Alphabet soup

Home Care & Hospice Jargon

Years ago I was a wide eyed college kid sitting in on my first grassroots advocacy meeting in Washington D.C., it was somewhere near 13th and Metro Center. I was an intern for the American Academy of Pediatrics and, along with other interns and paid staff from a bunch of non-profit associations, we were drafting a letter to send to President Clinton before his State of the Union Address. These were great groups; all really wonderful people, looking out for the health and well being of the nation’s most vulnerable.

I was 21, a pretty confident little thing, but I had NO IDEA what they were saying. SO much jargon, so MANY ACRONYMS! Case in point; they kept referring to Hick Va. What the heck is a Hick Va? It seemed really important, and everyone else seemed to know what it was, but I had no idea. It was 1997. I didn’t have a smart phone, I couldn’t google it. Also, google wasn’t invented yet.

What does a kid in that situation do?

Call dad, obviously. I used my Motorola flip phone and called him up.

“Dad, what’s Hick Va? It keeps coming up. It sounds like a cat coughing up a fur ball. Have you heard of it?” He lol’d (except internet slag wasn’t really popular yet either).

“It’s actually HCFA. The Health Care Financing Administration,” and then he took an hour to explain what that was, how it related to Health and Human Services, and who Secretary Donna Shalala was and how other parts of the Administration, like the Department of Aging and Disabilities, were vital to his work with the Home Care and Hospice Agencies back home in Vermont.

Then he told me; start a list.

These will become common phrases to you, but they won’t be for everyone and they constantly change. When you come across a new one, add it in, and then hand it off to the next kid at the table; send that elevator back down.

(If that phrase is new to you, google it, then live by it).

Anyway, my list was created in Windows 95, has been transferred to a 3″ floppy, burned to a couple of CDs and put on a thumb drive. Now it lives in the cloud as a google doc that I can update on the fly with my iPhone. Twenty-one year old me did not see that coming.

Lots has changed; too much has not.

Two decades ago I worked on industry standardization for child safety seats, a public relations campaign for SIDS reduction, and legislation developing Children’s Health Insurance Programs in every state. Two decades ago I understood how industry jargon can get in the way of actual communication, and make someone feel incompetent. Somehow I had forgotten.

I am proud of all the campaigns I have been a part of over the years. Truth is, though, I definitely have not done enough to send that elevator back down. I cannot offer much, but I can offer my list. It’s pasted below. Copy it, share it, make it your own… or ignore it. Then send that elevator back down.

This is MY list, and is in no way endorsed – or proofread- by my employer, the board or any agencies which they may belong. This list is entirely my responsibility. I share it with kindness, only. There will be errors, both in content and spelling. I’m sure there are omissions, and ones that are no longer needed.

Helpful comments welcome 🙂

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Glossary of terms

ADL- Activities of Daily Living

Activities of Daily Living: These are the everyday tasks that individuals do to manage their own personal care. Examples include eating, dressing, using the bathroom and walking.

Adult Day Care: This service provides a protective setting for individuals who are functionally impaired. This care is generally provided during daytime hours and offers a planned program that includes a variety of health, social and support services. Adult day service centers provide a coordinated program of professional and compassionate services for adults in a community-based group setting. Services are designed to provide social and some health services to adults who need supervised care in a safe place outside the home during the day.

Advance Directive: Also known as a living will, this document states a person’s healthcare decisions in the event that person becomes incapacitated and can no longer make these choices.

Aides for Independent Living: These devices or tools make living easier and safer for older persons. Some examples include long-handled shoehorns, touch fasteners on clothing, bathtub stools, and telephone amplifiers. Senior service and healthcare agencies often provide booklets describing such aids and where to purchase them.

Alternate Family Care: Also known as adult foster care, this community-based health program offers room, board, and personal care services to physically impaired individuals who are seeking an alternative to institutionalization. Participants are placed in the homes of carefully screened caregivers who provide supervision and assistance with activities of daily living. Depending on the individual’s needs, placement is on a short- or long-term basis.

Area Agency on Aging: Each area in New Hampshire has an Area Agency on Aging designed to provide information on local community resources for older adults.

