Approval:
Refers to the process whereby a managed care organization (MCO), insurance plan, or some other payer agrees to pay for a health care service being requested. Many patients misinterpret a payer's "approval" or "denial" of a recommended health care service as a conclusive statement as to whether they can or can not access the recommended service. A payer's approval means that they agree to pay for the service. A denial means they will not pay for the service. There are various reasons why a payer may deny a recommended service. There are also procedures available to appeal a denial. It is important for patients to understand that they always have the right to access a recommended service, but will need to pay for it themselves. Authorization:
Refers to the process whereby a physician seeks a managed care organization's approval, agreement to pay, for a recommended test, procedure, or consultation, on behalf of a patient. In most managed care plans the primary care physician can only request services that need authorization. The managed care organization controls the approval or denial process.
Basic health services:
Benefits that all federally qualified HMOs must offer.
Behavioral health care:
Assessment and treatment of mental and/or psychoactive substance abuse disorders.
Beneficiary:
Any person, either a subscriber or a dependent, eligible for service under a health plan contract.
Benefit package:
A collection of specific services or benefits covered by a managed care plan or insurance carrier.
Capitation:
A method of reimbursement where a health care organization, physician, or other provider of health care services is paid a fixed amount of money per-member-per-month (PMPM) to provide all of the needed covered and contracted services for those members. The risk of patient services lies with the provider. As an example, we get paid $12.00 per commercial member per month for our HMO patients.
Closed panel:
The physicians whom members of a managed care plan are required to see because the plan has contracted with them to be on the panel; the managed care plan will not pay for services rendered to members by physicians or other providers that are outside of the panel.
Coordination of benefits:
A cost-control mechanism used by most insurers and managed care plans to avoid duplication of paying benefits when there is more than one insurance or managed care company responsible for payment of claims.
Co-payment:
A cost-sharing dollar amount that an insured person pays out-of-pocket for medical services.
Cost sharing:
A general set of financing arrangements via deductibles, copays, and/or coinsurance in which a person covered by the health plan must pay some of the costs to receive care.
Deductible:
The up-front annual dollar amount that must be paid by the subscriber/member before insurance benefit coverage applies.
Denial:
Refers to the process whereby a managed care organization (MCO), insurance plan, or some other payer does not agree to pay for a health care service being requested. Many patients misinterpret a payer's "approval" or "denial" of a recommended health care service as a conclusive statement as to whether they can or can not access the recommended service. A payer's approval means that they agree to pay for the service. A denial means they will not pay for the service. There are various reasons why a payer may deny a recommended service. There are also procedures available to appeal a denial. It is important for patients to understand that they always have the right to access a recommended service, but will need to pay for it themselves.
Dependents:
Generally the spouse and children, as defined in a contract, of a person or subscriber covered by a health plan.
Disenrollment:
The process of termination of coverage.
Drug formulary:
A listing of prescription medications that are preferred for use by the health plan and that will be dispensed through participating pharmacies to covered persons. This list is subject to periodic review and modification by the health plan.
Employee Assistance Program (EAP):
Services designed to assist employees, their family members, and employers in finding solutions for workplace and personal problems. Services may include assistance for family / marital concerns, legal or financial problems, elder care, child care, substance abuse, emotional stress issues, etc.
Encounter:
Face to face meeting between a covered person and a health care provider where services are provided or rendered.
Enrollee:
Any person eligible for services, either as a subscriber or a dependent, in accordance with a contract.
Exclusions:
Special conditions, such as preexisting conditions or circumstances, that are not covered in a group health plan.
Exclusive Provider Organization (EPO):
A form of managed care plan that is similar to an HMO in that it can use primary care physicians as gatekeepers, often capitates specialty providers, has a limited provider panel, and uses an authorization system.
Explanation of benefits (EOB) statement:
A statement mailed to a member or covered insured explaining how reimbursement was determined, why a claim was or was not paid, and the general appeal process.
Extended care facility:
An institution that provides skilled nursing, intermediate, or custodial care.
Fee-for-service:
A traditional form of reimbursement in health care where total reimbursement is made on the basis of the number of services rendered to the patient. The risk of patient services lies with the insurers / payers.
Gatekeeper:
A "primary care" physician or clinic responsible for all health care services provided to plan members. If plan members require services not available through the primary care physician, the primary care physician would submit a referral authorization request to the managed care organization.
Grievance procedure:
A formal process for the resolution of member or provider complaints, generally mandated by state law or federal qualification standards for HMOs.
