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General Medical Definitions

And Terminology for Durable Medical Equipment

Acceptance

One of the five stages of grief; is acknowledging a situation, whether it be an illness or death. The individual does not have to like what has happened. They merely reach a point where they are no longer trying to change the situation through feelings of denial, anger, bargaining, or depression. They are acknowledging the reality of the problem or event.

Activities of Daily Living (ADL)

Activities of daily living are activities such as bathing, dressing, and meal preparation which you perform daily.

Traditional_Medicine_Conventional_Medicine

Acute Phase

The second phase is associated with a terminal illness. The individual now has a diagnosis (or name) of the symptoms, and a treatment plan may be discussed. The individual may experience the grief stages of anger and denial.

Acute Rehabilitation Facility

A hospital that provides moderate to intense rehabilitation services. Patients must participate in 1-3 hours of rehabilitation per day and show continued signs of improvement to qualify for ongoing treatment.

Advance Health Care Directives

Known by many names, including health care proxy, advance directives, living will, it is a document that has been written and signed by a competent individual with two witnesses' signatures (is not notarized.) The paper provides health care instructions and appoints a proxy (health care agent). If the individual is unable to speak for themselves, the agent ensures the healthcare team carries out the health care decisions outlined in the document by the individual. The paper tends to be detailed instructions addressing wishes related to withdrawing food and fluids, ventilator support, dialysis, and other aggressive or “heroic” measures.

Aggressive Treatment

Care is designed to preserve life. Aggressive care would include cardiopulmonary resuscitation (CPR), dialysis, chemotherapy, surgeries, etc.

Alternative Medicine/Alternative Therapy

Insurance carrier definition of any non-traditional form of healthcare. Typical forms of alternative medicine include acupuncture, massage, and chiropractic medicine. Insurance carriers consider you to be using alternative therapy when you use only alternative therapies and do not combine them with traditional/conventional medicine.

Anger

One of Elisabeth Kubler-Ross’ five stages of grief. A feeling of rage with pain as the underlying emotion. An example would be, “This is wrong! It isn’t fair!!!!”

Anticipatory Grief

They live expecting a loss to occur and experiencing the grief associated with that loss before it happens. This is most common with terminal illnesses.

Administrative Service Only (ASO)

Employer insurance plans in which the employer takes on the entire risk for financing the health care benefits it provides to its employees. Employers may contract with Third Party Administrators (TPA), such as insurance carriers, to provide certain administrative services such as claims processing. It may also be referred to as Self-Funded HealthCare.

Aspiration Pneumonia

Foreign material such as vomit, food, or fluids enters the lungs, causing inflammation and infection.

Attendant Care/Shift Care

Care provided in the home in shifts of 8 hours or more. The care may be considered skilled if it requires a licensed person to perform specific tasks, or it could be regarded as custodial (does not require the skills of an authorized person to complete).

It may also be called Home Care or Domicile Care.

Bargaining

One of the five stages of grief was identified by Elisabeth Kubler-Ross. You may accept what is happening in this stage, but you are bartering or negotiating for more time. For example: “If I could only stay long enough to see my child’s wedding.”

Breakthrough Pain

Pain that is not controlled by the typically scheduled pain medication routine. It may feel like a pain spike or surge. Things that can cause pain spikes include an increase in inactivity.

Calendar Year

Most benefits and the deductible fall between January 1 and December 31.

Case Manager

A Case Manager is a nurse or social worker who acts as a point person for individuals with complex medical needs to coordinate services and evaluate treatment plans.

Cheyne-Stoke Respirations

The rhythm or breathing pattern change is noted in the end phase of life. The distinctive way is shallow pants followed by periods of not breathing.

Chronic Illness

Long-lasting or continuous illness such as diabetes or arthritis.

Chronic Phase

This third phase of a terminal illness may take days, weeks, or years. Chronic does not refer to the period. The individual may or may not be receiving treatment. It refers to the “mental state” of adjusting to the diagnosis with all of its ramifications. The stages of grief the individual may experience are bargaining, anger, depression, and, if the illness extends over several years, they may experience denial again.

Coordination of Benefits (COB)

Agreement among insurance carriers to prevent the same claim from being paid by two or more pages resulting in an overpayment of the claim. Suppose two or more insurance policies insure an individual. In that case, one of the insurance policies will agree to be primary, making the initial payment on the claim. In contrast, the other policy will be secondary, covering the remaining portion of the claim. It may also be referred to as coinsurance.

Co-Morbidity

The existence of other illnesses/ diseases in the presence of a primary diagnosis/illness.

Complementary Medicine/Alternative Medicine (CAM)

They are also known as Alternative Medicine or Alternative Therapy. More and more often, the acronym “CAM” is utilized to describe the combination of using both conservative/traditional medicine in combination with alternative medicine. Complementary/alternative medicine is any practice outside of the conventional form of medicine. In addition to the most common forms of complementary/alternative medicine of massage, chiropractic, and acupuncture, biofeedback and spiritual healing are two of the many other forms of alternative medicine practices.

