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Billing Terms Glossary
Value-Based Care Terms: Definitions for Therapists and Psychiatrists
In this section
- 16 terms defined
- Written for psychotherapists and psychiatrists
- Source organization linked on every entry
Accountable Care Organization (ACO)
General (all payers)Also called: ACO
- Definition
- A group of providers that voluntarily accepts responsibility for the cost and quality of care for a defined population.
- Why it matters
- Behavioral health providers may be part of ACO networks with quality and cost targets.
- Illustrative example
- An ACO shares savings if quality and cost targets are met.
Related terms Medicare Shared Savings Program (MSSP)Shared Savings
Reference source CMS (Centers for Medicare & Medicaid Services) · NAACOS
Categories Value-Based Care Terminology
Alternative Payment Model (APM)
General (all payers)Also called: APM; advanced APM
- Definition
- A payment approach that departs from fee-for-service, such as ACOs or bundled payments.
- Why it matters
- Some APMs qualify under Medicare's Quality Payment Program.
- Illustrative example
- A practice participates in an advanced APM.
Related terms MIPS (Merit-Based Incentive Payment System)MACRAQuality Payment Program (QPP)
Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Quality Payment Program
Categories Value-Based Care Terminology
Bundled Payment
General (all payers)Also called: episode payment; bundled payments
- Definition
- A single payment for all services in an episode of care.
- Why it matters
- Requires coordination and cost management.
- Illustrative example
- A payer pays one amount for a defined treatment episode.
Related terms Value-Based CareCapitation
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Value-Based Care TerminologyPayment & Reimbursement
Capitation
General (all payers)Also called: capitated payment; PMPM
- Definition
- A payment model in which a provider or organization is paid a fixed amount per member for a period, regardless of services used.
- Why it matters
- Shifts financial risk to providers and changes billing to encounter reporting.
- Illustrative example
- A behavioral health organization receives a per-member monthly payment.
Related terms Per Member Per Month (PMPM)Encounter Data
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Value-Based Care TerminologyPayment & Reimbursement
Care Management
General (all payers)Also called: chronic care management; care coordination
- Definition
- Services that coordinate a patient's care across providers, sometimes billed with monthly codes when requirements are met.
- Why it matters
- Supports value-based care and can produce additional revenue where covered.
- Illustrative example
- A care manager tracks patient outreach and time.
Related terms Behavioral Health Integration (BHI)Collaborative Care Model (CoCM)
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Value-Based Care Terminology
Encounter Data
General (all payers)Also called: encounter claim; shadow claim
- Definition
- Records of services delivered under capitated arrangements that must be submitted even though payment is not per claim.
- Why it matters
- Missing encounter data can hurt rate setting and quality measurement.
- Illustrative example
- A capitated provider submits encounter claims to the plan.
Related terms CapitationMedicaid Managed Care Organization (MCO)
Reference source CMS (Centers for Medicare & Medicaid Services) · Medicaid.gov
Categories Value-Based Care TerminologyMedicare & Medicaid Terms
Fee-for-Service (FFS)
General (all payers)Also called: FFS; traditional payment
- Definition
- A payment model in which providers are paid for each service delivered.
- Why it matters
- The default model for most outpatient behavioral health.
- Illustrative example
- A therapist is paid per session.
Related terms Value-Based CareCapitation
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Value-Based Care TerminologyPayment & Reimbursement
MACRA
General (all payers)Also called: Medicare Access and CHIP Reauthorization Act
- Definition
- A federal law that created the Quality Payment Program, replacing the older Medicare payment update formula with MIPS and advanced APM tracks.
- Why it matters
- Explains why some Medicare clinicians report quality data.
- Illustrative example
- A clinician reports to MIPS under MACRA rules.
Related terms MIPS (Merit-Based Incentive Payment System)Quality Payment Program (QPP)Alternative Payment Model (APM)
Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Quality Payment Program
Categories Value-Based Care TerminologyQuality & Risk Adjustment Terms
Medicare Shared Savings Program (MSSP)
General (all payers)Also called: MSSP; Shared Savings Program
- Definition
- A Medicare program that lets ACOs share in savings when they meet quality and cost benchmarks.