Assisted Living: This senior housing option for older adults combines housing, personal care services, and light medical care in an atmosphere of safety and privacy. Based on a monthly fee, basic services typically include meals, laundry, housekeeping, recreation and transportation. Additional services might include help with dressing, bathing, and medication management. Some facilities offer housing to recently discharged hospitalized patients who need to regain strength in a supportive environment before returning to their own home. Assisted living is primarily an out-of-pocket, private pay option, although some facilities accept Medicaid.

ALF – assisted living facilities (ALFs) (above)

AFR- Agency Financial Report (AFR). An annual report of the Department of Health and Human Services’. It provides fiscal and high-level performance results that enable the President, Congress, and American people to assess our accomplishments for each fiscal year (October 1 through September 30). This report provides an overview of our programs, accomplishments, challenges, and management’s accountability for the resources entrusted to us. The report is prepared in accordance with the requirements of Office of Management and Budget (OMB) Circular A-136, Financial Reporting Requirements.

ALJ Hearing – The Office of Medicare Hearings and Appeals (OMHA) is suspending, for at least 24 months, the assignment of new provider requests for Administrative Law Judge (ALJ) hearings on Medicare appeals. Hearing requests from Medicare beneficiaries will still be processed. The reason for the suspension was the “exponential growth in requests for hearings” and the backlog created among the 65 ALJs that hear Medicare appeals. OMHA currently has over 460,000 appeals pending and receives over 15,000 new requests weekly. NAHC reports that agencies that file an ALJ request in January 2014 should not expect a hearing until 2016. The increase in hearing requests is concurrent with the increase in Medicare claims reviews by MACs, along with RACs and ZPICs. NAHC recommends that agencies continue to pursue ALJ appeals they deem appropriate.  

Affinity Groups – people who have the same job function across various agencies

  • CQI- Continuous Quality Improvement, CQI is a management philosophy which contends that most things can be improved.
  • Clinical Directors
  •  BH – Behavioral Health
  •  Private Duty – Non- skilled care. Support patients with ADL’s etc
  • Lymphodema Work Group
  • Hospice Administrators
  •  Rehab- Therapists group- Physical, speech and Occupational therapist (not behavioral)

AO- Accrediting Organizations: Accreditation is a process of review that allows healthcare organizations to demonstrate their ability to meet regulatory requirements and standards established by a recognized accreditation organization. Some Accrediting Organizations in herath care are below.

  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 
  • National Committee for Quality Assurance (NCQA), 
  • American Medical Accreditation Program (AMAP), 
  • American Accreditation HealthCare Commission/Utilization Review Accreditation Commission (AAHC/URAC)
  • Accreditation Association for Ambulatory HealthCare (AAAHC). 
  • Foundation for Accountability (FACCT) 
  • Agency for Healthcare Research and Quality (AHRQ) 

APRN – Advanced practice registered nurses (APRN) are a vital part of the health system of the United States. They are registered nurses educated at Masters or post Masters level and in a specific role and patient population. APRNs are prepared by education and certification to assess, diagnose, and manage patient problems, order tests, and prescribe medications.

BBA- Balanced Budget Act 

BEAs Bureau of Elderly and Adult Services

Board and Care Home (also known as a residential care facility): These homes provide older persons with room and board and, if required, personal assistance with activities of daily living such as medication supervision, meal preparation and other supportive services. This type of housing is typically paid for privately by the individual unless the home accepts and the person qualifies for Medicaid.

BLS: Bureau of Labor & Statistics

Chore Services: Employment or home-care agencies supply workers to perform light housekeeping, minor house repairs, and yard maintenance.

Companion Services: Intermittent or round-the-clock personnel provide support, encouragement and companionship to older adults in their own homes or institutional settings. Some services may provide assistance with daily living activities such as meal preparation, dressing and grooming.

Congregate Housing: This housing option offers private living quarters, usually in a multiunit complex, along with supportive services such as communal meals, personal-care services, and social and recreational activities supervised by a professional staff.

Conservatorship: Also known as “guardianship of the estate,” this court process secures an individual’s right to manage another person’s financial affairs after that person has become unable to do so and a power of attorney or trust has not been established.

Continuing Care Retirement Community: This senior housing option offers a comprehensive continuum of care from independent living to skilled care in a nursing home. Typically, the able-bodied person enters an apartment or cottage and, as needs increase, proceeds through increasing levels of care. There are requirements for incoming residents based on age, financial assets, income, as well as physical health and mobility. All require substantial entrance fees in addition to fluctuating monthly rent.

