Glossary of Health Care Business Terms

accountable care organizations (ACOs)
Accountable care organizations (ACOs) are designed to be patient-centered and to network physicians, hospitals, and other health care professionals, such as audiologists and speech-language pathologists, with the patients and each other for partnering in care decisions.
balance billing
Balance billing refers to the ability to bill the patient for the remaining cost of the service not reimbursed by insurance. Balance billing is not common in contracts with private insurance companies and cannot be utilized with Medicare beneficiaries. 
bells and whistles
In the hearing health care domain, bells and whistles refers to add-on features to hearing aids that may be unnecessary or unwarranted, but are offered to make a product more appealing to the consumer. Because consumers can spend considerable time and money to improve their hearing, hearing health professionals, including audiologists, should consider whether specific added features are truly beneficial for individual consumers.
Bluetooth technology was created to make communication between devices such as computers and cell phones easier. This wireless technology can be used on many devices, including new, specially equipped hearing aids. The hearing aids that support Bluetooth allow for audio signals from mobile phones and computers to be received wirelessly. These hearing aids enable the user to receive mobile phone calls directly and to access music from a PC.
brick and mortar
In the Internet age, brick and mortar refers to businesses that have physical locations, properties, or storefronts as opposed to businesses that operate virtually from an online website.
Bundling is a business practice of offering two or more goods or professional services together in a package. In audiology, it is combining the cost of hearing aids with follow-up care and service at a single price point. Unbundling of charges separates the services from the product. See Unbundling Hearing Aid Sales.
Centers for Medicare & Medicaid Services (CMS)
The Centers for Medicare & Medicaid Services (CMS) is the agency in the U.S. Department of Health and Human Services that runs the Medicare program and works with the states to run the Medicaid program. The CMS website contains the latest information on Medicare enrollment, benefits, and other helpful tools for the consumer and professional resources on billing, coding forms, and contracting.
The deductible is the amount a consumer owes for health care services covered by his or her health insurance or plan before the health insurance or plan begins to pay. See National Association of Insurance Commissioners website.
direct billing
Direct billing refers to the ability of a health care provider to bill directly for services as an independent practitioner, rather than have his or her services billed "incident to," or under the supervision of, a physician. Audiologists and speech-language pathologists are recognized by CMS as independent practitioners and must direct bill.
Direct-to-consumer refers to the practice of promoting and/or selling a product or service directly to potential consumers via broadcast and print media such as television, radio, magazines, billboards, and the Internet. When used to advertise hearing aids, this business model can exclude referral to audiology professional services. The hi HealthInnovations business model is an example of a direct-to-consumer model. See hi HealthInnovations and UnitedHealthcare: Hearing Benefit.
durable medical equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use are durable medical equipment (DME). Hearing aids may be considered DME. Coverage for DME may include oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics. For more information on hearing aid DME coverage, see Summary of Self-Referral and Anti-Kickback Regulations Under Medicare and Medicaid.
external environments
External environments are the conditions and events surrounding a business that influence decisions, choices, and activities. These environments help determine opportunities and risks of choices.
external forces
External forces comprise pressures from outside a business that can affect the business; such factors include the market prices for supplies and devices, the consumer demand for accessible and affordable care and products, and government regulations and competition.
U.S. Food and Drug Administration (FDA)
The U.S. Food and Drug Administration (FDA) is the federal agency responsible for protecting the public health by assuring the safety, efficacy, and security of drugs, biological products, medical devices, the nation's food supply, and other areas. It has responsibility for regulating the manufacturing, marketing, and distribution of medical devices (including audiologic equipment and hearing aids). FDA is also responsible for advancing the public health by helping to speed innovations that make medicines more effective, safer, and more affordable and by helping the public get the accurate, science-based information they need to use medicines and foods to maintain and improve their health. See FDA Medical Devices webpage.
family practitioners
Family practitioners are medical doctors who have completed a family practice residency and are board certified or eligible. The scope of practice includes children and adults of all ages.
feasibility study
A feasibility study is a controlled process for developing analysis, assessing outcomes, and defining cost benefit and project viability. See Conducting a Feasibility Study.
fee for service
A payment model that involves paying for an unbundled professional service separately is termed fee for service.
A person, bank, credit union, or other entity holding assets (cash, property) or information as an agent for customers, members, or stockholders is a fiduciary. A fiduciary has the duties of loyalty, transparency, diligence, and accounting for all monies handled for the principals.
Franchising is a business model in which many different owners share a single brand name. See Buying or Selling an Audiology Business.
gap analysis
Gap analysis refers to a technique to identify next steps for advancing a business to a desired future state. Synonyms include need-gap analysis, needs analysis, and needs assessment. To do this analysis for an audiology practice, one must list current characteristic factors, competencies, and levels of services—the "what is"—and then cross list the future actions required to reach business objectives—the "what should be." The comparison will yield gaps that need to be addressed.
