Guide to Managed Healthcare

By

Joseph A. Velky

[ Table of Contents]
 Go to Chapter [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [Glossary]

PHind GLOSSARY

Provider Health insurance network directory

A B C D E F G H I J K L M N O P Q R S T U V W

A

AAPCC
-See ADJUSTED AVERAGE PER CAPITA COST

ACCREDITED STANDARDS COMMITTEE X12
The American National Standards Institute (ANSI) group, established in 1979, is the primary leader in developing electronic data interchange protocols for business transactions.  The ASC X12 standards are the basis for healthcare data exchange under HIPAA.

ACR 
-See ADJUSTED COMMUNITY RATE

ACR_NEMA
American College of Radiology and the National Equipment Manufacturers Association.  Corroboratively, these two groups have determined the DICOM standard and many of the standards for teleradiology.

ACUTE ALCOHOLISM 
Severe intoxication with temporary mental disturbances caused by the excessive consumption of alcohol which may require a short period of detoxification (also see Chronic Alcoholism). 

ACUTE IN-PATIENT CARE 
Care rendered in the course of treating an illness, injury, or condition marked by a sudden onset or abrupt change of status requiring prompt attention (which may include hospitalization), but which is of limited duration and not expected to last indefinitely (also see Chronic In-patient Care).

ACUTE PSYCHIATRIC HOSPITAL
A facility duly licensed as an acute psychiatric hospital in the state in which it is located. The facility must have an organized medical staff which provides 24-hour in-patient care for mentally disordered, incompetent, or other patients. The hospital must provide the following basic services: medical, nursing, rehabilitative, pharmacy, and dietary services. 

ADJUSTED AVERAGE PER CAPITA COST (AAPCC)
Adjusted Average Per Capita Cost - The Healthcare Financing Administration's (HCFA's) estimate of the cost to care for a Medicare recipients under fee-for-service Medicare Program in a given geographical area.

ADJUSTED COMMUNITY RATE (ACR)
Adjusted Community Rate - The calculation of a premium a plan would charge for providing the Medicare-covered benefits to a group. The ACR includes an adjustment to allow for the greater intensity and frequency of utilization by Medicare recipients. The ACR includes a normal profit of a for-profit HMO. The ACR may be equal to or lower than the APR but can never exceed it.

ADMISSION CERTIFICATION
A process established by a managed care plan to authorize an admission to a hospital or facility. MHIS includes all programs that managed care plans refer to by names such as pre-certification, pre-admission review, pre-notification, pre-authorization, prior authorization or other related programs and names.  Some plans use these names for authorizations for both inpatient, outpatient, and non-hospital care. MHIS differentiates between admission certification (AD) and ambulatory procedures (AM). Both AD and AM programs of managed care plans require authorizations for treatment to be covered.

ADMISSION-DISCHARGE-TRANSFER SYSTEM (ADT)
A software system used by healthcare facilities to track patients from their arrival to their departure.

ADT
-See ADMISSION-DISCHARGE-TRANSFER SYSTEM (ADT)

ADVERSE SELECTION 
The selection of members in a managed care plan who are less healthy than the general population. 

AFE-HCT
-See ASSOCIATION FOR ELECTRONIC HEALTH CARE TRANSACTIONS

AGENT
An individual, department, or company that performs utilization review or billing services for managed-care plans. The agent may be a third party agent or an employee of the insurer, network, or employer. 

ALLOWED COST
The total amount of reimbursement a provider is entitled to receive, including any patient co-payment and incentive withhold, but excluding other coverage.

ALTERNATIVE DELIVERY SYSTEM
Health maintenance organizations, or preferred provider organizations are alternative delivery organizations. These health plans deliver health services through networks of physicians and hospitals

AMBULATORY CARE
Services for patients who do not need an overnight stay in a healthcare facility.  Also referred to as outpatient care.

AMBULATORY PATIENT GROUP (APG)
Originally developed by 3m Health Information Systems and later modified by HCFA.  This coding hierarchy packages related ambulatory medical and surgical services together for the purpose of Medicare reimbursement under the prospective payment system.  Its inpatient sibling is the DRG (diagnosis related group). See ambulatory payment classification.

AMBULATORY PAYMENT CLASSIFICATION (APC)
This coding hierarchy collects and separates ambulatory service and procedural codes from HFCA’s Procedural Coding System (HCPCS) into 346 groups.  These service bundles are the basis for Medicare reimbursement for both hospital and physician services under the prospective payment model.  APCs are a migratory outgrowth of their predecessors, ambulatory patient groups, and are similar to inpatient DRGs (diagnosis related groups).

AMBULATORY PROCEDURE/SURGERY 
Procedures to be performed on an outpatient basis in an office, clinic, or hospital. Many managed care plans have criteria or a list of ambulatory procedures. Authorization by the insurer, third party review organization or gate keeper is generally required.

AMBULATORY SURGICAL CENTER 
A public or private medical-surgical establishment with an on site organized medical staff of physicians and a permanent facility with operating room equipment which does not provide services or accommodations for patients to stay overnight. 

ANCILLARY SERVICES
Procedures, tests, imaging and support services provided in a healthcare setting.

ANNUAL BENEFIT MAXIMUM 
A dollar or service amount which is specified in the schedule of benefits as the maximum amount that the insurer or payor is obligated to pay on behalf of a member for covered services. The maximum may be for a particular type or category of services provided to a member in any given calendar year. In some cases, the maximum is a number of days or visits rather than a dollar amount. 

APC
-See AMBULATORY PAYMENT CLASSIFICATION

APG
-See AMBULATORY PATIENT GROUP

APPEALS 
A process for providers or patients to request a reconsideration of a payment or denial of service. The steps in the appeal process can vary among managed care plans.  The process generally begins by contacting the agent who denied approval or payment. Written statements follow with detailed descriptions of the diagnosis and treatment. The managed care plans use many different procedures to review and process an appeal. Some have special provider committees or review by a board. Other plans use arbitration to resolve appeals. The state department of insurance has procedures for appeals if enrollees are not satisfied with a decision. The Department of Corporations reviews the Health Maintenance Organizations.

APPLICATION SERVICE PROVIDER (ASP)
An entity that allows clients to tap into and use applications held on an off-site third-party server, usually on a subscription or per member, per month basis.  Halfway between on-site processing and outsourcing, this model allows the client to control the processing workflow while eliminating the need to purchase and maintain the application software.

APR
-See AVERAGE PAYMENT RATE

ASP
See APPLICATION SERVICE PROVIDER

ASSOCIATION FOR ELECTRONIC HEALTH CARE TRANSACTIONS (AFE-HCT)
A healthcare organization that works to reduce healthcare costs through improved and pervasive use of electronic data exchange (www.afehct.org).

AUTHENTICATION
A confirmation of a user’s identity, generally through username and password of biometric characteristics.  Compare authorization.

AUTHORIZATION 
1. The procedure for obtaining prior approval for all services provided to members under the terms of their health services contract.
2. A confirmation of a user’s access levels within a network after successful login and authentication.

AVERAGE PAYMENT RATE (APR)
Average Payment Rate - The amount that HCFA could conceivably pay an HMO for services to Medicare recipients under a risk contract. The figure is derived from the AAPCC for the service area, adjusted for the expected characteristics of the Medicare recipients that enroll in the plan.      