Comprehensive Plan

A fee-for-service plan combines the covered benefits of the primary and significant fee-for-service into one program.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

1986 Federal legislation impacting health plans for businesses with twenty or more employees. COBRA allows you to continue to receive your health care insurance for up to 18 months, as long as you pay your insurance premiums.

Contracted Rate

The discounted amount your insurance company and participating provider/par-provider have agreed upon for services.

Conventional Medicine/Traditional Medicine

A health care delivery system in which medical doctors (MDs) and other health care professionals treat symptoms and diseases. Another term used to describe this form of medicine is allopathic.

Co-Payment/Copay

You are responsible for paying the set amount towards any healthcare services you access.

Covered Charges/Covered Expenses

Services that are included benefits in your insurance plan. Your insurance policy may exclude certain items, such as prescription benefits. Medical expenses are only applied to services covered under the procedure, and your insurance carrier is only responsible for paying its share of the cost on covered services.

Cure

the restoration of health. The absence of disease activity over some time. With the more excellent passage of time, the statistics of the disease returning becomes less.

Custodial Care

Care provided to assist the individual in performing activities of daily living such as bathing, dressing, or meal preparation. Typically they were not covered by standard insurance policies.

Death Rattle

A gurgling or rattling sound at the back of the throat is noted when breathing. This is present in the end phase of life and is caused by the collection of respiratory secretions.

Deductible

You must pay the initial, specified amount before your insurance company begins to make payments towards your medical claims.

Delayed Grief

The grief may occur months or even years after the event. This is often seen when the individual must address other responsibilities first (such as funeral preparations or financial issues.)

Denial

One of the five stages of grief was identified by Elisabeth Kubler-Ross. It is the disbelief in what you are experiencing. For example: “I feel fine! The doctor must be wrong.”

Depression

One of the five stages of grief was identified by Elisabeth Kubler-Ross. Feelings are of sadness so severe that you are unable and have no desire to participate in the activities of daily living. In depression, you may not see the point of doing anything.

Diagnosis

Name given to a group of signs and symptoms after obtaining a history, physical examination, evaluation of laboratory results, and test/procedures.

Durable Medical Equipment (DME)

Medical equipment which can withstand repeated use during a course of treatment. Examples of durable medical equipment include hospital beds, canes, and braces. Medicare defines glucose test strips, glucose monitors, and insulin pumps as durable medical equipment.

Durable Power for Health

Durable Power for Health is a document written by a mentally competent individual with the assistance of a lawyer or paralegal, with notarized signatures from the individual and witness. The document names an agent who will make medical decisions if the individual is incapacitated. Unlike the Living Will, this document may not be as detailed in outlining the individual's wishes, leaving much in the way of interpretation on the part of the agent.

Employee Retirement Income Security Act (ERISA)

As it pertains to health insurance, federal law regulates self-funded health plans. There are many parts to the ERISA law and recent amendments, including the Health Insurance Portability and Privacy Act (HIPPA). ERISA's issues or concerns fall under the US Department of Labor (US DOL).

Evidence-Based Guidelines (EBG)

Guidelines based on research are used to help make medical decisions and standardize the practice of medicine for specific conditions. Milliman and Interqual are examples of evidence-based guidelines. Information to create the EBGs is obtained from the consensus of experts within a particular field and clinical trial data. While EBGs may appear to be a great way of standardizing medical practices, they fail in several areas (see the section on “legal issues and laws.”)

Exclusion

Exclusion is any service that is not considered part of your insurance plan concerning your insurance coverage. Custodial care is an example of a commonly excluded benefit.

Explanation of Benefits (EOB)

A statement provided by your insurance carrier detailing the activities or actions taken on claims submitted by healthcare providers for consideration of payment.

Fee-for-Service (FFS)

An insurance plan allows you to receive services from any healthcare provider without restrictions. The policy is limited in what it covers. There are two types of FFS plans: primary and effective. The basic plan covers some physician visits, hospitalization stays, and prescriptions, while the effective plan covers serious, long-term illnesses. Some insurance carriers combine the primary and significant plan into one comprehensive plan.

Fully Funded Plan

A medical insurance carrier entirely manages a health insurance plan. An example of a fully-funded plan is an individual policy you may purchase for yourself.

Formulary

The formulary is a list of drugs covered by a policy concerning medical insurance. The list is based on cost, safety, and effectiveness.

Generic

Medication whose ingredients are therapeutically the same as the manufacturer’s brand and can be offered lower costs.

Grief

The multifaceted emotional response to any loss. An individual may experience any of the five stages of: denial, anger, bargaining, depression, and acceptance, as outlined by Kubler-Ross.

