Press Home Page > GLOSSARY OF HEALTHCARE RELATED TERMS
Glossary of Healthcare Related TermsAccreditation - evaluative process in which an external body examines a health care organization's operating procedures to determine whether these procedures meet designated criteria as defined by an accrediting body, usually the National Committee for Quality Assurance (NCQA) or the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).
Actuary - person professionally trained in the technical aspects of insurance and related fields, particularly in the mathematics of insurance, such as the calculation of premiums, reserves and other values.
Acupuncture - insertion of hair-fine needles into specific points on the body to help stimulate the flow of one's Qi (pronounced "chee") or natural healing energies. Applying needles to the acupuncture points releases chemicals in the nervous system, which help to moderate pain and stimulate the body's natural healing abilities.
Acupuncturist - trained practitioner that works to relieve obstructions in energy channels that interrupt the flow of energy in the body.
Acute Care - short-term, intense medical care for an illness or injury usually requiring hospitalization.
Administrative Costs - operating costs that are incidental to the delivery of health care services.
Administrative Services Only (ASO) - arrangement between an insurance company, third party administration (TPA) or health maintenance organization (HMO) and an employer who self-insurers its benefit plan by which the insurance company, TPA or HMO performs administrative services only. Such services usually include claims processing but may include other services such as actuarial analysis and utilization review. Employer self-insured plans are generally exempt from state insurance laws and regulation.
Admission Per Thousand (APT) - method of comparing the number of hospital admissions for defined populations. Calculated by taking the number of hospital admissions for a defined population and dividing it by the total number of persons in that population, then multiplying by 1,000.
Advance Directive - generic term for legal documents (such as a living will or health care proxy) that state a person's preferences for medical treatment in the event he or she is unable to make his or her own decisions due to serious illness or injury. Advance directives are legally valid throughout the United States, however, the laws governing advance directives differ from state to state.
Adverse Selection - occurs when a plan enrolls a disproportionately high number of individuals who require more care than the average individual, resulting in greater costs than for an average cross-section of the population.
Alternate Delivery Systems - health services provided in other than an inpatient, acute-care hospital or private practice (e.g., skilled and intermediary nursing facilities, hospice programs, and home health care). Alternate delivery systems are designed to provide needed services in a more cost-effective manner.
Alternative Medicine Rider - Oxford-specific product that allows members to visit chiropractors, acupuncturists, and naturopaths (only in Conn.) without a referral from a primary care physician (PCP). Members, who have this rider, pay the alternative medicine co-pay for medically necessary services. Product is available to large groups in CT, NY, and NJ.
Ambulatory Surgical Facility (AMB/SURG/FAC) - facility currently licensed by the appropriate state regulatory agency for the provision of surgical and related medical services on an outpatient basis.
American Managed Care and Review Association (AMCRA) - trade association representing managed indemnity plans, preferred provider organizations (PPOs), managed care organizations (MCOs) and health maintenance organizations (HMOs). Tends to focus on issues important to open panel types of plans.
American Medical Association (AMA) - organization of physicians that works to develop and promote a set of standards in medical practice, research and education.
Ancillary Services - services, such as x-rays and anesthesia, performed in addition to direct hospital or physician services.
Any Willing Provider (AWP) - form of state law that requires a managed care organization (MCO) to accept any provider willing to meet the terms and conditions in the MCO's contract, whether or not the MCO wants or needs that provider.
Assignment of Benefits - payment of medical benefits directly to a provider of care rather than to a member. Generally requires either a contract between the health plan and the provider or a written release from the subscriber to the provider allowing the provider to bill the health plan.
Authorization - documentation to indicate that the health plan has approved certain medical and/or surgical procedures.
Balance Billing - practice of a provider billing a patient for applicable plan copayments, coinsurance and deductibles and for services not covered under the benefit plan.
Bed Days per 1000 - number of hospital inpatient days per 1,000 health plan members.
Benefits Package - services an insurer, government agency or health plan offers to a group or individual under the terms of a contract.
Birthday Rule - guideline established by the National Association of Insurance Commissioners (NAIC) that states when a dependent child is covered under both parents' health plans, the plan of the parent whose birthday falls earlier in the calendar year pays first. Only the month and the day are considered, not the parents' years of birth. For example, if the mother's birthday month is March and the father's birthday month is June, then the mother's health plan is primary.