B

BACK END, FRONT END
The back end is the server or host, and the front end is the client or user interface, such as a graphical screen or a Web site.   Front end is what the user sees and interacts with for online architectures; the back end is the Web server and its corresponding host computers.

BALANCED BUDGET ACT OF 1997 (BBA)
A five-year federal budget balancing plan to restructure the Medicare system.  The BBA includes limits on payment growth rates, restructured reimbursement methods, reductions in update factors for the prospective payment system and incentives to decrease the number of medical residents.

BAYESIAN NETWORK
A form of artificial intelligence (named for Bayes’ Rule) that calculates probability based on a group of related or influential signs.  Once a Bayesian network is taught the symptoms and probable indicators of a particular disease, it can assess the probability of that disease based on the frequency of signs in a patient.

BBA
-See BALANCED BUDGET ACT OF 1997

BEAM SPLITTER
A device that divides the image beam of a clinical examining scope so the physician has the choice of looking at the image on a video monitor or directly through the scope.

BEHAVIORAL DISORDER 
A pathological state of mind producing clinically significant (including, but not limited to affective, cognitive, and behavioral) or physiological symptoms (illness) together with impairment in one or more major areas of functioning (disability) wherein behavioral health services can reasonably be anticipated to result in improvement. 

BEHAVIORAL HEALTH SERVICES 
Services, supplies, and/or accommodations provided in a practitioner's office, a person's home, a facility, an out-patient treatment program, or at the scene of an accident. These services, supplies, and/or accommodations are generally recognized as appropriate for diagnostic or therapeutic purposes in the treatment of a behavioral disorder, chemical dependency, or psychological injury. Behavioral health services include, but are not limited to, the following: assessment; diagnosis; treatment planning; medication management; individual, family, and group psychotherapy; counseling; art and recreational therapy; psychological education; and psychological testing. 

BEN
-See BENEFITS

BENEFIT AGREEMENTS 
The written agreement entered into by the managed-care plan and a group or individual under which the managed-care plan provides, indemnifies, or administers health-care benefits. 

BENEFITS (BEN)
Those health-care services which a member is entitled to receive pursuant to the terms of their health-services contract.

BILLED CHARGES 
The amount actually charged for covered services.

BIOINFORMATICS
The use of IT to acquire, store, manage, and analyze any type of biological data.  Today’s accelerated progress in genetic research is possible, in part, because of this combination of biology, powerful algorithm tools, and immense databases.  See geonomics.

BIOMETRICS
Electronic capture and analysis of biological characteristics, such as fingerprints, facial structure, or patterns in the eye.  Through advancements in smart cards and cheaper reader prices, biometrics is catching on as an alternative to password security.

BIRTHDAY RULE 
A rule used to determine the primary and secondary carrier in administering benefits for a patient who has dual coverage and a coordination of benefits clause. The subscriber with the earliest birth date in the year determines the primary carrier.

BLOCK GRANT
 proposed method of administering Medicaid benefits.  Under a block grant system, Medicaid would not be federally controlled—instead each state would be given a single grant, and the state would have to decide who is eligible for the benefits and how to divide the funds.

BUSINESS COALITIONS ON HEALTH
Groups of business owners (especially self-insured companies), associations, and others that discuss ways to keep healthcare affordable.

C

CALENDAR YEAR 
A period commencing on January 1 of any year and terminating on midnight December 31 of the same year. 

CAPITATION 
A pre-paid monthly fee paid for each member in exchange for the provision of comprehensive health-care services to enrolled members. The set amount of money received or paid out is based on membership rather than on services delivered, and is usually expressed in dollars per member per month (PMPM). Opposite of fee-for-service.

CARE MANAGEMENT
This traditional utilization management approach coordinates care focusing on the event.

CARRIER 
An insurer with whom a patient has health or worker's compensation insurance coverage.

CARVE-IN, CARVE-OUT
Carve-in programs operate on the healthcare organization’s existing network and usually focus on specific diseases.  Carve-out programs exclude certain services—usually from an organization’s capitated rate—and tend to focus on one disease, in depth.

CASE-BASED REASONING
A form of artificial intelligence, often used by expert systems, that bases decision-making on prior case experience instead of a pre-defined rule set.  Each new problem is compared to similar cases the system has encountered.

CASE MANAGEMENT
The idea of creating a coordinated, ongoing, and personalized strategy for patients who have a variety of healthcare needs such as the elderly and those with long-term illnesses.  A primary care physician acts as a case manager, planning specialist referrals and giving a sense of continuity within the separate services delivered.  See disease management.

CASE MIX
The collective pool of patients in any health system or physician office, including data on age, gender, and health status.

CCOW
-See CLINICAL CONTEXT OBJECT WORKGROUP

CHAMPUS
Civilian Health and Medical Program of the Uniform Services. A federal program of the Department of Defense to provide health care to military personnel, military retirees, or their dependents.

CHAMPVA
Civilian Health and Medical Program of the Department of Veterans Affairs.  A cost-sharing health plan for the dependents of qualifying disabled veterans.

CHARGE MASTER, CHARGE DESCRIPTION LIST
An electronic list of a provider facility’s services and supplies, their billing codes and the associated charges.  The charge master must be kept updated to the latest codes and government billing regulations for health claims, often via a grouper.

CHEMICAL DEPENDENCY 
A condition of psychological and/or physiological dependence upon or addiction to alcohol, psychoactive drugs, or medication, which results in functional (physical, cognitive, mental, affective, social, or behavioral) impairment wherein behavioral health services can reasonably be anticipated to result in improvement. 

CHEMOTHERAPY 
The treating of disease by the infusion, injection, or ingestion of a chemical substance. 

CHRONIC ALCOHOLISM 
Long-term psychological disturbances resulting from habitual, heavy consumption of alcohol (also see Acute Alcoholism). 

CHRONIC CARE 
Care rendered in the treatment of an illness, injury, or condition that is long-lasting or frequently recurring. Although hospitalization is not required, confinement in other types of facilities may be appropriate (also see Acute In-patient Care).

CHRONIC INPATIENT CARE 
Care rendered in the treatment of an illness, injury, or condition that is long-lasting or frequently recurring. Although hospitalization is not required, confinement in a lesser facility maybe appropriate (also see Acute Inpatient Care). 

CLAIM 
A charge billed to a payor for covered services rendered to a person covered by the managed care plan.  A provider sends the claim to the patient’s insurance or health plan, which may review the claim for validity before paying the benefits.

CLAIMS ADMINISTRATOR 
The agent or payor designated by the insurer, employer, or network to adjudicate claims and provide other services for the insurer.

CLEARINGHOUSE
A service that takes claims and other electronic data from providers, verifies the information, and forwards the proper forms to the payors.  More than a transfer station, a clearing house acts as a fact-checker and data format translator.

CLIMS
-See CLINICAL LABORATORY INFORMATION MANAGEMENT SYSTEM

CLINICAL CONTEXT OBJECT WORKGROUP (CCOW)
An independent, open-membership group of vendors and users that work to form agreements on integration methods and to develop specifications for interfacing products from multiple vendors.

CLINICAL LABORATORY INFORMATION MANAGEMENT SYSTEM (CLIMS)
A management system that receives all information for ordered lab procedures, deliver the results to care givers and stores the data for future reference.