CHAMP – the Collaboration for Home Care Advances in Management & Practice, the CHAMP Program was the first national initiative to advance home care excellence for older people. CHAMP’s goal was to make the latest evidence based tools, e-learning and expert advice easily accessible to home care clinicians, from any computer.  

CHIP- Children’s Health Insurance Program

CEU- A continuing education unit (CEU) or continuing education credit (CEC) is a measure used in continuing education programs to assist the professional to maintain his or her license in their profession. Also, CEH Continuing education hour.

CPM: Cost per Minute

CNA- Certified Nursing Assistant: A CNA or certified nursing assistant is an individual who studied and passed the licensure exam for nursing assistant. He or she assists the patients in providing health care needs and supervised by a Licensed Practical Nurse or a Registered Nurse.

Custodial Care or Personal Care: Residents depending upon custodial care receive supervision and assistance with personal care and other activities of daily living. This level of care is suitable for people who do not need the care of a practical nurse. Often this level of care is provided for people suffering from illnesses such as Alzheimer’s disease.

CFI- The Choices For Independence Program (formerly known as the Home and Community-Based Care program for the Elderly and Chronically Ill, or HCBC-ECI) is available for seniors and adults with chronic illnesses who are financially eligible for Medicaid and medically qualify for the level of care provided in nursing facilities.

CMS-Centers for Medicare and Medicaid Studies – The Centers for Medicare & Medicaid Services (CMS)  is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children’s Health Insurance Program (CHIP), and health insurance portability standards. In addition to these programs, CMS has other responsibilities, including the administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA), quality standards in home care and long-term care facilities, through its survey and certification process, clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments, and oversight of

CoP- Conditions of Participation. The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule in the October 24 Federal Register that revises the requirements – commonly referred to as Conditions of Participation (CoPs) – that hospitals and critical access hospitals must meet to participate in the Medicare and Medicaid Programs.

 CWF- Common working File

CY: Calendar Year

 DHHS- Dept of Health and Human Services

Durable Medical Equipment (DME): Doctors can order this medical equipment for home use. These items are reusable such as walkers, wheelchairs, or hospital beds. The equipment is available for rent or purchase depending upon the user’s financial status and insurance coverage.

Elder Lawyers: These law professionals specialize in the comprehensive planning for the needs of older adults and their families. Examples include estate planning, Medicaid and asset protection planning, power of attorney, living wills and legal housing contracts.

Geriatric Care Manager: This professional is trained to assess a person’s total-care needs and to arrange necessary services. Care managers typically evaluate the older person’s situation, make recommendations, arrange appropriate services and keep family members informed. Since care problems rarely occur one at a time and services may be fragmented, this service can be used by caregivers to coordinate a care plan. There is a fee for this service and each individual care manager determines rates.

FFS – fee-for-service (FFS)

FI (Fiscal Intermediary) for Region 1 – Starting last October the company that handles home health and hospice claims (basically payments) was changed from NHIC to National Government Services, Inc (NGS). Last  February, CMS awarded its Region 1, 5-year, $493.2 million contact to NGS. I doubt that there has been much impact since NGS contracted many of the tasks to NHIC anyway. The fear by some agencies is that the new company, which is located out of New England, will not be as responsive as was NHIC, which is based in Maine. 

FISS– Fiscal Intermediary Standard System

HCPCS – Healthcare Common Procedure Coding System, HCPCS is an acronym for Healthcare Common Procedure Coding System (HCPCS). Standardized code sets are necessary for Medicare and other health insurance providers to provide healthcare claims that are managed consistently and in an orderly manner.

HH: Home Health

HHA: Home Health Agency

HHRGs: Home Health Resource Groups

HHS:  The United States Department of Health & Human Services (HHS), also known as the Health Department, is a cabinet-level department of the U.S. federal government with the goal of protecting the health of all Americans and providing essential human services.

HH PPS: Home Health Prospective Payment System

HHVBP (Home Health Value Based Purchasing): The overall purpose of the HHVBP Model is to improve the quality and delivery of home health care services to Medicare beneficiaries with specific goals to: … study new potential quality and efficiency measures for appropriateness in the home health setting; and, enhance the current public reporting process. See also Value Based Purchasing

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

HIPPS: Health Insurance Prospective Payment System

Home Care: Trained personnel from home-health agencies, the Visiting Nurses Association, and public health departments provide in-home health and supportive services including nursing, therapies, and assistance with personal care. 