Board Certified Physician - doctor who has passed an examination given by a medical specialty board and has been certified as a specialist in that medical area.
Board Eligible Physician - provider who is eligible to take the specialty board examination because he or she graduated from an approved medical school, completed a specific type and length of training, and practiced for a specified amount of time.
Brand Name Drug - trade name under which a drug is advertised and sold.
Capitation - a set dollar amount, per member, paid to a health care provider regardless of the amount of services supplied. The set amount is usually paid to the provider each month based on the number of members for whom the provider is responsible.
Care Management - process, which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs. Health care providers and the insurance company coordinate resources to promote quality and cost-effective outcomes.
Carrier - insurer or managed care plan that underwrites or administers a range of health benefit programs.
Carve Out - refers to a set of medical services that are removed from a basic arrangement. In terms of plan benefits, it may refer to a set of benefits that are contracted for separately (e.g., mental health/substance abuse services).
Case Management - method of managing the provision of health care to members with chronic or high-cost medical conditions. Goal is to coordinate the care to improve both continuity and quality of care and to lower costs.
Case Manager - experienced professional (nurse, doctor or social worker) who works with patients, providers and insurers to coordinate services necessary to provide the patient with a plan of medically necessary and appropriate health care.
Certificate of Authority (COA) - state-issued operating license for a health maintenance organization (HMO).
Certificate of Coverage (COC) - outlines the terms of coverage and benefits available in an insurance company's or health maintenance organization's insured health plan.
Chiropractic Care - involves adjusting the spinal column using very short, quick thrusts to release spinal joints in order to influence the body's nervous system and natural defense mechanisms to alleviate pain and improve overall health.
Coinsurance - a defined percentage of the cost of care that a person is required to pay under the terms of his or her benefit plan.
Common Procedural Terminology (CPT) Codes - list of codes published by the American Medical Association (AMA) to be used by physicians to describe the procedure they have performed.
Competitive Medical Plan (CMP) - federal designation that allows a health plan to obtain eligibility to receive a Medicare risk contract, without having to obtain federal qualification as a health maintenance organization (HMO).
Complementary and Alternative Medicine (CAM) - emphasizes healing and disease prevention by treating the mind, body and spirit. Therapies are used in conjunction with conventional treatments to prevent illness, reduce stress, prevent or reduce side effects and symptoms, or control or cure disease. Some commonly used methods of CAM include acupuncture, chiropractic, vitamins, herbs, massage therapy and yoga. Although CAM is becoming more popular, many of the techniques and procedures used in CAM are still, for the most part, unfamiliar to the majority of the public.
Concurrent Review - assessment of hospital admissions, conducted by medical management nurses, via telephone or on-site visits during a covered person's hospital stay, to evaluate care, treatment, length of stay (LOS) and to conduct discharge planning.
Consolidated Omnibus Budget Reconciliation Act (COBRA) - federal law passed in 1985 which allows employees who become ineligible for group benefits (because of a change in employee class or a reduction in hours worked) and dependents who become ineligible (because of loss of dependent status or the employee's death) to continue their health care coverage. The member must pay the full premium plus a two-percent administrative fee. COBRA is required to be offered by companies that have an average of 20 or more employees in the previous year.
Contracted Rate - negotiated rate between the health plan and each provider type that represents the maximum allowable fee a provider can charge a member. If the provider's usual fees are lower than the contracted rate, the usual fees should be charged to the member. These rates represent a fair and standardized rate for quality service.
Conversion Policy - option to continue membership in an insurance program or health maintenance organization (HMO) on an individual (direct pay) basis once a member no longer qualifies for coverage through a group and has exhausted any coverage extension mandated by federal or state law.
Coordination of Benefits (COB) - contract provision that applies when a person is covered under more than one group health benefits program. COB requires that payment of benefits be coordinated by all programs to prevent duplication of benefits.
Copayment - predetermined fees paid at the time of service for physician office visits and other services. Usually a fixed amount, such as $15.