CLINICAL PSYCHOLOGIST
A person who is qualified and duly licensed by the state in which the person lives to practice clinical psychology and who has a doctoral degree in the behavioral sciences from an accredited institution of higher learning. 

CLINICAL SOCIAL WORKER 
A person qualified and duly licensed by the state in which the person lives to practice clinical social work and who has a Master's Degree in Social Work (MSW) from an accredited institution of higher learning.

CLOSE RELATIVE 
The spouse, children, brothers, sisters, or parents of the member. The eligibility for coverage of various close relatives is determined by the employer and insurer. Some groups do not include all the close relatives identified above. 

CMP
-See COMPETITIVE MEDICAL PLAN

COB
-See COORDINATION OF BENEFITS

CO-INSURANCE 
The percentage to be paid by the patient. The co-insurance amount is stated in the applicable group enrollment agreement and disclosed in the applicable Combined Evidence of Coverage and Disclosure Form. Co-insurance is determined as percentage of either the charge billed by a provider for covered services, or the applicable rate for the covered service listed on the insurer's (payor's) negotiated rates schedule. Most managed care plans determine the percentage from the lesser of charges or the negotiated schedule. The amount that a member must pay is separate from and in addition to any applicable co-payment and/or deductible. Co-insurance amounts generally are to be paid by members directly to the provider who bills for the covered services. 

CO-INSURANCE LIMIT 
The maximum aggregate total expenses provided for in the applicable group enrollment agreement and disclosed in the applicable Combined Evidence of Coverage and Disclosure Form that members must pay during a calendar year as co-insurance amounts for all covered services. Certain expenses paid by members are not included in determining whether the co- insurance limit has been met, generally including: 

1. Co-payments and deductibles;
2. Any expenditures or reductions in benefit coverage resulting from a member's failure to comply with the managed-care program;
3. Expenses for covered services in excess of the negotiated rates schedule; or
4. Expenses for services not included as covered services in the applicable Combined Evidence of Coverage and Disclosure Form.

COMMISSION
A type of finder’s fee set by insurance brokers or agents for selling health plans.  The commission fee is built into the premiums paid by the group insured.

COMMON OBJECT REQUEST BROKER ARCHITECTURE (CORBA)
A framework for object-oriented communications developed by Object Management Group.  CORBA uses Object Request Brokers as traffic conductors to funnel requests across multiple platforms.  Compare Component Object Model.

COMMUNITY HEALTH INFORMATION NETWORK (CHIN)
Providers and payors within a specific area who are networked to exchange medical and administrative information among them, eliminating redundant data collection and reducing paperwork.

COMMUNITY RATING 
Premium rates determined on the basis of community wide health care cost experience, rather than the experience of a particular employer group or class of people. Community rating does allow the payor to consider differences for age, sex, mix (average contract size), and industry factors in determining a groups' premium rates.

COMMUNITY RATING BY CLASS 
Premium rates determined on the basis of community wide health care cost experience, but with separate premium rates for various age and sex categories.

COMPETITIVE MEDICAL PLAN (CMP)
A federal designation that allows a health plan to obtain eligibility to receive a Medicare risk contract without having to obtain qualification as an HMO. Requirements for eligibility are somewhat less restrictive than for an HMO.

COMPUTER-BASED PATIENT RECORD (CPR)
Also called electronic medical record or patient health record.  Much more than a computerized medical chart, a CPR acts as a ‘personal health library’ providing access to all resources on a patient’s health history and insurance information.  A CPR is a linking system rather than an independent database, and is more a process than a product.  An integrated CPR will link to separate sources, detailing medical history and images, laboratory results, and drug allergies.  Several organizations are focused on creating standards for CPRs, including common coding terminology, clinical decision support, patient confidentiality, and secure data transfers.

CONCURRENT REVIEW 
A utilization program to review medical care of patients currently hospitalized or under treatment. A case manager or review agent will coordinate decisions regarding a patients length of stay and discharge plans. Approval for an extension of a stay or denial of care would be part of the concurrent review program. The insurer may delegate review to a medical review organization or a hospital. Managed care plans have many different administrative arrangements for concurrent review.

CONSUMER INFORMATICS
Any computer-based information available to the general public, including electronic databases, CD ROMs, and the World Wide Web.  See patient education.

CONTRACT YEAR 
Enrollees of a health plan are generally covered for a period of one year. The year begins generally on the first day of the month. The effective date or termination date may be on the ID-Card. Generally coverage is for a twelve month period. Some plans enroll a group for 24 months.

CONVALESCENT CARE, REHABILITATION, OR REHABILITATIVE CARE
The restoration of an individual's ability to function as normally as possible after a disabling illness or injury.

COOKIE
A piece of information passed from a Web server to the user’s Web browser.  If the browser accepts the cookie, its data, accessible only by the server/domain that sent it, is stored on the user’s hard drive and retrieved automatically whenever that server’s page is visited.  Used to store passwords, ordering information, preferences, and bookmarks.  Some cookies expire the same day; others can last several years.

COORDINATION OF BENEFITS (COB)
When a patient is covered by two or more group health plans, coordination of benefits divides the responsibility of payment between the health plans so that the coverage combined will pay up to 100% of hospital and professional services within the limits of all contracts.  Insurers and health plans use this verification system to make sure the same claim is not paid twice.

CO-PAYMENT 
An amount which a member is required to pay for certain benefits. The co-payment is usually a fixed amount, such as $5 in many HMOs.

CORBAmed
A healthcare task force that recommends standards for object-oriented communication in the healthcare industry.

COSMETIC SURGERY 
A surgery designed to improve the appearance of the individual which the patient desires for purposes of beautification or aesthetics. Cosmetic surgery is generally a non covered service. 

COST CONTAINMENT
A program designed to control the cost of medical treatment covered by the health or workers compensation carrier. The programs may take many different forms. Co-payments, deductibles, concurrent review, utilization review, admission certification, prior authorization, pre-certification, benefit limits, claims review and numerous other programs are all types of the cost containment programs. 

COST-PER-CLICK
A rate model for Web site advertising, where the advertiser’s charges are based on the number of users who click on the ad.

COST SHIFTING
A leveling method that involves one patient group being charged more to make up for another group’s underpayment or inability to pay.

COVERED CHARGES 
The amount payable under the Plan for covered services. Such charges are subject to any contractual agreements, exclusions and limitations. The plan will pay amounts not to exceed contractual agreements.

COVERED SERVICES
Those services provided to a member pursuant to the terms of a group or individual health services contract. 

CPT-4
-See CURRENT PROCEDURAL TERMINOLOGY

CREDENTIALING
The examination of a healthcare professional’s credentials, practice history, and medical certification or license.

CURRENT PROCEDURAL TERMINOLOGY (CPT)
A procedure identification system that serves as the basis for healthcare billing.  CPT coding assigns a five-digit code to each service or procedure provided by a physician.  CPT coding simplifies billing and protects a patient’s medical privacy.  The 1988 version of the fourth edition of the CPT-4 manual published by the American Medical Association, as publications may be updated and/or amended from time to time.  See HCPCS.

