Replaced by Utilization and Quality Control Peer Review Organization (PRO) in 1982 and in 2003 called Quality Improvement Organization (QIO) program.

1. Compilation of financial data maintained by an insurance carrier for reimbursement purposes. Also see physician’s fee profile. 2. Data segregated by specific time period (e.g., quarterly, annually) and target area (e.g., facility or state) for the purpose of identifying patterns. This may include diagnoses, procedures, diagnosis-related groups, and so on.

Examination and assessment of activities of patients and physicians to show trends and patterns of health care services.

Twelve-month period that traditional indemnity insurance companies maintain to determine allowable charges.

Evaluation of a physician’s practice that includes demographics of patients, morbidity data, mortality rates, and treatment patterns. Also called physician profiling.

Dollar amount that remains from a payment after all expenses for the service have been paid.

Type of plan in which an employer pays a portion of the company’s profits to the employees. Such plans can be used as retirement income or for short-term savings.

Prediction of a probable course of a disease or condition of injury and the chances of recovery.

Electronic data report containing hospital-specific data for a number of problem areas identified by the Centers for Medicare and Medicaid Services (CMS) at high risk for payment errors such as specific DRGs and discharges. PEPPER data allow hospitals to compare their performance to other short-term, acute care prospective payment system hospitals as a means of reducing and preventing payment errors.

TRICARE central coordinating agency that investigates and reviews alleged cases of fraud and abuse committed against the Military Health System (MHS) TRICARE program, its beneficiaries, and U.S. taxpayers. Their active involvement investigating and prosecuting health care fraud cases has resulted in a return of millions of dollars to the federal government and Department of Defense (DoD).