Healthcare Industry Terminology Every SDR Should Know

Accountable Care Organization (ACO)
Healthcare organization that ties payments to quality metrics and the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation. They collaborate voluntarily to give high-quality care to a designated group of patients. More than half of community hospitals are in an ACO.

Academic Medical Centers (AMCs)
Different than Community Medical Centers, an Academic Medical Center is a tertiary care hospital that is organizationally and administratively integrated with a medical school. Typically, due to a higher percentage of uncompensated services, AMCs have above average cost and narrow margins.

ADT Feed
Captures important elements pertaining to a patient’s demographic and clinical information, from their name and address to their medical record number. The messages usually communicate a patient’s demographics and status (admitted, discharged, or transferred).

Adult Gerontology Acute Care Nurse Practitioner (AGANCP)
The patient population of the adult gerontology acute care nurse practitioner (AGACNP) includes young adults (late adolescents and emancipated minors), adults, and older adults. AGACNP disciplines include cardiology, pulmonary, neurology, hematology/oncology, ENT, surgery services, palliative care, and pain management. New practice areas for AGACNPs are hospitalists and surgical first assistants, which is reflective of the diverse practice opportunities available to meet the needs of acutely ill patients.

American Psychiatric Association (APA)
It is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. The association publishes various journals and pamphlets as guides to mental disorders.

Birth Center
A birth center is a healthcare facility, staffed by nurse midwives, midwives and/or obstetricians, for mothers in labor, who may be assisted by doulas and coaches. By attending the laboring mother, the doulas can assist the midwives and make the birth easier.

Bundled Payments
A comprehensive payment covering the costs of all applicable services and other appropriate services furnished to an individual during an episode of care. (source: NCHA.org)

Bundled Payments for Care Improvement (BPCI)
This initiative is comprised of four broadly defined models of care, which link payments for the multiple services Medicare beneficiaries receive during an episode of care.

Capital Expenditure (CAPEX)
The money an organization or corporate entity spends to buy, maintain, or improve its fixed assets. It is considered a capital expenditure when the asset is newly purchased or when money is used towards extending the useful life of an existing asset.

Capitation
The payment of a fee or grant to a doctor, or other person or body providing services to a number of people, such that the amount paid is determined by the number of patients, students, or customers.

Centers for Medicare and Medicaid Services (CMS)
As part of the Department of Health and Human Services, the CMS is responsible for serving the public to advance health equity, expand coverage, and improve healthcare outcomes.

Certified Nurse Midwives (CNM)
CNMs provide care of women across their lifespan, including pregnancy and the postpartum period, and well woman care and birth control.

Children’s Health Insurance Program (CHIP)
This program provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. Each state offers a form of CHIP coverage with some covering pregnant woman. The program works closely with their respective state Medicaid program.

Clinical Blocks
As an alternative to traditional residency, blocks allow students take one course at a time to fully focus on the content area, such as cardiovascular, respiratory, renal, gastrointestinal, endocrine, reproductive, musculoskeletal, integumentary, human behavior and the nervous system. The course work runs concurrently with the blocks. This method is designed to give students a complete understanding of each discipline before moving on to the next course.

Clinical Rotations
Designed to turn classroom theory into practice, rotations occur in the third and fourth years of medical school. Clinical rotations give medical students real world experience while they learn the specialties they have selected. As members of a medical team, they learn what is involved in the daily life of a healthcare worker.

Community Medical Center (CMC)
A CMC is a non-academic provider such as a community hospital. CMCs have patient populations that are mostly made up of privately insured individuals. Their staff members may be more generalist than specialists. CMCs are more focused on efficiency and treat a greater number of patients than their AMC counterparts. This blog post by George Washington University compares CMCs to AMCs.

Current Procedural Terminology Code (CPT code)
They describe medical, surgical, and diagnostic services and are designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. Identifies the services rendered.

Deductible
The amount a consumer owes for healthcare services before the health insurance or plan begins to pay.

Diagnosis Code
Diagnostic coding is the translation of written descriptions of diseases, illnesses, and injuries into codes from a particular classification.

Diagnosis Related Group (DRG)
A system which classifies hospital cases according to certain groups, also referred to as DRGs, which are expected to have similar hospital resource use (cost).

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition [DSM-5] 
Last updated in 2013, DSM-5 is the American Psychiatric Association’s authoritative guidance on classifying mental disorders to help improve diagnosis, treatment, and research.  Most government and private payers require clinical documentation to be compliant with DSM-5 criteria.

Doctor of Osteopathic Medicine (DO)
DO stands for “Doctor of Osteopathic Medicine,” and refers to a doctor who practices medicine whose medical school training included a focus on the muscular and skeletal systems to treat problems throughout the body.

Durable Medical Equipment (DME)
Equipment or supplies used by a health care provider for everyday use are durable medical equipment (DME). Coverage for DME may include oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics.

Electronic Health Record (EHR)
Digital records of health information. They contain all the information you’d find in a paper chart — and a lot more. EHRs include past medical history, vital signs, progress notes, diagnoses, medications, immunization dates, allergies, lab data and imaging reports. They can also contain other relevant information, such as insurance information, demographic data, and even data imported from personal wellness devices

Electronic Medical Record (EMR)
The legal patient record created in hospitals and ambulatory environments, which is the data source for the EHR.