CUSTODIAL OR MAINTENANCE CARE
Care furnished primarily to provide room and board. The care may include nursing care, training in personal hygiene and other forms of self care and/or supervisory care by a physician. The care is for a patient:

1. Who is not under specific medical, surgical or psychiatric treatment to reduce the disability to the extent necessary to enable the patient to live outside an institution providing such care; or
2. When, despite such treatment, there is no reasonable likelihood that the disability will be so reduced. 

D

DATA
Pieces of information or commands.

DATABASE
An aggregation of records or other data that is updateable.  Databases manage and archive large amounts of information.  See relational database.

DATA ENTRY
The transcription of information from the original source into a machine-readable form.  Although keyboard entry is the most familiar, other fast-growing methods include scanners, speech recognition, and automatic device-to-system technology.

DATA MART
A well organized, user-centered, searchable database system.  A data mart picks up where a data warehouse stops—by organizing the information according to the user’s needs (usually by specific subjects), with ease of use in mind.

DATA MINING
The comparison and study of large databases in order to discover new data relationships.  Mining a clinical database may produce new insights on outcomes, alternate treatments, or effects of treatment on different races and genders.

DATA REPOSITORY
A database acting as an information storage facility.  Although often used synonymously with data warehouse, a repository does not have the analysis or querying functionality of a data warehouse.

DATA WAREHOUSE
This vast database stores information like a data repository, but goes a step further, allowing users to access data to perform research-oriented analyses.

DAY OF SERVICE 
The measure of time during which a member of a health-service plan receives hospital services. A day occurs when a member occupies an in-patient, acute-care bed as of 12:00 midnight, or when a member is admitted and discharged within the same day, provided that admission and discharge are not within twenty-four (24) hours of a prior discharge. 

DECISION SUPPORT SYSTEM
Software that taps into database resources to assist users in making decisions on care options.  A clinical decision support system gives physicians structured (rules-based) information on diagnoses and treatments.

DEDUCTIBLE 
The portion or amount specified in the applicable group enrollment agreement and disclosed in the applicable Combined Evidence of Coverage Disclosure Form. Members are required to pay this amount, either in the aggregate or for a particular type or category of covered service, before the insurer (payor) has any financial responsibility for the provision of such covered services. Amounts paid by members to providers as co-payments and co-insurance amounts are not included in determining whether the deductible has been met. Note: that deductibles are not allowed in federally qualified HMOs. Deductibles are common in indemnity insurance plans, EPOs, and PPOs. 

DEMAND MANAGEMENT
Easing the demand for direct healthcare services by delivering information to patients and caregivers, often through call centers, disease hotlines, consumer health education Web sites, or physician-centric resources.  Demand management empowers both patients and providers, and may include aspects of disease management.  See triage.

DEPENDENT 
1. A subscriber's spouse who is not a subscriber and not legally separated from the subscriber.
2. An employee's unmarried child, stepchild, legally adopted child, or foster child who is primarily dependent upon the employee for support and maintenance, is less than "X" years of age, is not covered for benefit as a subscribing member and is not a member of the Armed Forces. Insurers establish different age limits for dependents. Generally the upper age limit is either 21 or 23 years old. 

DEPENDENT MEMBERS 
An employee's dependents who have been enrolled and accepted by the insurer as members and have maintained their membership in accordance with their contract. 

DETOXIFICATION
A person's medically supervised withdrawal from chemical dependency caused by an addictive or habitual substance including, but not limited to, alcohol, opiates, benzodiazepines, and barbiturates.

DIAGNOSIS RELATED GROUP (DRG)
Patient study groups classified by age, gender, health condition, and predicted treatment needs.  A formula is calculated based on the particular DRG to determine how much money providers will be given to cover future procedures and services, primarily for inpatient care.

DIAGNOSTIC STATISTICAL MANUAL (DSM-III-R)
The revised edition of the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (APA) copyrighted and published in 1987 by the APA, or updated or amended from time to time. 

DICOM
Digital Imaging and Communications in Medicine.  A standard developed by the American College of Radiology Manufacturers Association to define the connectivity and communication protocols of medical imaging devices.

DIGITAL CERTIFICATE
Also called a digital ID.  An official electronic identity document based on public/private key encryption and obtained through a certificate authority.  Includes a user’s name, registered serial number, the user’s public key, and its expiration date.  Most certificates conform to the International Telecommunication Union’s X.509 standard, but not all are compatible across all Web browsers.  Compare digital signature.

DIGITAL SIGNATURE
Also called an electronic signature.  An encrypted digital tag added to electronic communication to verify the identity of the sender.  The primary market force behind such signatures has been electronic commerce, but new uses are appearing in the healthcare industry, including electronic prescriptions and doctor-patient communications.  See Health Insurance Portability and Accountability Act and compare digital certificate.

DIGITAL SUBSCRIBER LINE (DSL)
A new digital phone connection envisioned as a solution to the limited speed of analog telephone lines.  More than five times faster than and ISDN, a DSL skips the analog-digital-analog conversions and sends data directly in digital format.  Signal splitting also will allow simultaneous voice and data communication on the same line.

DISABILITY 
A bodily injury, illness, pregnancy, or nervous or mental disorder. However,

1. All bodily injuries sustained in any one accident will generally be considered one disability;
2. All illnesses existing simultaneously which are due to the same or related causes will be considered one disability;
3. If any illness is due to causes which are the same as or related to the causes of any prior illness, the succeeding illness will be considered a continuation of the previous disability and not a separate disability.

DISCHARGE PLANNING 
Most managed care plans assign a length of stay and begin plans for the treatment after the hospitalization. Some plans rigorously coordinate transfer of patients to lower cost environments. Other plans rely on the physician or hospital to handle the discharge plan. Home care, hospice, a skilled nursing facility, durable medical equipment needs, and other benefits may be considered as part of the discharge planning process.

DISEASE MANAGEMENT
The development of an integrated treatment plan for patients with long-term illnesses or recurring conditions instead of viewing each physician visit as a separate event.

DISENROLLMENT
The act of terminating the membership of a person or group in a health plan.

DME
-See DURABLE MEDICAL EQUIPMENT

DOCTOR OF MEDICINE 
A licensed medical doctor (M.D.) or doctor of osteopathy (D.O.). (Also see Physician.)

DOMICILIARY CARE 
Care provided in a hospital or other licensed facility because care in the individual's home is not available or is unsuitable. 

DPR
-See DRUG PRICE REVIEW

DRG
- See DIAGNOSIS RELATED GROUP

DRUG PRICE REVIEW (DPR)
A monthly report that lists the average wholesale prices of prescription drugs.

DRUG UTILIZATION REVIEW (DUR)
A study of drug prescriptions to evaluate a medication’s uses and cost-effectiveness.  Can be used to analyze practitioners’ treatment choices, suggest drug alternatives, or update an organization’s formulary.

DSM-III-R
-See DIAGNOSTIC STATISTICAL MANUAL

DUAL CHOICE 
An employer provides two HMO options because Section 1310 of the federal HMO regulations that require any employer with 25 or more employees residing in the HMO's service area, who pays minimum wage, and who offers health coverage, to offer a federally qualified HMO. The HMO must request the employer mandate. 

DUAL COVERAGE 
An individual or family covered by more that one health benefit plan. Most plans have coordination of benefit provisions to exclude or limit benefit payments for any services covered by another plan. Health benefit plans also have rules to determine which health plan is primary and which is secondary when dual coverage exists. 

