To help make terminology used on this website easier to understand, we offer this easy-to-use glossary for quick reference.
Accountable Care Organization (ACO): A health care organization that ties provider reimbursement to quality metrics and reductions in the cost of care.
Aggregate Data: Information combined from multiple sources or multiple participants. Individual sources of information may no longer be identifiable. Also known as group data.
Anonymous Data: Information that is not identified by name. It cannot be tracked back to the participant and reporting of participants or outcomes is not available based on this information.
Average Length of Stay (ALOS): Refers to the number of hospital days per admissions (total days/total admissions). May also be called length of stay (LOS) and estimated length of stay (ELOS).
BeneFIT Corporate Wellness SM: A corporate wellness program affiliated with Valley Preferred and LVHN that provides business clients with customized services to develop cultures that encourage healthy lifestyles. Bundled payments: A reimbursement model in which all costs for an entire medical procedure are combined and paid for as a single “episode of care.”
Care Management Committee (CMC): LVPHO committee designed to monitor quality improvement, cost containment, utilization review, clinical pathways and primary care coordination for clients of Valley Preferred.
Care Coordination: Involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.
Clinical Integration: Collaboration across providers and resources to support quality patient care and improved outcomes. Tenets include electronic health records, population health management, engaged physicians, care coordination, payer relationships, and a performance-based incentive plan.
CMS: Centers for Medicare and Medicaid Services are U.S. federal government health care funding programs.
Coinsurance: The portion of the cost for care received, and for which an individual is financially responsible. Usually this is determined by a fixed percentage, as in major medical coverage. Often coinsurance applies after a specified deductible has been met.
Consumer Driven Health Plan (CDHP): A continuum of health plans with varying degrees of employer and employee participant responsibility that engages consumers in their health care by giving them control of routine health decisions and dollars, along with the tools to make wise and informed decisions about their care.
Deductible: The part of an individual’s health care expenses that the patient must pay before coverage from the insurer begins.
Delegated Credentialing: This occurs when a health care entity gives another health care entity the authority to credential its health care practitioners (e.g., a preferred provider organization [PPO] delegates its credentialing to a hospital).
Disclosure: Releasing, transferring, or providing access to or divulging information in any other manner outside of the entity holding the information.
Disease Management: A system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.
Dis-enroll: To terminate participation in programs and services.
EHR: Electronic Health Record, also called EMR, Electronic Medical Record. Interconnected communication and information system used by doctors and hospitals to track and inform patient care.
Eligible individual: An individual who is eligible to participate in any aspect of a wellness and health promotion program provided by the organization.
Enrollment: The process of converting subscriber group eligible individuals into members or the aggregate count of enrollees as of a given time.
Epic: Epic Systems is one of the largest providers of health information technology, used primarily by large U.S. hospitals and health systems, including LVHN, to access, organize, store and share electronic medical records.
ERISA: The Employee Retirement Income Security Act was enacted in 1974 and sets federal requirements for pension and employee benefit plans to include employer health plans.
Evidence-based information: Information derived from scientific evidence or professional standards.
Fee-For-Service (FFS): The traditional reimbursement model in which doctors and hospitals are paid for each individual service in a patient’s care. This is being phased out as value based reimbursement, where payment is determined by quality of patient outcomes, takes hold.
Flexible Spending Account (FSA): There are two types of FSAs: A Health Care FSA (HCFSA) pays for the uncovered or unreimbursed portions of qualified medical costs. A Dependent Care FSA (DCFSA) allows members to pay eligible expenses for dependent care with pre-tax dollars. All employee contributions to FSAs are made from pre-tax earnings, thereby increasing disposable income.
Global payment: A single payment to cover all costs (e.g. physician visits, tests, procedures) related to a discrete episode of patient care (e.g. knee replacement).
Greater Lehigh Valley Independent Practice Association (GLVIPA): The physician shareholders of the Lehigh Valley Physician Hospital Organization. The Association was organized to enable its physician members to deliver comprehensive health care services in the most beneficial and cost-effective way.
