There are a myriad of organizations and regulations instituted to establish, enforce, and apply policies related to the delivery and payment of healthcare in America. Their relevance to your patients, your place of work, and to your practice cannot be overstated. Here is a Quick-E overview on them:

Medicaid: A medical insurance program that provides benefits to low income and disabled individuals. It is coordinated at the federal level through the Centers for Medicare & Medicaid Services (CMS, formerly the Health Care Financing Administration, HCFA). It is jointly funded by both state and federal governments, and administered by state governments. The states determine eligibility based on federal guidelines.
Medicare: A federal health insurance program for retirees age 65 or older and for qualified disabled people. Medicare has two parts: Part A pays primarily for inpatient hospital care. Part B pays for physician’s services and other health services. Medicare is funded through mandatory contributions by employers and employees, general tax revenues, premiums paid by beneficiaries, and co-payments of supplemental health insurance.
HMO: Health Maintenance Organization. A form of health insurance combining a range of coverage in a group basis. A group of physicians and other healthcare professionals offer care through the HMO for a flat monthly rate with no deductibles. Only visits to professionals within the HMO network are covered. All visits, prescriptions, and other care must be approved by the HMO in order to be covered. A primary physician within the HMO handles referrals.
PPO: Preferred Provider Organization. A healthcare organization composed of physicians, hospitals, or other healthcare entities that provides services at a reduced fee. A PPO is similar to an HMO, but care is paid for as it is received instead of in advance in the form of a scheduled fee. PPOs may also offer more flexibility by allowing visits to out-of-network professionals at a greater expense to the insured. Visits within the network require only the payment of a small fee. There is often a deductible for out-of-network expenses and a higher co-payment. A policyholder has a primary physician who handles referrals. After any visit, the policyholder submits a claim, and is reimbursed for the visit minus the co-payment.
CMS: Centers for Medicare & Medicaid Services. Formerly the Health Care Financing Administration (HCFA). CMS is the federal agency responsible for administering Medicare, Medicaid, HIPAA, and several other health-related programs.
Prospective Payment System: The system used by Medicare to reimburse providers a set amount based on the patient’s diagnostic-related groups (DRGs). This system is commonly referred to as PPS or DRG payment system.
JCAHO: Now known simply as The Joint Commission, it was formerly called the Joint Commission on Accreditation of Healthcare Organizations. An independent, not-for-profit organization that evaluates the quality and safety of healthcare facilities. To maintain and earn accreditation, organizations must have an extensive on-site review by a team of Joint Commission healthcare professionals, at least once every three years. Accreditation may be awarded based on how well the organization meets the standards. Accreditation is sometimes used by insurance health plans in setting eligibility requirements and making payment decisions.

Editor’s note: This excerpt was taken from Quick-E! Charting: Documentation & Medical Terminology Clinical Nursing Reference. For information on this or any of the 10 titles in the series, click on the link at the top right of this page.