DUAL OPTION 
An employer offering both an HMO and a traditional insurance plan by one carrier.

DUE DILIGENCE
A legal term describing a thorough effort to intercept potential problems before they occur, such as preparing for y2k or monitoring for fraudulent claims.  In IT, the process includes documented evidence that information systems are regularly assessed, updated, and monitored for data integrity and security.  Due diligence will be intrinsically involved in the privacy and security regulations under HIPAA, via audit trails, user authentication, and access controls.

DUPLICATION OF BENEFITS 
An individual with dual coverage would have double coverage if the plan did not have a coordination of benefit provision. The COB requirements eliminate the duplication of benefits. 

DUR
-See DRUG UTILIZATION REVIEW

DURABLE MEDICAL EQUIPMENT (DME)
Equipment designed for repeated use which is medically necessary to treat an illness or injury, to improve the functioning of a malformed body part, or to prevent further deterioration of the patient's medical condition. Durable medical equipment includes items such as wheelchairs, hospital beds, respirators, and other items that the insurer determines are covered durable medical equipment.

E

EAI
-See ENTERPRISEWIDE APPLICATION INTEGRATION

E-BUSINESS, E-COMMERCE
An overarching term for service, sales, and collaborative business conducted over the Internet, either business-to-consumer or business-to business.  Some define e-commerce as a monetary transaction segment of e-business, by in most cases, the terms are synonymous.  See e-health and e-care.

E-CARE
An umbrella term referring to the automation of all aspects of the care delivery process across administrative, clinical and departmental boundaries throughout the healthcare delivery system.  The beneficiary of the convergence of multiple technologies such as object-oriented and adaptive applications that leverage the Web to link disparate system and enable automated, real-time responses to inquires, clinical alerts, etc.  Can incorporate disease management, workflow automation, and supply chain management.

EFFECTIVE DATE 
The date that coverage for the group or subscriber begins.

EFT
-See ELECTRONIC FUNDS TRANSFER

E-HEALTH
Both a concept and a business strategy, e-health empowers users by bringing health information, products, and services online.  Portals and niche sites can include everything from consumer health content, health plan descriptions, and insurance quotes to ask-a-doctor messaging.  Some sites, such as online pharmacies, cross over into e-business, e-commerce. 

ELECTRONIC FUNDS TRANSFER (EFT)
Financial transactions or data exchanged between computers, or “electronic banking.”

ELIGIBILITY 
A person is an eligible subscriber of a plan if they meet the requirements for coverage under the plan. The requirements vary among insurers and employers. The following factors are considered to determine eligibility: date of employment, relationship to subscriber, age of dependent, attendance at school by a student dependent, handicapped dependent child, election of coverage by an employee, divorce, inactive employee status, part-time employee status, dual coverage, coordination of benefits, and other such factors.

ELIGIBILITY LIST 
The list of members eligible for benefits. or Eligibility lists are generally issued to providers for HMOs with individual IPAs responsible for a panel of patients. Most payors maintain their eligibility list internally and require that the provider call either the employer, union, insurer, payor or agent for verification of eligibility.

EMERGENCY SERVICES 
Those services required for the treatment of a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate care could reason ably result in: 

1. permanently placing the member's health in jeopardy;
2. causing other serious medical consequences;
3. causing serious impairment to bodily functions; or
4. causing serious and permanent dysfunction of any body organ or part.

EMERGENCY TREATMENT 
Services required for the alleviation of the sudden onset of an unforeseen illness or injury which if not treated would lead to further disability or death.

EMPLOYEE ASSISTANCE PROGRAMS 
A mental health reimbursement plan which provides benefits for certain expenses related to the treatment of nervous and mental disorders or chemical addiction. 

EMPLOYEE CONTRIBUTION
The portion of a health plan premium paid by an employee (often debited from wages) to the company’s contracted payor.  See employer mandate.

EMPLOYER GROUP 
The organization, firm, or other entity and its employees and their dependents. The employer group may contract with an insurer or other managed care plan or self insure the health benefits for its employees. 

EMPLOYER MANDATE
For companies that provide health insurance for their employees, this stipulation forces the company to pay for at least part of the insurance premium for each employee.

ENROLLEE
A member of a health plan or a member’s qualifying dependent.

ENTERPRISE BUSINESS APPLICATION
Generally, a business application “shell” or suite that operates across an enterprise, allowing access to key work tasks and applications.  Such applications are usually large, often configured to be corporate-specific, and can cross over into knowledge management.  Compare enterprisewide application integration.

ENTERPRISE RESOURCE PLANNING (ERP)
The use of software tools to automate tasks and track data generated by specific departments, primarily finance, inventory, and human resources.  ERP is reaching further into supply chain management, and some consider the two terms nearly equivalent.

ENTERPRISEWIDE APPLICATION INTEGRATION (EAI)
This big-picture approach studies the separate applications in an enterprise and incorporates middleware tools and message brokers to consolidate and/or synchronize disparate applications.  EAI’s hot potential is in linking legacy systems and dissimilar platforms with current Web-enabled technology.  Compare Enterprise business application.

ENTERPRISEWIDE NETWORK
A system where all computers in a healthcare system’s various buildings are connected to exchange information.

EOB
-See EXPLANATION OF BENEFITS

EPISODE OF CARE
Healthcare services provided for a specific illness, during a set time period.

EPO
-See EXCLUSIVE PROVIDER ORGANIZATION

ER (EMERGENCY MEDICAL CARE)
An abbreviation for emergency medical care, emergency services, or emergency treatment. 

ERISA
Employee Retirement Income Security Act of 1974.  A federal outline for regulating employee benefit plans, including healthcare plans sponsored and/or insured by an employer.

ERP
-See ENTERPRISE RESOURCE PLANNING

EVIDENCE-BASED MEDICINE
Physician care based on best practice guidelines developed from the scope of clinical literature.  Burgeoning electronic access to current practice guidelines and specialty-specific literature is enhancing the development of expert systems and helping physicians stay updated on treatments.

EXCLUSION 
Any service, supply, or accommodation specifically listed or described as excluded in the applicable Combined Evidence of Coverage and Disclosure Form. 

EXCLUSIVE PROVIDER ORGANIZATION (EPO)
This provider network is more restrictive than a preferred provider organization (PPO). Patients enrolled in an EPO only receive benefits from contracting providers. An EPO is similar to an HMO in that it uses primary physicians as gatekeepers. The patient generally will have no coverage from non-participating providers. Emergency care may be covered from non-participating providers with approval of EPO. EPOs are generally regulated under insurance statutes rather than HMO regulations. 

EXERCISE PROGRAM 
Entails prescribed supervision of bodily movement for the purpose of restoring diseased or injured tissue to normal functions. 

EXPERIENCE RATING 
The practice of basing premiums on actual health care cost experience of a given employer group. 

EXPERIMENTAL OR INVESTIGATIONAL 
Any treatment, therapy, procedures, drug or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supplies which are not recognized in accordance with generally accepted professional medical standards as being safe and effective for use in the treatment of the illness, injury, or condition at issue. 
Services or supplies which require approval by the federal government or any agency thereof, or by any state governmental agency, prior to use and where such approval has not been granted at the time the services or supplies were rendered, shall be considered experimental or investigational. Services or supplies which themselves are not approved or recognized in accordance with the accepted professional medical standards but nevertheless are authorized by law or a government agency for use in testing, trials, or other studies on human patients, shall be considered experimental or investigational. 