Emergency Nurse Practitioner (ENP)
Emergency nursing is a specialty within the field of professional nursing focusing on the care of patients who require prompt medical attention to avoid long-term disability or death. ENPs typically practice in EDs or urgent care settings.

Employed Physician Practices
Increasingly, physicians are being employed within one of several practice models. Some hospitals may purchase and manage existing solo or group practices or may directly hire physicians to work in their inpatient facility or ambulatory clinics. Health care corporations may own and run clinics with employed physicians. And some physician-run groups are structured on an employment model, where a group practice is structured more like a corporation that employs clinicians instead of pursuing a more traditional partnership model.

Episode of Care
An interval of care by a provider for a specific medical issue. It may be continuous or it may consist of a series of intervals with brief pauses in care.

Family Nurse Practitioner (FNP)
Family nurse practitioners (FNP) are advanced practice registered nurses who work autonomously or in collaboration with other healthcare professionals to deliver family-focused care.

Federal Qualified Health Center (FQHC)
FQHCs are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas.

Fee-for-Service
A system of health insurance payment in which a doctor or other health care provider is paid a fee for each particular service rendered, essentially rewarding medical providers for volume and quantity of services provided, regardless of the outcome.

Fellowship
A fellowship follows a physician’s completed residency, or specialty training program. Fellows can act as an attending physician or consultant physician in their chosen specialty. After completion of their fellowship, the physician is permitted to practice without the supervision of another physician in the given specialty.

General Practitioner (GP)
An attending physician whose practice is based on a broad understanding of all illnesses and not limited to a particular specialty or field of medicine.

Generalized Anxiety Disorder 7 [GAD7]
A self-reported questionnaire for screening and severity measuring of generalized anxiety disorder.  GAD-7 has seven items, which measure severity of various signs of GAD according to reported response categories with assigned points.[2] The GAD-7 items include: 1) nervousness; 2) inability to stop worrying; 3) excessive worry; 4) restlessness; 5) difficulty in relaxing; 6) easy irritation; and 7) fear of something awful happening.  Assessment is indicated by the total score, which is made up by adding together the scores for the scale of all seven items.

GMA Median
The median value of a physician’s performance or compensation is based on MGMA data.

Group Practices
Group practices are typically divided into single-specialty and multispecialty practices. The defining characteristic of single-specialty practice is the presence of two or more physicians providing patients with one specific type of care (i.e., primary care or a specific subspecialty practice), while multispecialty group practices are defined as offering several types of medical specialty care within one organization.

HHS (The US Department of Health and Human Services)
As stated on their website “The mission of the U.S. Department of Health and Human Services (HHS) is to enhance the health and well-being of all Americans, by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services.”

HHS agencies include:

SAMHSA – Substance Abuse and Mental Health Services Administration
NIH – National Institutes of Health
IHS – Indian Health Services
HRSA – Health Resources & Services Administration
FDA – US Food & Drug Administration
CMS – Centers for Medicare and Medicaid Services
CDC – Centers for Disease Control and Prevention
AHQR – Agency for Healthcare Research and Quality
ACL – Administration for Community Living
ACF – Administration for Children & Families
Office of the Surgeon General

Health Insurance Portability and Accountability Act (HIPAA)
Designed to improve the efficiency and effectiveness of the US health care system, HIPAA involves ensuring health insurance coverage, and the privacy and security of health information collected from patients.

Health Resources and Services Administration (HRSA)
HRSA is an agency of the U.S. Department of Health and Human Services located in North Bethesda, Maryland. It is the primary federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable.

Health Systems
A health system, also sometimes referred to as health care system or as healthcare system, is the organization of people, institutions, and resources that deliver health care services to meet the health needs of target populations.

International Statistical Classification of Diseases and Related Health Problems – 10^th revision [ICD-10]
A medical classification list by the World Health Organization that contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.

Managed Care Organization (MCO)
Intended for delivery of managed care, a Managed Care Organization contracts with health care providers to deliver health services on a per-member per-month (capitated) basis.

Medicare Access and CHIP Reauthorization Act (MACRA)
MACRA replaces the current Medicare reimbursement schedule with a new pay-for-performance program that’s focused on quality, value, and accountability. The Centers for Medicare and Medicaid Services (CMS) stated that MACRA enacts a new payment framework that rewards health care providers for giving better care instead of more service. It was signed into law on April 16, 2015.

Medical Doctor (MD)
MD is a Doctor of Medicine. Typically requires a 4-year medical degree after undergraduate.

Medical Group Management Association (MGMA)
The premier association for professionals who lead medical practice. Since 1926, through data, people, insights, and advocacy, MGMA empowers medical group practices to innovate and create meaningful change in healthcare.

Mental Health
It encompasses emotional, psychological, and social well-being and influences cognition, perception, and behavior.  Mental health also determines how an individual handles stress, interpersonal relationships, and decision-making.