Home health aides (HHA)- provide personal care for patients who need assistance for a variety of reasons including illness, advanced age, disability, or cognitive impairment. Home health aides may work with patients as part of a hospice care program also.

Home Modifications: Adaptations are made in the home to accommodate changing physical needs. Examples include installing grab bars and handrails by the bathtub and toilet, enlarging doorways and installing ramps for wheelchairs. Many home-health agencies have professionals on staff who can help evaluate a home and recommend modifications.

Hospice: This program provides supportive care with an emphasis on pain relief and comfort for terminally ill persons and their families. Services may be provided at home or in a facility. End of life care. Not curative in nature.

IADL- Instrumental Activities of Daily Living: These are tasks that enable people to live independently in the community. Examples include shopping, cooking and house cleaning.

ICD-9 CM to ICD-10- the old format of recording data to the new (below)

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.

Intermediate Care: Residents requiring intermediate care receive assistance with activities of daily living, some health services and nursing supervision, but not constant nursing care. Care is ordered by a physician and supervised by a registered nurse.

IUR- Informational Unsolicited Response

IV: Intravenous

Level II  G Codes: Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician’s office. (see also HCPCS)

LUPALow Utilization Payment Adjustment. CMS has announced a hold on LUPA payments. (Home care gets paid two ways, mostly by PPS payments – Prospective Payment System – which are basically payments that cover 60 days of care – I think there are 162 possible payments, depending on the diagnosis –   However, for patients who have 5 or fewer visits in 60 days, the agency gets a per visit payment for these patients rather than a two-month payment -LUPA stands for Low Utilization Payment Adjustment – basically 5 visits or fewer.) According to Bill Dombi at NAHC, Medicare contractors have identified an incorrect payment calculation affecting LUPA home health claims. To prevent incorrect payments Medicare contractors will hold all home health LUPA claims until the Medicare systems are corrected. This correction should occur in early February, 2014.  Home health agencies do not need to take any action. Medicare contractors will release the claims as soon as the correction is complete.

Long-Term Care Insurance: These privately sold insurance policies help pay for long-term care services such as home-health care, adult day care, respite care and nursing home care.

MAC- Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.  CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.  MACs perform many activities including:

MCOs–  Managed Care Organizations

MMCAC– Medicaid Medical Care Advisory Committee

MAC– From the Medicare Modernization rule of 2003, CMS began replacing Part A FIs and Part B carriers with Medicare Administrative Contractors (MACs).  Contracting reform was intended to improve Medicare’s administrative services to beneficiaries and health care providers through the use of new contracting tools including competition and performance incentives. Medicare Administrative Contractor are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.

Market Basket: It’s a formula from CMS to calculate & update payments and cost limits in the various CMS payment systems. The market basket is described as a fixed-weight index because it answers the question of how much more or less it would cost, at a later time, to purchase the same mix of goods and services that was purchased in a base period. As such, it measures “pure” price changes only. A market basket is constructed in three steps. First, a base period is selected and total base period expenditures are estimated for mutually exclusive and exhaustive spending categories based upon type of expenditure. Then the proportion for total costs that each spending category represents is determined. These proportions are called cost or expenditure weights. The second step is to match each expenditure category to an appropriate price/wage variable, called a price proxy. In the third and final step, the price level for each spending category price proxy is multiplied by the expenditure weight for that category. The sum of these products (that is, weights multiplied by proxied index levels) for all cost categories yields the composite index level in the market basket in a given year. The CMS market baskets reflect input price inflation facing providers in the provision of medical services

MMIS Medicaid Management Information Systems, MMIS-Health Enterprise System: NH MMIS is a web-based healthcare administration application that gives patients, doctors, pharmacists, and others efficient and secured access to healthcare information using only a Web browser.

Meaningful Measures Initiative: Centers for Medicare and Medicaid Services’ nitiative which identifies the highest priorities for quality measurement and improvement. It involves only assessing those core issues that are the most critical to providing high-quality care and improving individual outcomes

Medicaid: This state administered health program is designed to cover the healthcare needs of low-income people. It is financed with federal, state and local tax funds. Medicaid pays an eligible patient’s medical bills, in whole or in part, directly to the provider of healthcare services and suppliers (physicians, hospitals, pharmacists, etc.).