EXPLANATION OF BENEFITS (EOB)
The managed care plan issues the EOB when it processes the claim. Information on the EOB can be used to determine how the plan determined the allowed amount paid. The EOB is also used to determine amounts to be billed to a secondary carrier or for Medicare complimentary coverage. 

EXTENSION OF BENEFITS 
If a person is totally disabled when coverage terminates, benefits for treatment of the condition causing this total disability will be extended by some insurers. This extension ceases on the first to occur of the following: 

1. The date the covered person is no longer totally disabled;
2. The last day of the twelfth month following the month in which coverage terminated; and
3. The date on which the covered person's maximum benefits are reached.

F

FAMILY DEPENDENT 
A member of a subscriber's family eligible and enrolled in accordance with all applicable requirements of the applicable group enrollment agreement, and on whose behalf the insurer (payor) received premiums. 

FEDERAL EMPLOYEE HEALTH BENEFITS (FEHB)
An abbreviation for Federal Employee Health Benefits Program. The program provides health benefits to federal employees.

FEE FOR SERVICE (FFS)
A reimbursement arrangement for the insurer to pay the provider for each service.  The most common U.S. healthcare payment system.  A physician declares his or her own rates and is paid after each medical service delivered, as opposed to a flat-rate plan such as capitation.  See fee schedule.

FEE SCHEDULE
A list of maximum fees, per service, a provider will be reimbursed within a fee-for-service payment system 

FEHB
-See FEDERAL EMPLOYEE HEALTH BENEFITS

FFS 
-See FEE FOR SERVICE
An abbreviation for fee for service. A reimbursement arrangement for the insurer to pay the provider for each service. 

FILE TRANSFER PROTOCOL (FTP)
A standard application governed by TCP/IP for transferring files between computers or across the Internet.  These days, nearly every system can accept FTP files.

FORMULARY
A list of pharmaceutical products and dosages deemed by a healthcare organization to be the best, most economical treatments.  The list varies from one organization to another, and in some healthcare systems, providers are expected to use the listed products.

FTP
-See FILE TRANSFER PROTOCOL

G

GAP ANALYSIS
Traditionally, this is an assessment of what a given population needs vs. the facilities, services and expertise available to serve those needs.  It now includes what’s accessible online, and a gap analysis can pick up where a click-stream study leaves off showing marketing departments what customers and providers wish they could do on the Web site.

GATE KEEPER 
The provider who must coordinate the medical or mental health treatment for a patient under the requirements of the managed care plan. Health maintenance organizations may require that the patients primary care physician serve as the "gate keeper" and coordinate all patient care and issue all referrals to specialists or other providers for treatment. The gatekeeper shares in the financial risk for providing that care (often through a capitation arrangement). To effectively monitor total care and manage the associated financial risk, the PCP controls, through an authorization process, all care for panel patients to be performed by other providers. Not all HMOs require a gatekeeper.

GB (GIGABYTE)
About 1,000 megabytes (MB) of data.

GENOMICS 
The study of the genome—an organism’s biological blueprint of DNA, chromosomes, and genes.  Information systems, databases, and computerized research tools have joined forces in Human Genome Project, a worldwide collaborative effort to identify and record the 80,000+ genes and 3 billion DNA segments that define the human species.  See bioinformatics.

GPWW
-See GROUP PRACTICE WITHOUT WALLS

GRIEVANCE PROCEDURE 
The procedures established by the insurer (payor) to resolve member and provider grievances. 

The steps in the appeal process can vary among managed care plans. The process generally begins by contacting the agent who denied approval or payment. Written statements follow with detailed descriptions of the diagnosis and treatment. The managed care plans use many different procedures to review and process an appeal. Some have special provider committees or review by a board. Other plans use arbitration to resolve appeals. The state department of insurance has procedures for appeals if enrollees are not satisfied with a decision. The Department of Corporations reviews the Health Maintenance Organizations. 

GROUP
An employer or other legal entity that has entered into a contract with the insurer (payor) under which the insurer (payor) will provide or arrange for the provision of covered services to eligible members of the group. 

GROUP ENROLLMENT AGREEMENT 
The written agreement between the insurer (payor) and a group that obligates the insurer (payor) to provide covered services to members and sets forth the terms and conditions applicable to such coverage.

GROUPER
A software tool that collects the various service, treatment, and diagnosis codes for a care episode and groups them under the relevant procedural codes for claims processing.  Not keeping the grouper updated to the latest coding guidelines can affect the charge master and result in error-ridden or duplicate claims.

GROUP MODEL HMO 
A contract arrangement between and HMO and one or more multi-specialty physician group practices to provide all physician services to the HMO's members. The physicians in the group practice are employed by the group practice and not by the HMO.

GROUP PRACTICE 
Three or more physicians working together and agreeing to distribute their income according to some prearranged formula Physicians in a group practice share facilities, equipment, medical records, and support staff. In many cases, the group practices treats patients from several HMOs, PPOs, EPOs and fee for service patients.

GROUP PRACTICE WITHOUT WALLS (GPWW)
A recent group practice alternative somewhere between a private practice and a HMO.  The physician group owns the assets of the collective practices and shares some costs, but each physician controls his or her patient appointments and staff.  Since the physicians are not necessarily in the same building, the group is “without walls.”

GROUPWARE
Any technology that allows people to collaborate electronically, including email, real-time networking, and conference tools based on telephony, video, or the Web.  Workflow automation, enterprise resource planning, and even telemedicine systems are all groupware at the root.

H

HCFA
-See HEALTHCARE FINANCING ADMINISTRATION

HCFA INTERNET SECURITY POLICY (HISP)
The security requirements issued by the Health Care Financing Administration (HCFA) for sending or receiving HCFA-governed data over the Internet, including firewalls, encryption during transmission, and sender/receiver authentication protocols.  Prior to this 1998 policy, the Internet was not permitted as a communications medium for HCFA-related data.  See the document at www.hcfa.gov/security/isecplcy.htm.

HCPCS
HCFA Common Procedural Coding System.  An expansion of billing codes (CPT codes) to account for additional services such as ambulance transport, supplies, and equipment.

HEALTHCARE FINANCING ADMINISTRATION (HCFA)
This federal agency administers all aspects of health financing for Medicare and manages the Office of Prepaid Healthcare.

HEALTHCARE INFORMATICS STANDARDS BOARD (HISB)
A group within the American National Standards Institute that works on standards for computer-based patient records, coding, terminology, international data exchange and patient privacy.  Members include medical organizations, corporations and federal representatives.

HEALTH INFORMATION AND APPLICATION WORKING GROUP (HIAWG)
As part of the U.S. Information Infrastructure Task Force, this group makes federal recommendations on how the National Information Infrastructure can be used to benefit healthcare and encourages cooperation among healthcare application designers.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)
A complex law that protects a person’s credit for previous healthcare insurance to cover preexisting conditions when changing health plans and institutes new mandates concerning electronic healthcare transactions and data.  HIPAA requires that the Department of Health and Human Services adopt standards for electronic health transactions, including health claims and attachments, enrollment/disenrollment, eligibility, payments and premiums, claims status, referral authorizations, and digital signatures.  HIPAA also requires the creation of unique identifiers and standards for data confidentiality.  Once standards are adopted, healthcare organizations will have 24 to 36 months to comply, depending on the size of the organization.  See National Provider Identifier and www.hcfa.gov/HIPAA/HIPAAHM.htm.