Guidelines: ( clinical practice guidelines)
Systematically developed statements on medical practice that assist a provider and a patient in making decisions about appropriate health care for specific medical conditions. Guidelines are frequently used to evaluate appropriateness and medical necessity of care. Outcomes can be used as information to modify or improve guidelines.
HCFA: (Health Care Financing Administration)
The federal agency responsible for administering Medicare and overseeing each state's administration of Medicaid. HCFA also manages HMO qualification and other utilization and quality review programs.
HMO: (Health Maintenance Organization)
An organization responsible for providing or arranging the provision of comprehensive health care services, usually on a prepayment basis; for example, to enrolled persons within a designated population. Some HMOs emphasize prevention, wellness, and the gatekeeper model of primary care to maintain the health of their enrolled populations and lower costs.
HEDIS: (Health Plan Employers Data Information Set)
A set of health plan performance measures that permits the trending of a specific health plan's data from year to year or comparison of measures among plans. Five major areas of performance are (1) quality of care, (2) access and patient satisfaction, (3) membership, (4) utilization, and (5) descriptive information on health plan management.
Hospice:
A facility and or outpatient service program that provides palliative care for the terminally ill by relieving pain and providing counseling.
Indemnity:
An insurance program in which the insured person is reimbursed for covered expenses.
IPA: (Independent Physician or Practice Association)
A health care model that, on the one hand contracts with insurance plans to care for their enrollees, and on the other hand contracts with providers to render the covered health care services, usually in return for a negotiated fee. Physicians continue in their existing individual or group practices, and are compensated on a per capita, fee schedule, or fee-for-service basis.
JCAHO: (Joint Commission on Accreditation of Healthcare Organizations)
A private, not-for-profit organization that evaluates and accredits hospitals and other health care organizations providing home care, mental health care, ambulatory care, and long-term care services.
Length of stay: (LOS)
The number of days that a patient stayed in an inpatient facility i.e. Hospital. This number is commonly tracked by managed care organizations in an attempt to monitor a provider's ability to control health care costs by minimizing the number of hospitalized days it takes to resolve a particular disease process.
Long-term care:
Assistance and care for persons with chronic disabilities. Long-term care's goal is to help people with disabilities be as independent as possible; thus it is focused more on caring than on curing. Long-term care is needed by a person who requires help with activities of daily living (ADLS) or who suffers from cognitive impairment.
Managed care:
Form of health coverage where enrollee utilization patterns and provider service patterns are monitored before, during, and after the actual delivery of services. Managed care usually has the insurer and the managed care organization playing a much more active role in determining what is done for an enrollee, where it will be done, who will do it, and what they pay for it. Managed care entities can be designed in many ways; that is, as PPO's, HMO's, OPA's, or alternative delivery systems / integrated provider networks.
Managed Care Organization (MCO):
A managed-care organization (MCO) is an organization that coordinates health-care services in order to reduce the costs associated with those health-care services. Health care insurers, whether they be a health maintenance organization (HMO) or a preferred provider organization (PPO) are examples of different types of managed-care organizations. In most instances where your insurer is an HMO, it has contracted with another type of managed-care organization, an independent physician association (IPA). Insurers contract with IPA's to "down load" the risk of providing health-care services to their enrollees. They do this by paying the IPA a set amount of money per member per month to pay for all the health-care services utilized by all of its members that month. The IPA's are also responsible for contracting with all of the needed providers.
Maximum allowable charge: (MAC)
The maximum that a provider may charge for service.
Medicaid:
A health insurance program adopted in 1965 for eligible disabled and low-income persons and administered by the federal government and participating states. The program's costs are shared by the federal and state governments, and paid for by general tax revenue.
Medicare:
A nationwide, federally administered health insurance program that covers the cost of hospitalization, medical care, and some related services for eligible persons, usually patients over 65 years old. Medicare has two parts: Part A covers inpatient costs. Medicare pays for pharmaceuticals provided in hospitals, but not for those provided in outpatient settings. Also called supplementary medical insurance program, Part B covers outpatient costs for Medicare patients.
Medicare supplement policy:
A policy guaranteeing that a health plan will pay a policyholder's coinsurance, deductible, and co-payments and will provide additional health plan or non-Medicare coverage for services up to a predefined benefit limit. In essence, the policy pays for the portion of the cost of services not covered by Medicare.
Morbidity:
An actuarial determination of the incidence and severity of sicknesses and accidents in a well-defined class or classes of persons.
Mortality:
An actuarial determination of the death rate at each age as determined from prior experience.
Out-of pocket maximum:
The maximum amount that an insured will have to pay for covered expenses under the plan.