Medicare Managed Care: Also known as Medicare HMO, Medicare managed care is a healthcare option available as part of Medicare benefits. When enrolled in a Medicare managed care plan, the person selects a doctor from the plan’s list of primary care physicians. The chosen primary care physician is responsible for coordinating all of the person’s healthcare needs.

Medicare: This is a federal health insurance program for people 65 years old or over and for certain disabled people under 65. A person is automatically enrolled in Medicare hospital insurance (Part A) when he or she applies for Social Security benefits upon reaching 65. Part A covers inpatient care in a hospital or skilled nursing facility for a limited period of time. Part B covers doctor’s services and outpatient hospital services. This is paid for out of the enrollee’s Social Security. Medicare does not pay full cost of some covered services. For this reason, it is important to have a Medicare Supplement or Medigap insurance (see definition below).

Medicare Supplement: Also known as Medigap insurance, this privately sold insurance policy fills the “gaps” in Medicare coverage. There are 10 standardized policies labeled Plan A through J. Medigap policies only work with the Medicare plan.

MedPAC- The Medicare Payment Advisory Commission (

Merit-based Incentive Payment System (MIPS) quality performance category accounts for 45% of a clinician’s or group’s performance in 2019. Selecting appropriate quality measures can be challenging, especially when trying to determine how your performance will translate to a MIPS score.

MFP-Money Follows the Person (MFP) Rebalancing Demonstration Grant helps states rebalance their Medicaid long-term care systems

MMTA: Medication Management Assessment

MS: Musculoskeletal

MSS: Medical Social Services

Nursing Home: (also Skilled Nursing Facility – SNF) Also known as a long-term care facility or nursing and rehabilitation center, this facility provides continuous nursing care or 24-hour supervision. Most nursing homes provide rehabilitation programs as well as social activities. Care is generally provided on two or three levels including the following.

NAHC – National Association for Home Care

NEHCC- New England Home Health and Hospice Conference and Trade Show

NHDHHS– NH Department of Health and Human Services

NPPES: National Plan and Provider Enumeration System– assigns unique identifiers for health care in compliance with HIPPA

NGS- National Governmental Services- National Government Services, Inc. provides Medicare contracting services. … It serves providers, suppliers, and members of congress, as well as people with Medicare in the United States

NRS: Non-Routine Supplies

OASIS– Outcome and Assessment Information Set (OASIS) is the patient-specific, standardized assessment used in Medicare. 

OMB- Office of Management and Budget (OMB)

OMHA – Office of Medicare Hearings and Appeals – MHA administers appeal hearings for the Medicare program.  There are five levels in the Medicare claims appeal process.  OMHA’s Administrative Law Judges hold hearings and issue decisions related to Medicare coverage determinations that reach Level 3 of the Medicare claims appeal process.  This Web site was created to help you learn more about Level 3 appeals.  Basic descriptions of the other levels are also provided, to assist you in understanding the appeal process.

OIG- Office of Inspector General (OIG). The U.S. has issued its fiscal year 2014 Work Plan. Concerning Medicaid Home Health, OIG will review home health agency claims to state Medicaid programs to determine whether the billing providers met applicable criteria to provide home health services to Medicaid beneficiaries, and will also determine whether the beneficiaries met the criteria to receive such services. OIG also will review compliance with various aspects of the home health prospective payment system (PPS), including the documentation required in support of the claims paid by Medicare, and will determine whether home health claims were paid in accordance with federal laws and regulations.

Concerning Hospice in Assisted Living, OIG will review the extent to which hospices serve Medicare beneficiaries who reside in assisted living facilities (ALFs). OIG will determine the length of stay, levels of care received, and common terminal illnesses of beneficiaries who receive hospice care in ALFs. OIG also will assess the appropriateness of hospices’ general inpatient care claims and the content of election statements for hospice beneficiaries who receive general inpatient care. It will also review hospice medical records to ensure proper use of this level of hospice care.

OT: Occupational Therapy

Palliative Care: This term is used to describe a type of comprehensive medical care for people with life-ending illnesses. The goal is to ease the patient’s physical, emotional, social and spiritual suffering, as well as to support families. Like hospice, this type of care can be provided in various settings such as hospitals, nursing homes, or the patient’s home. Palliative care can begin after a doctor certifies a patient’s life expectancy is six months or less.