Health Coaching: When provided by BeneFIT, it’s a participant-driven process to identify an individual’s personal goals and work toward them together with a dedicated coach. Areas of concentration include nutrition, physical activity, weight management, stress management, tobacco cessation, work/life balance, and others.
Health Reimbursement Arrangement (HRA): A tax-favored program set up and paid for by an employer. Under an HRA, the employer reimburses a portion of each employee’s medical expenses, typically by paying part of the deductible.
Health Savings Account (HSA): A variation of the individual retirement account that would establish a tax-deferred savings account for an individual to cover the cost of health care services, combined with a low-cost, high deductible health insurance policy (required).
Heirarchical Condition Category (HCC): The name of the coding system implemented by CMS in order to inform and adjust reimbursement to doctors and hospitals for health care services provided. HCCs are also used by private insurance payers.
HIPAA: HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996. It covers the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs; reduces health care fraud and abuse; mandates industry-wide standards for health care information on electronic billing and other processes; and requires the protection and confidential handling of protected health information
Institute of Medicine (IOM): Chartered in 1970 by National Academy of Science to enlist distinguished members of appropriate professions in the examination of policy matters pertaining to the health of the public. Advisor to federal government on issues of medical care, research and education.
Joint Commission for the Accreditation of Healthcare Organizations (JCAHO): This not-for-profit organization accredits hospitals, outpatient facilities, and other institutions.
Lehigh Valley Business Coalition on Healthcare (LVBCH): A multi-state, not-for-profit coalition of employers striving to provide quality health care coverage for their employees, in the most economical fashion.
Lehigh Valley Physician Group (LVPG): A multi-specialty physician group practice managed by LVHN with multiple office locations. Includes specialists in family practice, internal medicine, pediatrics, psychiatry, surgery, obstetrics, and gynecology.
Lehigh Valley Physician Hospital Organization, Inc. (LVPHO): A health care delivery organization formed by the Greater Lehigh Valley Independent Practice Association and LVHN. LVPHO manages the Valley Preferred provider network (PPO).
Managed Care: Use of a planned and coordinated approach to providing health care with the goal of higher quality care at a lower cost. Usually emphasizes preventive care and often associated with an HMO.
Managed Care Organization (MCO): Refers to any type of organizational entity providing managed care such as an HMO, PPO, EPO, etc.
Medical Loss Ratio: Cost of care provided as a percentage of premium revenues, or the total cost of medical services as a percentage of premium revenues. Health plans often refer to the loss ratio as the cost of all health care versus the premium.
Medicare Supplement: Voluntary, private insurance coverage purchased by Medicare enrollees to cover cost of services not provided by Medicare.
Mindfulness: A mental state achieved by focusing one’s awareness on the present moment, while calmly acknowledging and accepting one’s feelings, thoughts, and bodily sensations, used as a therapeutic technique. LVHN maintains a Center for Mindfulness at its Cedar Crest campus in Allentown.
Payers: Insurance organizations that pay for health care provided to individual members covered by their plans. Includes commercial insurance corporations that underwrite health plan coverage for employee benefit plans, and public payers such as Medicare, Medicaid, CHIP, and other health insurance coverage provided by government entities.
Peer-to-Peer Counseling: This is when counseling or conversation is provided by those in the same profession, not necessarily credentialed counselors. The mentors are specially trained to provide personal guidance. Valley Preferred partners with LVHN’s EAP to offer Physicians-for-Physicians (P4P), a peer counseling program for health care professionals.
Physician Hospital Organization (PHO): An organizational entity formed between hospitals and physicians that promotes cooperation while allowing a level of independence to the participating parties. This organizational structure is usually formed to pursue managed care contracts.
Point-of-Service (POS): This refers to a transition product incorporating features of both HMOs and PPOs. Beneficiaries have the option to go outside the network for an additional cost.