Cost-Sharing - requirement that beneficiaries pay a portion of their medical costs directly in the form of copayments, deductibles and coinsurance.
Covered Lives - people enrolled in a managed care plan; also called enrollees.
Credentialing - most common use of the term refers to obtaining and reviewing the documentation of professional providers. Such documentation includes licensure, certifications, evidence of malpractice insurance and malpractice history. Generally includes both reviewing information furnished by the provider and verification that the information is correct and complete.
Custodial Care - care provided to an individual that primarily addresses the basic activities of living. May be medical or nonmedical, but the care is not meant to be curative or as a form of medical treatment, and it is often life long. Rarely covered by any form of group health insurance or health maintenance organization (HMO).
Deductible - portion of a an individual's or family's health care expenses that must be paid out of pocket before insurance coverage applies, usually based on a calendar year.
Department of Health and Human Services (HHS) - department within the United States government that is responsible for administering health and social welfare programs.
Diagnosis Related Group (DRG) - statistical system of classifying any inpatient stay into groups for purposes of payment.
Dietician - clinically trained individual who manages the dietary orders and dietary intake of patients. Analyze nutrient levels including vitamins, minerals and amino acids, to ensure that individuals are maintaining optimal physical and psychological health.
Direct Contract Model - managed care health plan that contracts directly with private practice physicians in the community rather than through an intermediary, such as an independent practice association (IPA) or medical group.
Discharge Date - date a member is released from the hospital.
Discharge Planning - part of utilization management concerned with arranging for care of medical needs to facilitate discharge from the hospital.
Discounted Fee-for-Service - physicians are paid a pre-determined amount for each service they provide in accordance with their contracts with a health plan. This amount may be different than the amount the physician usually receives from other payers.
Disease Management - process of intensively managing a particular disease. Encompasses all settings of care and emphasizes prevention and maintenance. Similar to case management, but more focused on a defined set of diseases.
Disenrollment - process of termination of coverage. Voluntary termination would include a member leaving the plan because he or she simply wishes to do so. Involuntary termination would include leaving the plan because of changing jobs or a dependent losing student status.
Dispense As Written (DAW) - instruction from a physician to a pharmacist to dispense a brand-name pharmaceutical rather than a generic substitute.
Durable Medical Equipment (DME) - medical equipment which is not disposable (i.e., is used repeatedly) and is only related to care for a medical condition. Examples would include wheelchairs and home hospital beds.
Eligibility Date - when an individual is eligible for coverage under a benefit plan.
Emergency - a medical or behavioral condition the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the afflicted person with such a condition in serious jeopardy, or, in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to the person's bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person. Also called Medical Emergency.
Employee Retirement Income Security Act (ERISA) - federal law enacted in 1974 which relates primarily to pension and welfare plans and was enacted to protect the interests of workers under these plans. ERISA imposes broad reporting and disclosure requirements on welfare benefit plans, sets standards for fiduciaries, provides remedies and sanctions for non-compliance and gives access to federal courts.
Enrollee - individual enrolled in a managed health care plan.
Enrollment - total number of covered persons in a health plan; the process by which a health plan signs up groups and individuals for membership; or the number of enrollees who sign up in any one group.
Exclusions - disorders, diseases or treatments listed as non-covered services (not reimbursable) in an insurance policy, for which the policy will not provide benefit payments.
Experience Rating - method of setting premium rates based on the actual health care costs of a group or groups.
Explanation of Benefits (EOB) - statement provided to a member or covered insured explaining how and why a claim was or was not paid.
Fee Schedule - listing of the maximum fee that a health plan will pay for certain services based on common procedural terminology (CPT) code. Also may be referred to as a fee maximum or a fee allowance schedule.
Fee-for-service (FFS) - payment of separate fees to physicians for services performed, such as an examination, a test, or a hospital visit.
Flexible Benefit Plan - a benefit plan whereby an employer allows employees to choose from a variety of benefit options. The employee can tailor his or her benefits package to optimize benefits for his or her particular needs.
Formulary - list of medications that are considered preferred therapy for a given managed population and that are to be used by a managed care organization's providers in prescribing medications.
