“THE LANGUAGE OF THE HOSPITAL”. KEY CONCEPTS. CAPACITY THE SIZE OR CAPACITY OF A HOSPITAL IS DETERMINED BY THE NUMBER OF BEDS SET UP AND STAFFED FOR INPATIENT USE. INPATIENT DAYS
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ABUSE: Any incident or practice of a provider, physician, or supplier which, although not usually considered fraudulent, is inconsistent with accepted and sound medical, business, or fiscal practices and directly or indirectly results in unnecessary costs to the Medicare program, improper reimbursement, or program reimbursement for services that fail to meet professionally recognized standards of care or, in some cases, may be medically unnecessary.
CASE MANAGEMENT: A process of identifying plan members with special healthcare needs, developing a health-care strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum healthcare outcome in an efficient and cost-effective manner. Also known as large case management (LCM).
DIAGNOSIS RELATED GROUP (DRG): PATIENTS WITH THE SAME DIAGNOSIS, THE SAME PROCEDURES, AND WITH SIMILAR CHARACTERISTICS, SUCH AS AGE AND PRESENCE OF OTHER SICKNESSES AND COMPLICATIONS. MEDICARE REIMBURSES ACUTE CARE HOSPITALS BY ASSIGNING SPECIFIC PAYMENTS TO EACH “DRG.”