Half-Life

Used about the time, it takes half of the medication to become inactive in your body. The half-life is given as a reference. You should consider any conditions that may slow the body’s ability to eliminate the medication, including kidney or liver disease.

Hallucinations

The perception that you are either hearing or seeing something not there.

Health Insurance Portability and Accountability Act (HIPAA)

Act passed by Congress in 1996, which revised the previous Employee Retirement Income Act (ERISA) and Public Health Service Act. HIPAA was designed to protect patient privacy and health insurance coverage.

Health Maintenance Organization (HMO)

A health care policy that a medical group manages (either an HMO or IPA group.) By requiring primary care physicians to see a large number of patients in a day and restricting the number of referrals to specialists, the HMOs can keep their costs down and pass on the savings to members in the form of affordable health care.

Hocus Pocus

Non-sense. Foolishness or empty pretenses disguise deception—a form of trickery.

Home Health Care

Skilled care in the home setting. Unlike attendant/shift care, home health care is brief (lasting no more than 3-4 hours a day) and intermittent over a short time. Services provided in the home include psychiatric nursing, social services, nursing care, the assistance of aid, and rehabilitation services, including physical, occupational, and speech therapy. Home care is created to assist the patient in their home setting.

Hospice

In medical terms, hospice provides palliative/comfort care to an individual thought to have six months or less to live. The care provided is both physical and spiritual and includes the individual’s family. The care is provided in the individual’s home or a hospital setting.

Hospitalist

A physician who specializes in providing care to hospitalized patients. Hospitalists often have a background in internal medicine or family practice. The position has been created to optimize time and curb costs for physicians who participate in a Health Maintenance Organization (HMO). By assigning a hospitalist to their hospitalized patients, physicians can focus on providing care to their office practice and making rounds to multiple hospitals in less time.

Incurable

The condition of having an illness or infection which has no chance of improvement despite treatment and will ultimately be fatal.

Independent Practice Associate (IPA)

A group of physicians establishes a contract to care for both HMO and PPO members.

Initial/Pre-Diagnosis Phase

When associated with a terminal diagnosis, it describes that period when testing begins to determine the cause of symptoms noted by the individual.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

An unbiased review organization assesses healthcare organizations such as hospitals and home care organizations to ensure quality, safety, and standardization of care.

Lifetime Maximum (Lifetime Max)

The capped amount of money your insurance carrier will pay out for services during your lifetime.

Long Term Acute Care Hospital (LTACH)

Acute care hospitals for patients who require intensive care for thirty days or more. Examples of patients who may need LTACH include those trying to come off breathing machines (weaned from ventilators).

Long-Term Care Insurance

Insurance policies are sold by life insurance companies that provide coverage for things generally not covered by medical/health insurance policies. Long-term care policies typically cover adult daycare, assisted-living facilities, Alzheimer’s, respite, and attendant care.

Managed Care

The healthcare system utilizes various methods to keep costs down and quality care up. Healthcare providers agree to contracted rates within the managed care system. By agreeing to accept lower fees for services, the contracted providers are promised referrals from the plan manager. Preferred Provider Organizations, Health Maintenance Organizations, and Point of Service plans are examples of managed care plans.

Masked Grief

Feelings of sadness are buried or denied. Masked grief can result from religious, cultural, or learned behavior. Repressing grief can result in unexplained medical conditions that may or may not have a psychosomatic connection.

Medical Necessity

There are multiple applied definitions for the term “medical necessity.” Speaking generically, medical necessity is any treatment for an injury or illness considered necessary to improve or restore health. Each insurance carrier defines medical necessity in its clients' benefit booklet.

Medicaid

Federal- and state-aided medical insurance program for low-income United States citizens (in California, the Medicaid plan is called “Medi-Cal.”)This is the link to Medicaid’s site.

Medicare

The United States federally funded health insurance policy administered by the U.S. Social Security Administration; available to the permanently disabled, seniors over 65 who have been citizens for five years or more.

Mottling

A blotchy discoloration of the skin is noted during the end phase of life due to the shunting of oxygenated blood from the skin surface, usually seen first in the lower extremities.

National Committee of Quality Assurance (NCQA)

A non-profit organization that reviews health maintenance organizations and other managed care organizations.

Non-Generic Drug

A drug created by the original manufacturer of the drug goes by the manufacturer’s brand name.

Non-Participating Provider (Non-Par) Out-of-Network Provider

Therefore, a healthcare provider who has not entered into a contract with your insurance provider is not part of the insurance network.

Out-of-Pocket (OOP)

The amount you pay in the form of deductibles and co-payments for services you or your family receives within a calendar year.