HEALTH INSURANCE PURCHASING COOPERATIVES (HIPCs)
An evolving method of insurance rate-setting and purchasing.  In most cases a HIPC will consider all people within a certain region for the purpose of determining insurance rates.  Using this risk pool, the cooperative then gives equal purchasing power to both large and small companies.

HEALTH MAINTENANCE ORGANIZATION (HMO)
A type of health plan which usually provides full medical coverage in return for a prepaid monthly premium. The HMO assumes financial risk for the cost of services in excess of premiums. Enrollees are generally limited to participating providers except in certain emergency situations, or services by non-HMO providers are authorized.

If an HMO has more than one office the primary office is designated in the phone table (claims).  HMOs use various approaches to gather their providers, including the staff model, group model, Independent Practice Association and network model.

HEALTH PLAN
A person’s specific health benefits package or the organization that provides such a package.  Blue Cross/Blue Shield offers health plans (benefits packages), but a health maintenance organization (a company) also is a health plan.

HEALTHPLAN EMPLOYER DATA AND INFORMATION SET (HEDIS)
Healthplan Employer Data and Information Set.  Performance standards for health plans that employers can use as a guide to compare health plans and to understand what a plan offers.  Developed by the National Committee for Quality Assurance, HEDIS also is a way for health plans to see what is expected of them.  See satisfaction survey.

HEDIS
-See HEALTHPLAN EMPLOYER DATA AND INFORMATION SET

HIAWG
-See HEALTHCARE INFORMATION AND APPLICATION WORKING GROUP

HIPCs
-See HEALTH INSURANCE PURCHASING COOPERATIVES

HIS
-See HOSPITAL INFORMATION SYSTEM

HISB
-See HEALTHCARE INFORMATICS STANDARDS BOARD

HISP
-See HCFA INTERNET SECURITY POLICY

HL7 (HEALTH LEVEL 7)
1.   A standard interface for exchanging and translating data between computer systems.
2.   A non-profit organization accredited by the American National Standards Institute (ANSI) that develops standards for data transfer.

HMO
-See HEALTH MAINTENANCE ORGANIZATION

HOME HEALTH CARE 
Health-care services provided by a home-health agency at the patient's home, as prescribed by the physician. 

HOME HEALTHCARE AGENCY
An organization that arranges for and provides necessary healthcare services in a patient’s home.

HOME PAGE
The first or “main” page of a Web site.  This page usually acts as a table of contents for the layers of pages and additional hypertext links available within the site.

HOSPICE 
A program or facility designed to provide palliative and supportive care to individuals who have been diagnosis with a terminal illness. Supportive care is provided to the terminal patient and to eligible family members. A hospice must be licensed or certified under the laws of the state.

HOSPITAL 
1. Licensed facility which is primarily engaged in providing for compensation from patient, medical, diagnostic and surgical facilities for the care and treatment of sick and injured persons on an in-patient basis, and which provides such facilities under the supervision of a staff of physicians and 24 hour a day nursing services by registered graduate nurses. An institution which is principally a rest home, nursing home, or home for the aged is not included; or
2. A psychiatric hospital accredited by the Joint Commission an Accreditation of Hospitals. (Also see Preferred Hospital) 

HOSPITAL ALLIANCE
Hospital groups that agree to buy equipment and services jointly rather than incurring the costs separately.

HOSPITAL INFORMATION SYSTEM
A system that provides the information management features that hospitals need for daily business.  Typically includes patient tracking, billing, administrative programs, and also may include clinical features.

HOSPITAL SERVICES 
Those acute-care in-patient and hospital out-patient services that are covered by a managed-care plan benefit agreement. Managed-care plans do not include long-term non-acute care within their definition of hospital services.

HOST
A computer that acts as a source of information or capabilities for multiple terminals, peripherals and/or users.

HTML
HyperText Markup Language.  The basic programming language for Web sites.  This “skeleton” of codes surrounds blocks of text and/or images and contains all the display commands.  A browser is required to translate HTML into a graphical display.  See DHTML.

HTTP
HyperText Transfer Protocol.  A language protocol used when Web browsers and Web sites communicate.  When http appears as part of a site address (called a URL), it indicates to Web browsers, “HTML spoken here.”  Compare Gopher.

I

IBNR 
-See INCURRED BUT NOT REPORTED

ICD-9-CM
-See INTERNATIONAL CLASSIFICATION OF DISEASES

ID CARDS 
An identification card issued by a plan. The card provides information on benefits and about the subscriber. The card generally identifies the employer, insurer, network and benefit information. An ID card does not guarantee eligibility of an individual.

IDS
-See INTEGRATED SECURITY SYSTEM

INCENTIVE WITHHOLD 
An amount of money that the payor holds back at the time of payment. The amount withheld is used to cover the cost of care for the payor in the event that total cost of care exceeds the plan's budget. If costs of care are less than the budgeted amounts the payor distributes the withhold fund to participating providers. 

INCURRED 
A charge shall be deemed to be "Incurred" on the date the particular service or supply which gives rise to it is provided or obtained.

INCURRED BUT NOT REPORTED (IBNR)
An abbreviation for Incurred But Not Reported claims. It represents the amount of money that the plan should accrue for medical expenses that have been provided but not yet reported to the plan. These are medical expenses that the authorization system has not captured and for which claims have not been received.

INDEMNITY 
An insurer who agrees to compensate a patient for covered medical services. Indemnity insurers generally pay the subscriber directly for cost of care or require the insured to assign the payment to the provider. 

INDEPENDENT PHYSICIAN ASSOCIATION (IPA)
An IPA is a group of physicians that form a medical group to cover patients with health coverage from one or more insurers.

INDEPENDENT PRACTICE ASSOCIATION (IPA)
A type of health maintenance organization that contracts with a group of associated physicians for services to its members.  Under this model, physicians may keep their own private practices and may work for other HMOs.  Compare group model, network model, and staff model.

INDEPENDENT REVIEW ORGANIZATION 
A company that reviews the medical treatment plan, assign a length of stay, or coordinates other medical cost containment programs for an insurer, employer, union or payor.

INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
Also called patient identifiable information.  Any piece of health information that can be linked or traced to an individual or family.  The Department of Health and Human Services’ proposed patient privacy regulations forbid the circulation of protected health information unless it has been stripped of 19 identifiable items, including name, phone number, e-mail, health plan number, relatives’ names, and biometric ID patterns. 

INDIVIDUAL PRACTICE ASSOCIATION (IPA)
An IPA is a group of physicians that form a medical group to cover patients with health coverage from one or more insurers.

IN-PATIENT 
An individual who has been admitted to a hospital as a registered bed patient with the expectation of staying overnight and is receiving services under the direction of a physician. 

INPATIENT CARE
Services delivered to a patient who needs physician care for at least 24 hours, usually in a hospital.

INSTITUTE OF MEDICINE (IOM)
An organization within the National Academy of Sciences that acts as an adviser in health and medicine and conducts policy studies relevant to health issues.  The IOM coined the term “computer-based patient record” and emphasizes its importance for future healthcare management and delivery.