Freedom Plan (FP) - Oxford-specific product that combines a health maintenance organization (HMO) and an indemnity plan. The member has the option to use the HMO or indemnity plan, each time he or she needs health care.
Freedom Plan Metro - Oxford-specific small group plan that features lower premiums and access to Oxford's full network of doctors and hospitals in exchange for lower premiums and modestly higher copays at the point when individuals use health care services.
Frequency - number of times a service was provided.
Gatekeeper - a primary care physician (PCP) who provides a broad range of routine and preventive medical services and refers patients to specialists, hospitals and other providers for specialized services required. In some benefit plans a PCP referral is required to obtain coverage for services from other providers.
Generic Name Drug - official chemical name of a drug. For example, acetylsalicylic acid is the generic name for aspirin.
Global Capitation - capitation payment that covers all medical expenses, including professional and institutional expenses, although it may not cover optional benefits (e.g., pharmacy). Sometimes called total capitation.
Group Model HMO - health maintenance organization (HMO) that contracts with a medical group for the provision of health care services.
Group Policy - insurance policy purchased by an employer, organization or association as a benefit to its employees or members.
Group Practice - American Medical Association (AMA) defines "group practice" as three or more physicians who deliver patient care, make joint use of equipment and personnel, and divide income by a prearranged formula.
Group Practice Without Walls (GPWW) - group practice in which the members of the group come together legally but continue to practice in private offices scattered throughout the service area. Sometimes called "clinic without walls."
Health Care Financing Administration (HCFA) - federal agency that oversees all aspects of health financing for Medicare and also oversees the Office of Managed Care (OMC).
Health Care Fraud - intentional misrepresentation or miscoding of health care transactions by a provider, employer group, employee or member for the sake of personal financial gain (e.g., billing for services, procedures and/or supplies that were not provided, performing non medical or medically unnecessary services, etc.). Health Insurance Portability and Accountability Act (HIPAA) - federal legislation that ensures access to health care coverage for employees who move from one job to another, are self-employed or have pre-existing medical conditions.
Health Maintenance Organization (HMO) - an organization that arranges a wide spectrum of health care services which commonly include hospital care, physician's services and other services with an emphasis on preventive care.
Health Plan - health maintenance organizations (HMOs), preferred provider organizations (PPOs), insured plans and other plans that cover health care services.
Health Plan Employer Data Information Set (HEDISā) - developed by the National Committee for Quality Assurance (NCQA) with considerable input from the employer and the managed care communities, HEDIS is an ever-evolving set of data reporting standards. HEDIS is designed to provide some standardization in performance reporting for financial, utilization, membership and clinical data so that employers and others can compare performance among health plans.
Healthy Mother Healthy Baby (HMHB) - Oxford program that provides expectant mothers with information focused on how to maintain a healthy lifestyle during their pregnancies.
Hospice - facility, organization or agency, certified by Medicare, which primarily is engaged in providing pain relief, symptom management and supportive services to terminally ill individuals and their families.
Identification Card - card issued by a carrier, health plan or third-party administrator (TPA) to covered subscribers and/or members, identifying the person as being eligible to receive coverage for services.
Indemnity Plan - an insurance plan that reimburses for all services covered under its policy. The insured person may choose any provider and is subject to cost sharing, usually in the form of deductibles and coinsurance.
Independent Practice Association (IPA) - an association of physicians and other health care providers, including hospitals, who contract with a health maintenance organization (HMO) to provide services to enrollees, but usually continue to see non-HMO patients and patients from other HMOs.
Individual Enrollment - individuals enrolled in a health plan who are not members of a group.
Initial Eligibility Period - period of time specified in the contract during which the eligible subscribers and their eligible dependents may apply for enrollment in the health plan, without providing evidence of good health to the plan as specified in the contract.
In-Network Provider - physicians, hospitals and other providers who are under contract with a managed care organization and who provide health care services to members of the managed care organization.
Inpatient - care for an individual who has been admitted to a hospital as a registered bed patient and is receiving services under the direction of a physician for at least 24 hours.
Integrated Delivery System (IDS) - a financial or contractual arrangement between health care providers, usually hospitals and doctors, to offer a comprehensive range of health care services. May also include ancillary providers including home health care, physical therapy, etc.
