control and Prevention.
CPG represents Clinical Practice Guidelines.
CPT represents Common Procedural Terminology.
EBM represents Evidence-based Medicine.
ECOR represents External Quality Review Organization.
EDS is the fiscal agent for the Georgia Department of Community
Health.
EPSDT represents Early Periodic Screening, Diagnosis, and Treatment.
FFS represents Fee-for-Service.
HCFA represents Health Care Financing Administration.
HCFA 1500 is a claim form for Professional Health Services.
HEDIS represents Health Plan Employer Data and Information Set.
HIPAA represents Health Insurance Portability and Accountability
Act (I996).
HMO represents Health Maintenance Organization.
IOM represents Institute of Medicine
IPA represents Independent Practice Association.
MMIS represents Medicaid Management Information System.
MCPDP / ADA represents National Council for Prescription Drug Programs
and American Dental Association respectively.
NCQA represents National Committee on Quality Assurance.
NIH represents National Institute of Health.
PCCM represents Primary Care Case Management.
PCCMP represents Primary Care Case Management Provider.
PCP represents Primary Care Provider
PFA represents Partnership for Health and Accountability.
PHO represents Physician-Hospital Organization.
PPMCS represents Physician Practice Management Companies.
PPO represents Preferred Provider Organization.
PHP represents Prepaid Health Plan
PSO represents Provider Sponsored Organization.
QISMC represents Quality Improvement Systems for Managed Care.
TPA represents Third Party Administrator.
UB92 represents the HCFA Uniform Bill 92 form.
URO represents Utilization Review Organization.
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