- Why it matters
- Shapes how many practices are paid and measured.
- Illustrative example
- A practice joins an MSSP ACO.
Related terms Accountable Care Organization (ACO)Shared Savings
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Value-Based Care TerminologyMedicare & Medicaid Terms
MIPS (Merit-Based Incentive Payment System)
General (all payers)Also called: MIPS
- Definition
- A Medicare program that adjusts payment for eligible clinicians based on performance in quality, cost, improvement activities, and promoting interoperability.
- Why it matters
- Affects Medicare payment for clinicians above eligibility thresholds.
- Illustrative example
- A group reports MIPS quality measures.
Verify: measures and thresholds change yearly.
Related terms MACRAQuality Payment Program (QPP)HEDIS
Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Quality Payment Program
Categories Value-Based Care TerminologyQuality & Risk Adjustment Terms
NAACOS
General (all payers)Also called: National Association of ACOs
- Definition
- A national association of accountable care organizations and value-based care participants.
- Why it matters
- Resource on ACO and value-based payment.
- Illustrative example
- A practice reads NAACOS resources on ACO participation.
Related terms Accountable Care Organization (ACO)Value-Based Care
Reference source NAACOS
Categories Value-Based Care Terminology
Pay for Performance (P4P)
General (all payers)Also called: P4P; quality incentive
- Definition
- A payment approach that gives bonuses or penalties based on measured quality performance.
- Why it matters
- Ties revenue to quality measures.
- Illustrative example
- A payer pays a bonus for follow-up after hospitalization.
Related terms HEDISValue-Based Care
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Value-Based Care Terminology
Per Member Per Month (PMPM)
General (all payers)Also called: PMPM; per-member-per-month payment
- Definition
- A fixed payment or metric expressed per enrolled member per month.
- Why it matters
- Used in capitation and care management payments.
- Illustrative example
- A payer pays a care management fee PMPM.
Related terms CapitationValue-Based Care
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Value-Based Care TerminologyPayment & Reimbursement
Quality Payment Program (QPP)
General (all payers)Also called: QPP
- Definition
- The CMS program for Medicare clinician payment adjustments based on quality, including MIPS and advanced APMs.
- Why it matters
- Some practices are exempt or below thresholds; eligibility must be checked.
- Illustrative example
- A practice checks its MIPS eligibility each year.
Verify: eligibility rules change yearly.
Related terms MIPS (Merit-Based Incentive Payment System)MACRA
Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Quality Payment Program
Categories Value-Based Care TerminologyQuality & Risk Adjustment Terms
Shared Savings
General (all payers)Also called: shared savings program; gainsharing
- Definition
- A payment approach where providers share in savings achieved against a cost target, if quality standards are met.
- Why it matters
- Tied to quality performance.
- Illustrative example
- A provider group receives a portion of savings.
Related terms Accountable Care Organization (ACO)Value-Based Care
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Value-Based Care Terminology
Value-Based Care
General (all payers)Also called: VBC; value-based payment; pay for value
- Definition
- Payment models that reward quality and cost outcomes rather than volume of services.
- Why it matters
- Changes documentation, reporting, and revenue for practices in such contracts.
- Illustrative example
- A payer offers a bonus for meeting measurement-based care goals.
Related terms Pay for Performance (P4P)Alternative Payment Model (APM)Fee-for-Service (FFS)
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Value-Based Care Terminology
More billing terms
- Credentialing & Enrollment 58
- Contracting & Network Management 22
- Claims Processing 172
- Eligibility & Benefits 75
- Payment & Reimbursement 61
- Denials & Appeals 46
- Audits & Compliance 115
- Behavioral Health Specific Terms 148
- CPT, E/M & HCPCS Code Entries 54
- Telehealth Terms 23
- Revenue Cycle Metrics 44
- EDI & Clearinghouse Terms 63
- BCBS, UHC & Commercial Payer Terms 54
- Medicare & Medicaid Terms 145
- Prior Authorization Terminology 22
- Quality & Risk Adjustment Terms 34
- EHR & Healthcare Technology Terms 54
- Provider Data Management Terms 26
- Patient Financial Responsibility Terms 35
- AI & Healthcare Automation Terms 12
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