Intermediate Care Facility (ICF) - facility providing an intermediate level of care to individuals who do not require the degree of care and treatment that a hospital or skilled nursing facility (SNF) is designed to provide, but who do require care above the level of room and board.
International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) - listing of diagnoses and identifying codes for reporting diagnosis of health plan enrollees identified by physicians. The coding and terminology provide a uniform language that accurately will designate primary and secondary diagnosis, and provide for reliable, consistent communication on claim forms.
Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) - independent, not-for-profit organization that performs accreditation reviews primarily on hospitals, other institutional facilities and outpatient facilities.
Large Group - any person, firm, corporation, business or association that currently employs more than 50 employees.
Legend Drugs - drugs that by law can be obtained only by prescription and bear the label, "Caution: Federal Law prohibits dispensing without a prescription."
Length of Stay (LOS) - number of days that a member stays in an inpatient facility.
Liberty Plan (LP) - Oxford-specific product offered as a health maintenance organization, point-of-service, and preferred provider organization plan. The Liberty network of providers is a smaller subset of Oxford's Freedom Plan network of providers. In exchange for the smaller network, groups pay lower premiums. Members enrolled in this product must see a Liberty provider in order for services to be covered on an in-network basis.
Living Will - document signed with the formalities necessary for a will containing an individual's specific instructions concerning the type of health care choices and treatments he or she does or doesn't want to receive.
Long-Term Care - assistance and care for people with chronic disabilities. Goal is to help people with disabilities to be as independent as possible. Needed by a person who requires help with the activities of daily living (ADL) or suffers from cognitive impairment.
Maintenance Drugs - legend drugs that treat select chronic lifetime conditions.
Managed Care - health care delivery system that measures performance and influences the utilization and cost of services with the goal of providing quality, cost-effective health care.
Managed Care Organization (MCO) - generic term applied to a managed care plan. May apply to a preferred provider organization (PPO) or health maintenance organization (HMO).
Mandated Benefits - benefits that an insured health plan is required to provide by law.
Massage Therapy - therapy in which pressure is exerted on the body by the hands to increase energy, reduce pain, soothe injured muscles, stimulate blood and lymphatic circulation, and promote a deep sense of balance and relaxation.
Maximum Allowable Charge/Cost (MAC) - maximum that a vendor may charge for something. This term often is used in pharmacy contracting.
Maximum Out of Pocket (MOOP) - amount of money in deductible and coinsurance that an individual must pay out before claims will reimburse at 100 percent of the usual and customary rate (UCR).
Medicaid - jointly funded federal and state program that provides hospital expense and medical expense to low-income families with children and certain aged, blind and disabled individuals.
Medical Loss Ratio (MLR) - ratio between cost to deliver medical care and amount of money taken in by a health plan.
Medical Savings Accounts (MSA) - an account in which individuals can accumulate contributions to pay for out-of-pocket medical expenses.
Medically Necessary- services or supplies as provided by a hospital, skilled nursing facility, physician or other provider required to identify or treat a patient's illness or injury.
Medicare - federal program established under the Social Security Act that provides health insurance for elderly and certain disabled individuals. Medicare has two parts:
Medigap - a term used to describe private health insurance plans that supplement Medicare coverage.
Member - individual covered under a managed care plan. May be either the subscriber or a dependent.
National Association of Insurance Commissioners (NAIC) - association of the insurance commissioners from each state, which establishes national guidelines for insurance companies and health maintenance organizations (HMOs) in such areas as reporting guidelines.
National Committee for Quality Assurance (NCQA) - independent, not-for-profit organization that performs quality-oriented accreditation reviews of health maintenance organizations (HMOs) and similar types of managed care plans.
Naturopathy - a method of treatment focused on treating the whole person through a combination of herbal treatments, dietary supplements, acupuncture, lifestyle changes, stress management, counseling, hands-on manipulations, homeopathy, and other manual therapies.
Network - group of participating health care providers that has agreed to provide care for a health plan's members.
Non-Participating Provider - term used to describe a provider that has not contracted with a carrier or health plan to be a participating provider of health care services.
Office of Managed Care (OMC) - the federal agency that oversees federal qualification and compliance for health maintenance organizations (HMOs).