Merit-Based Incentive Payment System (MIPS)
Starting in 2019, a payment mechanism to provide annual updates to physicians based on performance in quality, resource use, clinical practice improvement activities and meaningful use of an EHR.

Neonatal Nurse Practitioner (NNP)
A neonatal nurse practitioner (NNP) is an advanced practice registered nurse (APRN) with at least 2 years’ experience as a bedside registered nurse in a level III NICU, who is prepared to practice across the continuum, providing primary, acute, chronic, and critical care to neonates, infants, and toddlers through age 2. Primarily working in neonatal intensive care unit (NICU) settings.

Non-Physician Practitioner (NPP)
Non-physician practitioners (NPP) are Physician Assistants (PAs)and Nurse Practitioners (NPs). They operate under the supervision of a physician and in accordance with their state’s laws.

Nurse Practitioner (NP)
A nurse practitioner (NP) is an advanced practice registered nurse and a type of mid-level practitioner. … The scope of practice for a NP is defined by legal jurisdiction. In some places, NPs are required to work under the supervision of a physician, and in other places they can practice independently.

Patient Health Questionnaire 9 [PHQ9]
A 9-question depression scale of PHQ.  The PHQ is a self-administered version of the PRIME-MD, a screening tool that assesses 12 mental and emotional health disorders. The PHQ is 59-question instrument.  It has modules on mood (PHQ-9), anxiety, alcohol, eating, and somatoform disorders.

Payer
The organization who reimburses health care providers for services delivered.

Payment Integrity
Payment integrity efforts are intended to control, limit, or eliminate fraud, waste and abuse by determining the correct party, membership eligibility, and contractual adherence. Payment integrity solutions help healthcare providers process claims accurately for both pre-pay and post-pay transactions.

Pediatric Nurse Practitioner (PNP)
A PNP is a nurse practitioner that specializes in care to newborns, infants, toddlers, preschoolers, school-aged children, adolescents, and young adults. Typically practices in the outpatient setting.

Pediatric Nurse Practitioner – Acute Care (PNP-AC)
A PNP-AC is a nurse practitioner that specializes in the care of newborns, infants, toddlers, preschoolers, school-aged children, adolescents, and young adults with acute, critical, and/or complex chronic health conditions. Typically practices in the inpatient setting.

Per diem Nurse (PRN)
Per diem nurses work on an on-call, temporary basis, filling in for nurses on leave or providing additional help when patient intake rises.

Physician Assistant (PA)
PA, or physician assistant, is licensed to practice medicine with physician supervision. They undergo three years of training. PAs will often perform physical exams, diagnose ailments, request, and interpret tests, provide advice on preventive health care, assist in surgery, and can write prescriptions.

Population Health
The health status and outcomes within a group of people rather than considering the health of individuals. For healthcare providers, improving population health involves understanding and optimizing the health of a population within a defined geography.

Preceptor
A preceptor is an experienced practitioner who provides supervision during clinical practice and facilitates the application of theory to practice for students and staff learners. A preceptor works with the learner for a defined period to assist the learner in acquiring new competencies required for safe, ethical, and quality practice. They assist the learner by setting expectations, providing effective feedback about their performance, and providing appropriate opportunities to meet their learning objectives.

Primary Care Provider (PCP)
A primary care provider (PCP) is a health care professional often considered the main health care provider for non-emergency situations. The PCP’s role is to provide preventive care, treat common conditions, and make referrals for specialized care. PCPs can be MDs, PAs, or NPs.

Providers
Include Physicians, Physician’s Assistants, Nurse Practitioners, RN, other nurses, (anyone who sees a patient), Physician Administrators.

Psychiatrist
A physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders.

Psychologist
A professional who practices psychology and studies mental states, perceptual, cognitive, emotional, and social processes, and behavior.  They cannot prescribe medication.

Relative Value Units (RVU)
A measure of value used in the United States Medicare reimbursement formula for physician services. RVUs are a part of the resource-based relative value scale (RBRVS).

Residency
Residency or postgraduate training is specifically a stage of graduate medical education. It refers to a qualified physician (one who holds the degree of MD, DO, MBBS, MBChB), dentist (DDS or DMD) or podiatrist (DPM) who practices medicine, dentistry, or podiatry, respectively, usually in a hospital or clinic, under the direct or indirect supervision of a senior medical clinician registered in that specialty such as an attending physician or consultant. (source: Wikipedia)

Solo Practice
Solo practice is described by its name—a practice without partners or employment affiliations with other practice organizations. Although previously a common model, this type of medical practice is becoming less popular than in the past, although it is strongly preferred by some internists.

Women’s Health Nurse Practitioner (WHNP)
A WHNP is a nurse practitioner that specializes in continuing and comprehensive healthcare for women across the lifespan with emphasis on conditions unique to women from menarche through the remainder of their life cycle. Typically practices in the outpatient setting.

Value-based Care (VBC)
A payment model that rewards healthcare providers for providing quality care to patients. Under this approach, providers seek to provide better care for patients and better health for populations at a lower cost. To accomplish their VBC journey, many hospitals and health systems require solutions, such as the ones provided by Enlace Health.