PDGM: Patient Driven Groupings Model: CMS is moving home health agencies away from a volume-based payment model and to a new value-based payment system. The Patient-Driven Groupings Model (PDGM) would focus on patient needs and rely more heavily on patient characteristics in order to pay for home health services. Under prospective payment, Medicare pays home health agencies (HHAs) a predetermined base payment. The payment is adjusted for the health condition and care needs of the beneficiary. The payment is also adjusted for geographic differences in wages for HHAs across the country. 

PECOS Edit Began January 6th (from CMS) – On January 6, 2014 was the activation of the Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To get the homecare payments the physician who orders the care must be enrolled in PECOS (basically electronic relay of information – Medicare doesn’t want paper anymore). Apparently that is a problem for some agencies because their physicians have not yet enrolled. If the care is based on a care order from a non-enrolled physician, payment will be denied. In order to protect against non-payment by Medicare, home health agencies must verify enrollment of all ordering physicians. 

PECOS Claims Denials  – CMS has clarified in a recent communication (MLN Matters Article SE 1305) that claims denied because they failed the ordering/referring edit will not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice (notice sent to the patient that they may be liable for payment) is not appropriate in this situation. CMS also said in the memo that since the beneficiary cannot be held liable for services ordered by a provider who is not registered in PECOS, no notice is to be given because the beneficiary cannot be charged.

CMS’ position would prohibit the beneficiary from choosing to privately pay for services even if informed of Medicare non-payment in advance of the initiation of care. HCAF advises that home health agencies should not initiate services for beneficiaries who are unable to identify a PECOS-enrolled physician to assume ordering responsibilities for episodes of care beginning on and after.

Physician Fee Schedule: A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis.

PPS– A Prospective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups for inpatient hospital services)

PEPPER – Program for Evaluating Payment Patterns Electronic Report – PEPPER provides provider-specific Medicare data statistics for discharges/services vulnerable to improper payments. PEPPER can support a hospital or facility’s compliance efforts by identifying where it is an outlier for these risk areas. This data can help identify both potential overpayments as well as potential underpayments

PERM (Payment Error Rate Measurement). The Office of Management and Budget (OMB) has identified Medicaid and the Children’s Health Insurance Program (CHIP) as programs at risk for significant improper payments. As a result, CMS developed the Payment Error Rate Measurement (PERM) program to comply with the IPIA, IPERA, IPERIA and related guidance issued by OMB. The PERM program measures improper payments in Medicaid and CHIP and produces error rates for each program. The error rates are based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP in the fiscal year (FY) under review. It is important to note that the error rate is not a “fraud rate” but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements. CMS and HHS report improper payments annually in the Agency Financial Report (AFR)

Personal Care or Custodial Care: Residents depending upon custodial care receive supervision and assistance with personal care and other activities of daily living. This level of care is suitable for people who do not need the care of a practical nurse. Often this level of care is provided for people suffering from illnesses such as Alzheimer’s disease.

Personal Care Assistant (PCA): variously known under alternate names such as caregiver, personal care attendant, patient care assistant, personal support worker and home care aide – is a paid, employed person who helps persons who are disabled or chronically ill with their activities of daily living (ADLs) whether within the home, outside the home, or both. They assist clients with personal, physical mobility and therapeutic care needs, usually as per care plans established by a rehabilitation health practitioner, social worker or other health care professional.

Personal Emergency Response System: This is an electronic monitoring system in which a person carries a device that he or she can use to signal a central dispatcher in the event of a fall or the need for help. Emergency assistance is summoned if the person does not answer the telephone (or speakerphone). Help is available 24 hours a day.

Power of Attorney: This is a document by which one person (the principal) authorizes (the agent) to act legally on his or her behalf.

Probe and Educate (Targeted Probe and Educate) – In June 2016, CMS began a pilot program in one MAC jurisdiction called Targeted Probe and Educate (TPE).  This program is a medical review strategy that was intended to alleviate some of the burden for providers undergoing medical record review.  In July 2017, CMS expanded the program to three (3) additional MAC jurisdictions. The pilot has been such a success that as of October 1, 2017, the program has been expanded to all MAC jurisdictions.

Rather than reviewing all providers for a particular service as has been the previous strategy for medical record review, under TPE MACs will select claims that have a high financial risk for Medicare or that nationally have a high error rate.  The MACs will then focus only on those providers who have the highest error rates or whose billing practices designate them as outliers. The selection of specific claims/services and providers will be determined by detailed data analysis. The TPE process will include an initial review of 20-40 claims. 