Open Access - term describing a member's ability to self-refer for specialty care without a referral from another doctor.
Open Enrollment Period - period when eligible employees may enroll in or change health plans; usually occurs once per year.
Open Panel HMO - managed care plan that contracts (either directly or indirectly) with private physicians to deliver care in their own offices.
Out-of-Network Provider - a health care provider with whom a managed care organization does not have a contract to provide health care services.
Out-of-Pocket Costs - costs of health care to be paid by the recipient of care. For an individual covered by health insurance these costs generally include: deductibles, copayments, cost of excluded services and costs in excess of what the insurer has determined to be "customary, usual and reasonable."
Out-of-Pocket Maximum - most a member can pay for covered services subject to any applicable deductibles and coinsurance amounts. After reaching this maximum, covered services are paid in full.
Outpatient Services - health care services a person receives without being admitted to the hospital. Includes any health care services not provided on the basis of an overnight stay in which room and board costs are incurred.
Over-the-Counter (OTC) Drug - drug product that does not require a prescription.
Overutilization - utilization of medical services the cost of which exceeds the benefit to consumers, or the risks of which outweigh the potential benefits to be derived.
Palliative - serving to relieve or alleviate, such as pharmacological management of pain and relief of nausea.
Panel - providers selected to provide services to the members of a managed care plan; generally referred to as "preferred providers."
Participating Provider (PAR) - physician, hospital, pharmacy or other provider type which has contracted with the health plan to provide medical services to covered persons.
Peer Review - evaluation of the quality of total health care provided by medical staff with equivalent training.
Peer Review Organizations (PROs) - groups of health care professionals or practicing physicians paid by the federal government to review and evaluate the services provided by other health care facilities and providers, and to monitor the quality of care given to Medicare patients.
Per-Diem Reimbursement - reimbursement of an institution, usually a hospital, based on a set rate per day rather than on charges. Can be varied by service or can be uniform regardless of intensity of services.
Pharmacy and Therapeutics (P&T) Committee - Oxford-specific committee composed of pharmacists and physicians from various medical specialties that regularly review new and existing medications to ensure formularies remain responsive to the needs of members and providers.
Physician Hospital Organization (PHO) - legal (or perhaps informal) organizations that bond hospitals and their attending medical staff. Frequently developed for the purpose of contracting with managed care plans. May be open to any member of the staff who applies, or it may be closed to staff members who fail to qualify.
Physician Practice Management (PPM) Company - organization that manages physicians' practices, and in most cases either owns the practices outright or has rights to purchase them in the future. Concentrate only on physicians, not on hospitals, although some PPMs also have branched into joint ventures with hospitals and insurers. Many are publicly traded.
Point of Service (POS) - a health plan allowing members to choose to receive services from a participating or non-participating provider with varying levels based on the use of participating providers. Generally includes a gatekeeper function and utilization review.
Practice Guidelines - systematically developed statements on medical practice that assist a practitioner in making decisions about the appropriate health care for specific medical organizations. Managed care organizations (MCOs) use these guidelines to evaluate appropriateness and medical necessity of care. Synonyms include practice parameters, standard treatment protocols and clinical practice guidelines.
Precertification - authorization from a health plan for routine hospital admissions (in- or outpatient), required in advance of the proposed admission. Often involves appropriateness review against criteria and assignment length of stay (LOS). Failure to obtain precertification often results in a financial penalty to either the provider or the member.
Preferred Providers - physicians, hospitals and other health care providers who contract to provide health services to members covered by a particular health plan.
Preferred Provider Organization (PPO) - a network-based, managed care plan that provides a higher benefit level when a member seeks care from a network provider than when a member seeks care from a non-network provider. Usually incorporates utilization review.
Premium Rate - amount paid to a carrier for providing insurance coverage under an insurance contract.
Preventive Care - medical care aimed at prevention, early detection and early treatment of conditions, generally including routine physical examinations, immunizations and well person care.
Primary Care - basic, preventive or general health care typically provided by family practitioners, pediatricians, internists and general practitioners.
