November 27, 2019
Even if you’ve worked in healthcare or the insurance industry for years, there are a lot of different acronyms and terminology and it can be challenging to remember every meaning.
Even the simplest of terms–HMO and PPO–get mixed up. A health maintenance organization, or HMO, is a medical insurance group that offers healthcare services through a set group of providers. PPO, on the other hand, stands for the preferred provider organization. PPOs partner with health insurance companies or third-party administrators to provide healthcare to members at reduced rates.
Here’s a brief overview of a few common healthcare terms to brush up your knowledge:
The Office of the National Coordinator for Health Information Technology (ONC) defines EHRs, or electronic health records, as “digital versions of a patient’s paper chart and real-time, patient-centered records that make information available instantly and securely to authorized users.” Electronic medical records (EMRs), though similar to EHRs, are “electronic records of health-related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff within one health care organization.”
An acronym for the Health Insurance Portability and Accountability Act of 1996, HIPAA was enacted to protect the privacy and security in the electronic exchange of a patient’s health information. You’ve probably had to sign a HIPAA form at your doctor’s office more than once. Though it may seem tedious, it’s especially important in reducing the chances of your personal information being released. The act was expanded in 2009, adding in the HITECH (Health Information Technology for Economic and Clinical Health) Act. This was adapted to fit developments in EHRs and encourage providers to make the switch from paper to electronic records.
According to the Institute for Healthcare Improvement (IHI), the term population health management describes the work by healthcare organizations to improve outcomes for individual patients to maximize population health. By empowering members of a specific population to better manage their own health, the need for costly hospitalizations, procedures, tests and other healthcare can be reduced. This is especially important with the high cost of healthcare in the United States.
Gartner defines IoT as “the network of physical objects that contain embedded technology to communicate and sense or interact with their internal states or the external environment.” The global research and advisory firm forecasts that the total of connected devices will reach 25 billion by 2021. Examples of IoT devices in healthcare, also referred to as IoMT or the Internet of Medical Things, include wearables, smart televisions and ingestible sensors.
Cornell Law School’s Legal Information Institute describes a delegated entity as “any party, including an agent or broker, that enters into an agreement with a qualified health plan (QHP) issuer to provide administrative services or healthcare services to qualified individuals, qualified employers or qualified employees and their dependents.” A QHP is one that’s certified by the Health Insurance Marketplace and is compliant with the protections and requirements of the Affordable Care Act (ACA).
As we’ve discussed in previous blogs, IROs are designed to streamline the process of medical review and help ensure patients receive appropriate and necessary care. They serve multiple functions, most notably serving as unbiased, third-party reviewers of denied medical claims to determine whether or not a healthcare service is appropriate, medically necessary and or in compliance with a carrier’s plan or with applicable guidelines.
In one of our blogs last year, we outlined the differences between IME and IMR, or independent medical review. IMEs, conducted by medical providers, involves a physical exam by an independent physician who also reviews the medical history of the case. IMRs are a right provided to health plan members as part of the ACA and are used to determine coverage of medical necessity, experimental and/or investigational treatments, preexisting conditions and similar issues.
While the phrase “peer review” can have several different applications, independent medical peer review is the process through which a patient’s chart undergoes an evidence-based clinical review by a physician or allied health care provider. Peer review involves physician matching by state and specialty for the chart review, and its aim is to ensure the patient is given appropriate and necessary treatment that adheres to specific evidence-based medical guidelines and/or state and federal requirements. This also may include the reviewing physician contacting the original physician to discuss the medical care given for a complete understanding of the patient’s care.
Peer review can also refer to the professional and confidential evaluation of a physician’s job performance. This process is often done through internal or external peer review committees comprised of physicians with varying backgrounds and disciplines. Its goal is to improve the level of care provided by individual practitioners and monitor their performance.
At Advanced Medical Review, we set the industry standard in providing quality independent medical case reviews that are timely, customizable and affordable. Contact us today to learn about the advantages we offer, including our AMR Client Portal.
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