Glossary

HCFA

Health Care Financing Administration: Federal agency that administers Medicare and oversees state administration of Medicaid. HCFA resides within the Department of Health and Human Services. Now referred to as CMS Centers for Medicare and Medicaid Services. Now referred to as CMS Centers for Medicare and Medicaid Services.

HCFA 1500

The Health Care Finance Administration’s standard form for submitting provider service claims to third party companies or insurance carriers. HCFA is now called CMS, see CMS.

HCFA-1450

Health Care Financing Administration form 1450: Standard institutional (hospital) services claim form for the United States. Same as the UB92 (Uniform Billing 1992) form.

HCPCS

Healthcare Common Procedure Coding System Highlights: HCPCS Coding Process/Application.

Health

The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It is recognized, however, that health has many dimensions (anatomical, physiological, and mental) and is largely culturally defined. The relative importance of various disabilities will differ depending upon the cultural milieu and the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms or morbidity and mortality.

Health and Human Services (HHS)

The Department of Health and Human Services which is responsible for health-related programs and issues. Formerly HEW, the Department of Health, Education, and Welfare. The Office of Health Maintenance Organizations (OHMO) is part of HHS and detailed information on most companies is available here through the Freedom of Information Act.

Health Benefits Package

The services and products a health plan offers.

Health Care Financing Administration (HCFA)

The federal government agency within the Department of Health and Human Services which directs and oversees the Medicare and Medicaid programs (Titles XVIII and XIX of the Social Security Act) and conducts research to support those programs. It is now called CMS and generally it oversees the state’s administrations of Medicaid, while directly administering Medicare. See CMS, or Center for Medicare and Medicaid Services.

Health Insurance

Financial protection against the health care costs of the insured person. May be obtained in a group or individual policy.

Health Insurance Portability and Account (HIPAA)

Sometimes referred to as the Kennedy-Kassebaum bill, this legislation sets a precedent for Federal involvement in insurance regulation. It sets minimum standards for regulation of the small group insurance market and for a set group in the individual insurance market in the area of portability and availability of health insurance. As a result of this law, hospitals, doctors and insurance companies are now required to share patient medical records and personal information on a wider basis. This wide-based sharing of medical records has led to privacy rules, greater computerization of records and consumer concerns about confidentiality.

Health Insurance Purchasing Cooperative (HIPC)

Regional consumer groups that are establishes to shop for highest quality plan at lowest cost on behalf of large number of people, including employees of small businesses. Entity established to purchase bulk health insurance for businesses, groups or individuals. Was a key concept in the Clinton health plan and is not a current concept. Other cooperatives exist now, including business health action groups and health plan purchasing cooperatives. Although it may go by other names, we can expect such cooperatives to exist in the future.

Health Insurance Purchasing Cooperatives (HIPCs)

Public or private organizations which secure health insurance coverage for the workers of all member employers. The goal of these organizations is to consolidate purchasing responsibilities to obtain greater bargaining clout with health insurers, plans and providers, to reduce the administrative costs of buying, selling and managing insurance policies. Private cooperatives are usually voluntary associations of employers in a similar geographic region who band together to purchase insurance for their employees. Public cooperatives are established by state governments to purchase insurance for public employees, Medicaid beneficiaries, and other designated populations.

Health Level Seven (HL7)

A data interchange protocol for health care computer applications that simplifies the ability of different vendor-supplied IS systems to interconnect. Although not a software program in itself, HL7 requires that each healthcare software vendor program HL7 interfaces for its products.

Health Manpower Shortage Area (HMSA)

An area or group which the U.S. Department of Health and Human Services designates as having an inadequate supply of health care providers. HMSAs can include: (1) an urban or rural geographic area, (2) a population group for which access barriers can be demonstrated to prevent members of the group from using local providers, or (3) medium and maximum-security correctional institutions and public or non-profit private residential facilities.

Health Professional Shortage Area (HPSA)

A geographic area, population group, or medical facility that HHS determines to be served by too few health professionals of particular specialties. Physicians who provide services in HPSAs qualify for the Medicare bonus payments. This may also include re-payment of medical school loans or other incentives. These reports are published annually by HHS and can be of assistance to providers or groups wishing to recruit physicians to particular areas.

Health Resources and Services Administration

HRSA is a component of the U.S. Department of Health and Human Services. Included in HRSA responsibilities is administration of the Ryan White Care funds with a budget of about $1 billion/year to support a continuum of care services for persons with HIV infection.

Health Service Agreement (HSA)

Detailed explanation of procedures and benefits provided to an employer by a health plan.

Healthcare Effectiveness Data and Information Set (HEDIS)

The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of U.S. health plans to measure performance on important dimensions of care and service. More than 190 million people are enrolled in health plans that report quality results using HEDIS.

HIPAA

See Health Insurance Portability and Accountability Act of 1996, above.

HL7

Health Level 7: An accredited Standards Developing Organization that produces standards for various healthcare domains (i.e. Pharmacies, medical devices, claims processing, etc.)

Hold Harmless Clause

A clause frequently found in managed care contracts whereby the HMO and the physician hold each other not liable for malpractice or corporate malfeasance if either of the parties is found to be liable. Many insurance carriers exclude this type of liability from coverage. It may also refer to language that prohibits the provider from billing patients if their managed care company becomes insolvent. State and federal regulations may require this language.

Home Health Care

Full range of medical and other health related services such as physical therapy, nursing, counseling, and social services that are delivered in the home of a patient, by a provider.

Horizontal Integration

Merging of two or more firms at the same level of production in some formal, legal relationship. In hospital networks, this may refer to the grouping of several hospital, the grouping of outpatient clinics with the hospital or a geographic network of various health care services. Integrated systems seek to integrate both vertically with some organizations and horizontally with others. See vertical integration.

Hospice

Facility or program providing care for the terminally ill.

Hospital

Any institution duly licensed, certified, and operated as a Hospital. In no event shall the term “Hospital” include a convalescent facility, nursing home, or any institution or part thereof which is used principally as a convalescence facility, rest facility, nursing facility, or facility for the aged.

Hospital Affiliation

A contractual agreement between an health plan and one or more hospitals whereby the hospital provides the inpatient services offered by the health plan.

Hospital Alliances

Groups of hospitals joined together to share services and develop group purchasing programs to reduce costs. May also refer to a spectrum of contracts, agreements or handshake arrangements for hospitals to work together in developing programs, serving covered lives or contracting with payers or health plans. See also Network, Integrated Delivery System, PHO, or Provider Health Plan.

Hospital Audit Companies

Retrospective audit providers that typically achieve a 15-20 percent savings of billed claims.

Hospital Days (per 1,000)

A measurement of the number of days of hospital care HMO members use in a year. It is calculated as follows: Total Number Of Days Spent In A Hospital By Members divided by Total Members. This information is available through HHS, OHMO and a variety of sources.