Out-of-Pocket Maximum (or Maximum Out-of-Pocket Expense)

You will have to pay the maximum amount between the deductible and co-payments for policy-covered services before your insurance carrier covers your charges at 100%. Your policy will be divided into an individual out-of-pocket maximum, a family out-of-pocket maximum, and a non-participating provider (non-par provider) maximum. If you choose to use an out-of-network provider, you will have to pay more towards your out-of-pocket maximum before your carrier picks up 100% of the amount allowed (100% of what is considered usual and customary.) Your insurance carrier will only apply the amount you have paid for services that are part of your policy benefit and only the allowed amount (usual and customary.) You will not be given credit for any payments for services that are not part of your policy or above what is considered normal and expected.

Pain Scale

A pain scale is an assessment tool used to evaluate a person’s level of distress (whether physical or emotional). The ranking may either be based on degrees ranging from 0-10, with “0” being the absence of distress and “10” being extreme distress, or a scale of 0-5 in which “0” in the absence of pain and “5” is severe distress.

You can see that the 0-10 leaves a lot open for interpretation concerning the “odd” numbers, while the 0-5 scale consolidates your options.

Palliative Treatment

Treatment is provided to help relieve the symptoms or discomfort of an individual suffering from a terminal illness. This treatment is not designed to prolong one’s life. Hospice agencies support it.

Participating Provider (Par Provider)

Any healthcare provider who has a contract with an insurance plan and is, therefore, a member of that insurance plan network.

Participating Provider Organization Plan/Policy(PPO)

A form of managed care; a cross between a fee-for-service plan and a health maintenance organization; a group of physicians, healthcare agencies, and facilities who have agreed to accept lower/contracted rates with an insurance company in exchange for client referrals. The manager of the plan is the insurance carrier. The plan manager keeps costs down and quality up by contracting services with healthcare providers. Although you are free to choose any healthcare provider you desire, you are given an incentive of lower payments if you choose one of the contracted/PPO providers.

Primary Care Physician(PCP)

a physician contracted by a health maintenance organization (HMO) to coordinate all of your medical care. Primary care physicians typically specialize in family medicine or internal medicine.

Prognosis

The outcome of a disease. The prognosis is a prediction of how an illness will progress or the chance for recovery. It is based on symptoms, co-morbidities (other conditions present), and experience of how the primary disease has behaved.

Recovery Phase

In the case of terminal illness, the recovery phase does not deal with the person becoming well again. It deals with the individual reaching an acceptance of all aspects of your condition.

Remission

Being without disease activity for individuals diagnosed with a chronic or terminal illness.

Self-Determination Act

1991 Congressional Act which allows an individual to make their own medical decisions. From this Act, the Advanced Healthcare Directive was created.

Self-Funded HealthCare

A Self- Funded Healthcare plan is an Employer insurance plan in which the employer takes on the entire risk for financing the health care benefits it provides to its employees. Employers may contract with Third Party Administrators (TPA), such as insurance carriers, to provide certain administrative services such as claims processing. It may also be referred to as an Administrative Service Only (ASO).

Skilled Nursing Facility (SNF)

A facility provides long-term care for chronically ill patients or patients who are not acutely sick but still require skilled services such as physical rehabilitation or intravenous antibiotic therapy.

Stages of Grief

Elisabeth Kubler-Ross initially introduced this in 1969, also known as the Five Stages of Grief. There is no set order or rule which governs the individual’s experience of the five stages outlined by Kubler-Ross. The stages are denial, anger, bargaining, depression, and acceptance. Although she referenced the steps concerning her work with cancer patients in her book “On Death and Dying,” the stages can be applied to many aspects of life.

Sudden Grief

The death of a loved one may occur without warning, making the grieving process more difficult than if there had been time to prepare for the loss.

Terminal Agitation

Restlessness may be experienced in the end phase of a terminal illness.

Terminal Illness/Disease

Terminal illness is an infection or an illness that, despite treatments, will result in death.

Terminal Phase

The final phase of a terminal illness. The individual experiences a life-threatening event, which may result in the recommendation of hospice care.

Third-Party Administrator (TPA)

An independent organization that employer groups contracts to provide administrative services such as claims processing to an employer group. Health insurance carriers are one example of a TPA.

Traditional Medicine/Conventional Medicine

also referred to as Western Medicine. The form of medicine practiced by those holding a medical degree (MD) or doctor of osteopathy (DO) and other healthcare providers (nurses, physical therapists, speech therapists, occupational therapists, et al.) based on applied science.

Usual and Customary Fees

The average rate paid in a geographical area for a particular medical service. Insurance companies may use an individual’s zip code to determine the geographical location. Then, based on a statistical analysis of charges for services within that area, they can determine the usual and customary rate.

Utilization Review Accreditation Committee (URAC)

An impartial organization is set up to review various healthcare organizations such as insurance carriers. URAC may check a part of an organization (such as case management or credentialing) or the entire organization for quality and standards.