PT- Physical Therapy

QIN-QIO- The QIO Program’s 14 Quality Innovation Network-QIOs (QINQIOs) bring Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality. The New England Quality Innovation Network-Quality Improvement Organization (NE QIN-QIO) is a collaborative effort between Healthcentric Advisors and Qualidigm.

QPP- The Quality Payment Program (QPP): was created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The QPP transforms the Medicare physician payment system from one focused on volume to one focused on value.

Request for anticipated payment (RAP): under HH PPS. Effective for dates of service on or after October 1, 2000, home health services under a plan of care are paid based on a 60-day episode of care. Payment for this episode is usually made in two parts.

Rebasing: Under the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) is authorized to rebase home health payments between 2014 and 2017.   Rebasing is a process intended to align Medicare payment with costs. However, new data analyses find that current law Medicare home health cuts will cause the change intended by rebasing. Moreover, the analyses reveal that this current law trajectory will lead to negative margins in a number of states by 2017 – even if CMS does not reduce home health payments further as a result of the rebasing process.

Residential care facility: These homes provide older persons with room and board and, if required, personal assistance with activities of daily living such as medication supervision, meal preparation and other supportive services. This type of housing is typically paid for privately by the individual unless the home accepts and the person qualifies for Medicaid.

Rehabilitation Services: Trained professionals provide treatment to help disabled individuals attain maximum function, a sense of well being and a personally satisfying level of independence. Any disease or injury that causes mental or physical impairment serious enough to result in disability may require rehabilitation.

Respite Care: This general term is used to describe a variety of services that provide relief and free time to primary caregivers of a functionally disabled person. Respite services are offered through adult day health care, home care, and short term stays in a nursing home or rehabilitation center. Respite care is available for varying lengths of time from a few hours to several days.

Reverse Mortgages: This mortgage tool allows people to live off the equity of their home. Participants receive a monthly payment based on the equity they’ve put into their home. Loans are backed by the federal government and only given to people age 62 and older. The loan is not satisfied until the home is sold.

Senior Center: These community centers provide social, recreational and educational activities.

Skilled Care: Residents in need of skilled care receive skilled nursing care or rehabilitation and 24-hour medical supervision, but do not require hospitalization. A physician order is required for admission.

SLP: Speech Language Pathologist

SN: Skilled Nursing

SNF- Skilled Nursing Facility, Also known as a long term care home (nursing home, skilled  care facility or nursing and rehabilitation center), this facility provides continuous nursing care or 24-hour supervision. Most nursing homes provide rehabilitation programs as well as social activities. Care is generally provided on two or three levels including the following.

Transitional Care: Also known as sub-acute care, this comprehensive inpatient rehabilitation program is designed for individuals in need of special care due to illness, injury or disease (ie. a stroke, head trauma or kidney disease). Typically, the patient has a specific course of treatment and does not require intensive diagnostic or invasive procedures. In many cases, patients who participate in sub-acute care are rehabilitated and returned home.

Transportation Services: Senior centers or social service agencies in the community often provide transportation for free or for a minimal charge between an older adult’s home and senior centers, shopping malls and physician appointments.

Trust: This three-party agreement details the transfer of designated assets from one person (the grantor) to another person (the trustee). The trustee holds and manages the assets for the benefit of the third party (the beneficiary).

Value Based Purchasing- (VBP): is a methodology of healthcare payment reform that focuses on paying providers for quality and value, not just volume. Sometimes referred to as “pay-for-performance” (P4P), value-based purchasing is becoming the new normal in healthcare, linking provider reimbursements to quality measures and cost-efficiency.The traditional fee-for-service (FFS) payment model is “morphing” into alternative payment models (APMs) that increase provider accountability for both quality and total cost of care, while requiring a greater focus on population health management. Cheryl L. Damberg, et al., explains that value-based purchasing “refers to a broad set of performance-based payment strategies that link financial incentives to providers’ improvements in quality and slowing the growth in health care spending

WWMC: Wage Weighted Minutes

Wellness Centers/Programs: Healthcare organizations and hospitals often sponsor wellness centers or programs to help people achieve a healthy lifestyle both mentally and physically.

Will: This legal document states how an individual’s estate will be handled after death.XEROX- one of NH Medicaid Management Information System (MMIS).