Glossary

Funds actually spent or incurred providing goods, rendering services, or carrying out other mission related activities during a period. Expenses are computed using accrual accounting techniques which recognize costs when incurred and revenues when earned and include the effect of accounts receivables and accounts payable on determining annual income.

In the context of this report, an alternate name for "skilled nursing facility services."

Is the organization with which the State contracts to evaluate the care provided to Medicaid managed eligibles. Typically the EQRO is a peer review organization. It may conduct focused medical record reviews (i.e. Reviews targeted at a particular clinical condition) or broader analyses on quality. While most EQRO contractors rely on medical records as the primary source of information, they may also use eligibility data and claims/encounter data to conduct specific analyses.

Some plans may vary cost shares for services based on place of treatment; in effect, charging acost for the facility in which the service is received.

Occur when the medical record contains evidence of a service that does not exist in the encounter data. This is the most common problem in partially or fully capitated plans because the provider does not need to submit an encounter in order to receive payment for the service, and therefore may have a weaker incentive to conform to data collection standards.

Occurs when the encounter data contain evidence of a service that is not documented in the patient's medical record. If we assume that the medical record contains complete information on the patients medical history, a false positive may be considered a fraudulent service. In a fully capitated environment, however, the provider would receive no additional reimbursement for the submission of a false positive encounter.

Federal tax revenues (principally individual and business income taxes) not earmarked for a particular use.

Medicare's share of FICA is used to fund the HI Trust Fund. In FY 1995, employers and employees each contributed 1.45 percent of taxable wages, with no limitations, to the HI Trust Fund.

Provision authorizing taxes on the wages of employed persons to provide for the OASDI and HI programs. Covered workers and their employers pay the tax in equal amounts.

A program to identify management inefficiencies and areas vulnerable to fraud and abuse and to correct such weaknesses with improved internal controls.