Population Health Management: It’s defined as the science of preventing disease, prolonging life, and promoting health through organized efforts and informed choices. It incorporates using data to monitor and assess groups of health plan members toward the goals of preventive health care, intervention of high-risk patients, and identifying cost efficiencies.
Populytics: A wholly owned subsidiary of LVHN, and a population health management and analytics firm that facilitates the movement toward value-based care. Claims and clinical data are collected and aggregated via advanced analytics tools to provide actionable information. Services include population health analytics, health benefits administration, health benefits consulting, clinical care coordination, and employer solutions.
PPACA: The Patient Protection and Affordability Care Act of 2010 is a law whose primary aim is to decrease the number of uninsured, as well as to reduce costs.
Population Health: Accountability for the health of a defined population of individuals and the utilization of health services across the care continuum — from preventive to acute to subacute settings — to provide those individuals with better health and better care at lower costs. Note: There are many definitions for Population Health and they vary widely. This is a working definition as practiced by LVHN.
Preferred Provider Organization (PPO): A group of physicians and/or hospitals that contract with an employer to provide services to their employees. In a PPO, the patient may go to the physician of his/her choice, even if that physician does not participate in the PPO, but the patient receives care at a lower benefit level.
Primary Care Physician (PCP): Provides treatment of routine injuries and illnesses and focuses on preventive care. The American Academy of Family Practice defines primary care as “care from doctors trained to handle health concerns not limited by problem origin, organ systems, gender, or diagnosis.”
Protected Health Information (PHI): Health information, including demographic information, collected from an individual and created or received by a health care provider, health plan, employer or health care clearinghouse, that relates to the past, present, or future physical or mental health or condition of an individual and which identifies the individual or provides information that can lead to identification.
Providers: Usually refers to nurses, nurse practitioners, physician assistants, hospitals, or other individuals and/or organizations that provide health care services. Valley Preferred prefers to distinguish physicians from providers.
ROI: This stands for return on investment and is a common business term used to identify past and potential financial returns. Businesses and health care systems now frequently refer to VOI, or the value returned from an investment, which takes into account elements such as employee retention and increased morale.
Risk: Financially speaking, risk refers to the degree of uncertainty and/or potential financial loss inherent in an investment decision. In health care, risk has become a common topic in respect to insurance contracts that involve meeting certain benchmarks to see positive returns.
Service Area: The territory within certain boundaries that is designated for providing service to members.
Shared risk: Contractual arrangements between insurance payers and health services providers, in which both entities assume financial accountability for the cost and quality of patient outcomes.
Skilled Nursing Facility (SNF): May be a freestanding facility or part of a hospital that has been certified by Medicare to admit patients requiring subacute care and rehabilitation.
Stop-Loss: The purchase of insurance from a third party to cover unexpected financial loss to the plan or provider. Itmay be individual or aggregate and usually both. In the event of a catastrophic claim, stop-loss limits the exposure for both the insurer and the purchaser.
Third-Party Administrator (TPA): An administrative organization other than the employee benefit plan or health care provider that collects premiums, pays claims, and/or provides administrative services.
Utilization: The frequency and manner with which a health plan benefit is used.
Utilization Management: A process that measures use of available resources (including professional staff, facilities, and services) to determine medical necessity, cost-effectiveness, and conformity to criteria for optimal use.
Valley Preferred: The public-facing name for LVPHO. It is a leading Pennsylvania provider-led PPO partnership consisting of doctors and hospitals dedicated to improving health care quality, affordability, and effectiveness. Valley Preferred is not an insurance company, but contracts with insurance companies and TPAs. The organization provides education, outreach, and support for more than 1,300 physician members and health care provider participants.
Value based health care: The emerging model for health care reimbursement that prioritizes quality and cost as the key drivers for compensating providers. This model naturally incentivizes proactive management of chronic illnesses, adherence to best practices, and elimination of unjustifiable variations in patient care.