Outcome measurement:
Outcome measurement is recording the outcomes / results of health care intervention. Measuring outcomes permits comparison to the original situation of the patient and is used for comparing outcomes of multiple physicians for the same patient problem / service.
Outcome research:
Outcome research is research that is designed to identify and analyze the outcomes and costs of alternative interventions for a given clinical condition to determine the most appropriate and cost-effective means to prevent, diagnose, treat, or manage the condition, or to develop and test methods for reducing variations in care.
Open access:
A self-referral arrangement allowing members to see participating providers for open panel specialty care without a referral from another doctor.
Open enrollment period:
A period when a patient may change health plans. Usually occurs once per year.
Open panel:
A managed care plan that contracts with private physicians to deliver care in their own offices.
Out-of-area benefits:
The scope of emergency benefits available to HMO members while temporarily outside their defined service areas. Some HMOs offer unlimited out-of-area emergency coverage. Others impose a stated maximum annual dollar benefit. Emergency coverage is usually the only HMO benefit in the total benefit package for which members may need to file claims forms for reimbursement of their out-of-pocket expenditures for care.
Outpatient:
A person who receives health care services without being admitted to a hospital.
Participating provider:
A provider who has contracted with the health plan to provide medical services to covered persons. The provider may be a hospital, pharmacy, other facility, or a physician who has contractually accepted the terms and conditions set forth by the health plan.
Peer review:
Evaluation of a physician's performance by other physicians, usually within the same geographic area and medical specialty.
Per member per month:
Specifically applies to a revenue paid to providers for each enrolled member each month.
Point-of-service:
This product may also be called an open-ended HMO and offers a transition product incorporating features of both HMOs and PPOs. Beneficiaries are enrolled in an HMO, but have the option to go outside of the more limited HMO provider network, into a larger PPO provider network, for an additional cost paid by the enrollee.
Preadmission review:
A utilization review mechanism used by plans that have telephone-based nurses review cases, assign expected lengths of stay, and issue authorization numbers.
Pre-existing condition:
Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage.
PPO: (Preferred Provider Organization)
Term applied to a variety of contractual relationships between hospitals, physicians, insurers, employers, and / or third-party administrators. In a PPO, individual providers or organizations negotiate with group purchasers to make available health services for a defined population. This arrangement typically shares the following three characteristics: (1) a negotiated system of payment for services that may include discounts from usual charges or ceilings imposed on charges, per diems, or per discharge reimbursement; (2) financial incentives for individual insureds to use contracted providers, usually in the form of reduced co-payments and deductibles, broader coverage of services, or simplified claims processing; and (3) an extensive utilization review program of provider services.
Premium:
A prospectively determined rate that a member pays for specific health services. Generally, a comprehensive prepaid health plan has a premium rate established for single members and for families.
Preventive health services:
Preventive health services refers to those services, usually standardized through clinical practice guidelines, intended to assist in the identification and prevention of many significant disease processes.
Primary care:
Provision of basic or general health care by primary care physicians, nurse practitioners, physician's assistants, and other physician extenders. Primary care often emphasizes those medical services required to maintain good health or to treat simpler and more common diseases.
PCP:
(Primary Care Physician) A physician whose practice is usually devoted to internal medicine, family / general practice, or pediatrics.
Provider:
A physician, hospital, group practice, dentist, nursing home, home care agency, or any individual or group of individuals that provides a health care service.
Respite care:
Temporary care provided in a patient's home to give the primary caregiver time off from the demand of taking care of a family member.
Retrospective review:
Determination of medical necessity and / or appropriate billing practice for services already rendered.
SNF: (Skilled Nursing Facility)
A facility that provides health and social services to patients on a less than acute basis when ongoing skilled care is required. These are commonly referred to as nursing homes.
Standard benefit package:
A specified set of minimum medical benefits.
Sub-acute:
A level of institutional care for patients not requiring the intensity of services of a specialty or tertiary hospital but that typically support some services.
Tertiary care:
Those health care services provided by highly specialized providers such as thoracic surgeons. These services often require highly sophisticated technologies and facilities.
Triage:
The classification according to severity of sick or injured persons to direct care and ensure the efficient use of medical and nursing staff and facilities.
Utilization management:
Utilization management is a keystone to effective health care management, and is an important determination in both the cost and quality in a managed care organization. Appropriate utilization protocols and standards should be based on reasonable scientific evidence. Good utilization management systems monitor for underutilization as well as overutilization.
Waiting period:
The period of time between an employee's hire and his or her enrollment in a health care plan.
|