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act is a law designed to improve the efficiency and effectiveness of the nation's health care system, and involves ensuring health insurance coverage, and the privacy and security of health information.
health care reform
The Patient Protection and Affordable Care Act (commonly called the Affordable Care Act, ACA, or health care reform) is an important national issue. Although the outcome of debates over specific reforms is not known, audiologists, like other health care professionals, need to be familiar with such terms.
in-network co-insurance
The percentage the consumer pays (for example, 20%) of the allowed amount for covered health care to providers who contract with the consumer's health insurance or plan is the in-network co-insurance cost, which is typically less than a policy's out-of-network co-insurance cost. See National Association of Insurance Commissioners website.
medical home
The Patient-Centered Medical Home (PCMH) model of care offers personalized care through coordination by a primary care provider (PCP). The PCP is responsible for being the lead to the interdisciplinary team, encouraging cooperation and collaboration between the providers and the patient. The primary distinguishing characteristic of the PCMH is the focus on a single practice with multiple physicians, while its counterpart, the accountable care organization (ACO), houses many practices within one organizing entity.
Medicare Physician Fee Schedule (MPFS)
The Medicare Physician Fee Schedule (MPFS), published annually by the Centers for Medicare & Medicaid Services (CMS), outlines current rates for service codes. The MPFS, along with other national fee analyzers, can be used to determine rates for services in audiology practices. See  Private Health Plans: An Overview.
non-physician practitioner (NPP)
Non-physician practitioner (NPP), for Medicare purposes, "includes Physician Assistants (PAs), under supervision of a physician, and Nurse Practitioners (NPs), working in collaboration with the physician and state law." Both PAs and NPs can refer Medicare beneficiaries for diagnostic audiologic evaluation and provide a written referral.
In health care, network comprises the facilities, providers, and entities a health insurer or plan has contracted with to provide health care services. See National Association of Insurance Commissioners website.
nurse practitioners (NPs)
Nurse practitioners or NPs are advanced practice registered nurses (APRNs) who have completed graduate-level education (earned a Master of Nursing or Doctor of Nursing Practice degree). NPs can diagnose diseases and provide appropriate treatment including prescribing medications. They can serve as primary care providers (PCPs) or work within a medical practice. NPs have a holistic view and philosophy of individualized care and focus on medical conditions and wellness, prevention, and quality of life. NPs hold licensure and national board certification. NPs work in a variety of settings (within the Veterans Administration system, hospitals, private and community clinics, schools, nursing homes, and private medical practices).
primary care provider (PCP)
A primary care provider (PCP) is a health care professional often considered to be the medical home for individuals (see medical home). The PCP is the main health care provider for non-emergency situations. The PCP's role is to provide preventive care (including hearing screening), identify and treat common conditions, and make appropriate referrals for specialized services such as audiology. PCPs are often medical doctors but can also be physician assistants or nurse practitioners.
personal sound amplification product (PSAP)
Personal sound amplification products (PSAPs) are not intended to improve hearing for individuals with hearing loss. They are intended to amplify environmental sound for consumers with normal hearing. Examples of situations in which PSAPs typically are used include hunting (listening for prey), bird watching, listening to lectures with a distant speaker, and listening to soft sounds that would be difficult for normal hearing individuals to hear (e.g., distant conversations, performances). Because PSAPs are not intended to diagnose, treat, cure, or mitigate disease and do not alter the structure or function of the body, they are not devices as defined in the Federal Food, Drug, and Cosmetic Act. As such, there is no regulatory classification, product code, or definition for these products. Furthermore, there are no requirements for registration of manufacturers and listing of these products with the U.S. Food and Drug Administration. See FDA Regulatory Requirements for Hearing Aid Devices and Personal Sound Amplification Products.
physician assistants (PAs)
Depending on state laws, physician assistants (PAs) generally have a formal relationship with a physician supervisor. The physician must be licensed within the state in which the PA is working, but does not have to work at the same location. Supervision can be in person or via telecommunications or consultation. Many PAs practice alone in remote or underserved areas in satellite clinics. Physician assistants conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, give medical orders, and write prescriptions. PAs work in hospitals, clinics, and other types of health facilities and exercise autonomy in medical decision making as determined by the supervising physician.
social, technological, economic, environmental, and political (STEEP)
Factors that make up the current external environment of a practice/organization and influence and affect business decision making are STEEPsocial, technological, economic, environmental, and political.
A business or enterprise controlled by a parent company through greater than 50% of its voting stock is a subsidiary of the parent company. The company hi HealthInnovations is a subsidiary of UnitedHealthcare.
A superbill is a standard form used by health plans to process claims. For the professional rendering services, it provides a time efficient means to document services, fees, codes, and other information required by insurance companies. See Model Superbill for Audiology [DOC].
Telepractice is the application of telecommunications technology to deliver professional services at a distance by linking clinician to client, or clinician to clinician, for assessment, intervention, and/or consultation. See Telepractice.
usual, customary, and reasonable (UCR)
Usual, customary, and reasonable (UCR) refers to the amount paid for an identical or similar medical service in a geographic area or that providers in a specific area usually charge for a particular health care service. UCR is sometimes used to determine the allowed amount. See Private Health Plans: An Overview.

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