Primary Care Physician (PCP) - a physician, generally an internist, pediatrician, family or general practitioner, and occasionally an obstetrician/gynecologist who provides a broad range of routine services and refers patients to specialists, hospitals or other providers as required.
Prospective Payment System (PPS) - generic term applied to a reimbursement system that pays prospectively rather than on the basis of charges. Generally used to refer to hospital reimbursement as applied to diagnosis related groups (DRGs), but it may encompass other methodologies as well.
Prospective Review - reviewing the need for medical care before care is rendered.
Quality Assurance/Quality Management (QA/QM) - formal set of activities to review and affect the quality of services provided. Includes quality assessment and corrective actions to remedy any deficiencies identified in the quality of direct patient, administrative and support services.
Quality Improvement - continuous process that identifies and test solutions to problems in health care delivery, and constantly monitors the solutions for improvement.
Referral - recommendation by a physician and/or health plan for a member to receive care from a different physician or other provider (e.g., physical therapist).
Renewal - continuance of coverage for a new policy term.
Resource-Based Relative Value Scale (RBRVS) - developed by the Health Care Financing Association (HCFA) for use by Medicare. Assigns values to each common procedural terminology (CPT) code for services on the basis of the resources related to the procedure rather than simply on the basis of historical trends.
Retrospective Review - reviewing health care costs after the care has been rendered.
Risk contracting - arrangement in which a health plan or provider agrees to cover a high-risk group and assume the expense of increased health care utilization beyond projected costs or payment provided.
Second Opinion - opinion obtained from a second physician regarding the necessity for a treatment that has been recommended by the first physician. May be required by some health plans for specified treatments or procedures.
Self-funded - a business or company acts as its own insurance company by collecting premiums and paying claims.
Service Area - geographic area serviced by a network of health care providers.
Skilled Nursing Facility - an institution or a distinct part of an institution that is: 1. currently licensed or approved under state or local law; and 2. primarily engaged in providing skilled nursing care and related services as a skilled nursing facility, extended care facility, or nursing care facility approved by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of Hospitals of the American Osteopathic Association or a skilled nursing facility under Medicare law.
Small Group - any person, firm, corporation, business or association actively engaged in business for at least 3 consecutive months, who, on at least 50% of its working days during the preceding twelve months, employed no more than 50 eligible employees.
Staff Model HMO - health maintenance organization (HMO) that employs providers directly and those providers see members in the HMO's own facilities. A form of closed panel HMO.
Standards of Care (SOC) - clinical guidelines used by doctors to determine the usual and necessary procedures and treatments required to restore a person to health.
Subacute Care - various medical-surgical, oncological, rehabilitation and other specialty services for patients who no longer need acute care but require more than traditional skilled nursing care.
Subscriber - person responsible for payment of premiums, or whose employment is basis for eligibility for membership, in a health maintenance organization (HMO) or other health plan.
Summary Plan Description (SPD) - description of the benefits package available to an employee covered under an employer self-insured plan.
Third-Party Administrator (TPA) - firm that performs administrative functions, e.g., claims processing, membership and the like, for employer self-insured plans or a start-up managed care plan.
Unbundling - practice of a provider billing for multiple components of service that were previously included in a single fee.
Underwriting - process by which an insurance company determines medical risk and makes decisions about whom to cover and how much to charge.
Upcoding - billing for a procedure or service that has a higher reimbursement than the service or procedure actually provided.
Urgent Care - care for an illness or injury that is not a medical emergency but requires immediate medical attention.
Usual and Customary Rate - profile of prevailing fees in a geographical area on which providers' fees are based.
Utilization - extent to which members of a covered group use a program or obtain a particular service, or category of procedures, over a given period of time. Expressed as the number of services used per year or per 100 or 1,000 persons eligible for the service.
Utilization Review - a set of procedures used by purchasers of health benefits to contain health costs through assessment of the appropriateness of care, usually before the care is provided.
Utilization Review Organization (URO) - external organization which assesses the medical appropriateness of suggested courses of treatments for patients.
Waiting Period - period of time before an employee becomes eligible for medical benefits. Period of time determined by employer policy.
Yoga - the practice in which physical postures, breathing exercises and meditation are used to reduce stress, lower blood pressure and regulate heart rate.
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