INSURER 
An organization that provides medical or workers compensation coverage for individuals or groups. Insurers may provide coverage under an indemnity, preferred provider option. HMOs and Blue Cross Blue Shield plans are not insurers under the legal definition of an insurer. BCBS are medical service plans and except for the technical legal definition are providing coverage for medical care similarly to an insurer. An HMO is regulated by the state and or federal government to provide a comprehensive level of prepaid healthcare services to enrollees of the HMO. 

INTERFACE
The electronic connection where two parts of a system are joined, such as where a software program meets a hardware component, or where hardware meets and input device.  Also used to describe software that joins two different information systems.

INTEGRATED DELIVERY SYSTEM (IDS)
A unified healthcare system that provides physician, hospital, and ambulatory care services for its members by contracting with several provider sites and health plans.  Participants sometimes are called integrated providers.

INTERMEDIATE CARE FACILITY
A place that provides medical care to patients who don’t need to be in a hospital.

INTERNATIONAL CLASSIFICATION OF DISEASES (ICD-9-CM  ICD-10)
A list  that assigns codes to types of illnesses or conditions.  Whereas CPT codes represent procedures and other services, ICD codes represent diagnoses.  The ninth revision of the second edition (1980) of the International Classification of Diseases, Clinical Modification, of the US Department of Health & Human Services Public Health Service-Health Care Financing Administration, as publication may be updated and/or amended from time to time. 

INTERNET
An international network of computers that operates on a backbone system without a true central host computer.  Today’s Internet links thousands of universities, government institutions, and companies.  When it was created in the 1960s, the Internet linked just four computers.  Technically, the Internet and the World Wide Web are not interchangeable terms; the Web is an integral child of the Internet whose ease of use has made it much more popular than its less graphical parent.

INTERNET GRATEFUL MED
An online collection of medical databases maintained by the National Library of Medicine, including Histline, Medline, ChemID, and Toxline.  http://igm.nlm.nih.gov 

INTERNET SERVICE PROVIDER (ISP)
A company that provides modem or network users with access to the Internet and the World Wide Web.  Some charge by the hour, but most offer monthly or yearly flat rates.  Recently, some telephone companies have become ISPs, offering Internet access combined with local telephone service.

INTERNET TELEPHONY
Also called IP telephony.  A combination of hardware and software that allows the Internet to be used as a telephone carrier.  After the costs of initial set-up and access to an Internet Service Provider, long-distant voice calls can be made via the Internet free of charge, but current quality isn’t always as good a direct telephone service.

INTEROPERABILITY
The ability of hardware and software from different vendors to understand each other and exchange data, either within the same network or across dissimilar networks.

IOM
-See INSTITUTE OF MEDICINE

IPA
-See INDEPENDENT PHYSICIAN ASSOCIATION
-See INDEPENDENT PRACTICE ASSOCIATION
-See INDIVIDUAL PRACTICE ASSOCIATION

ISM BANDS
Industrial, Scientific and Medical bands.  In the 1980s the Federal Communications Commission assigned these three radio frequency ranges—902-928MHz, 2400-2483.5MHz, and 5752.5-5850MHz—for spread spectrum transmissions.  Use of these bands does not require a license, but transmission methods must conform to several FCC requirements.

ISP
-See INTERNET SERVICE PROVIDER

J

JCAHO
-See JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS (JCAHO)
An independent, non-profit group that accredits healthcare organizations.  Some of the healthcare network criteria in JCAHO’s accreditation manual includes heightened attention to patient education and management of information.

K

KNOWLEDGE MANAGEMENT
This still-evolving concept involves harnessing enterprisewide data, proprietary or otherwise, for comparative decision-making, workflow automation, supply chain management, and/or competitive  advantage.  Far more than information-aggregation, knowledge management seeks to enhance business value and help employees work more productively.

KNOX-KEENE ACT 
The act under which an HMO is licensed in California. A member and the benefit program is subject to the requirements of the California Knox-Keene Health-Care Service Plan Act of 1975 as amended.

L

LAN
-See LOCAL AREA NETWORK

LEGACY SYSTEM
An older computer system, often centered around a mainframe, that has been in place for a long time.  Since rather old technology is difficult to upgrade, owners of legacy systems often are faced with weighing the cost of replacing a system that technically “still works” with a faster, less bulky, fully integrated system.

LENGTH OF STAY (LOS)
The period of time a patient is hospitalized. A period of time authorized by a managed care plan prospectively or concurrently for hospitalization of a patient for a specific medical or surgical condition. 

LIFETIME BENEFIT MAXIMUM 
A dollar amount specified in the applicable group enrollment agreement and disclosed in the applicable Combined Evidence of Coverage and Disclosure Form, which is the maximum amount the insurer (payor) is obligated to pay on behalf of a member for covered services of a particular type or category provided to a member during the course of the member's coverage under the group enrollment agreement. 

LIMITATION 
Any provision other than an exclusion, contained in the applicable Combined Evidence of Coverage and Disclosure Form, which provision serves to limit the services to which members are entitled as covered services. 

LINUX
An operating system based on Unix and available free for all major platforms.  Burgeoned by its open architecture, scalability, and reliability, Linux is growing popular as a server and network OS alternative.

LOCAL AREA NETWORK (LAN)
A network of computers and peripherals in close proximity, usually in the same building.  A LAN can facilitate high-speed exchange of text, audio, and video data among hundreds of terminals.  Compare metropolitan area network and wide area network.

LOCK IN 
A requirement that enrollees receive all care from participating providers, or from a specified group of providers. 

LOINC
Logical Observation Identifiers, Names, and Codes.  A database protocol aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research.  Developed by the Regenstrief Institute for Health Care, LOINC is touted as a middleman solution to potential translation problems between labs that use HL7 reporting and recipient systems that may not be able to translate such data.

LONG TERM CARE 
Care that exceeds a specified period of time. Some insurers define long term in excess of 30 days while others might consider a period in excess of 60 days. Long term care programs generally cover nursing home or other non-hospital benefits. 

LOS
-See LENGTH OF STAY 

LOSS RATIO 
The ratio of the cost to deliver medical care and the capitation or premium received to provide care.

M

MAGNETIC STRIPE
Found on most plastic credit and ID cards, this electromagnetic surface is capable of holding a small amount of information.  Compare smart card.

MAILING LIST
A group of email addresses to which news or topical information is delivered, usually on a scheduled basis.  In a business context, it also can refer to an email list of clients or employees.

MAINFRAME
A powerful computer capable of organizing and executing multiple processing tasks at high speeds.  A mainframe often acts as the controlling agent in a centralized computing system.

MAN
-See METROPOLITAN AREA NETWORK

MANAGED-CARE PLAN 
A health benefit plan by which the insurer (payor) determines, under written standards, whether supplies, services, and/or accommodations are necessary and directs care to the most appropriate setting so as to provide quality care in the most cost-efficient manner. The managed-care plan includes, but is not limited to, requirements with respect to the following: prior authorization, prospective, concurrent, and retrospective utilization review, discharge planning, quality-assurance activities and reimbursement. 

MANAGED HEALTHCARE INFORMATION SERVICES (MHIS)
MHIS is a corporation that publishes information on managed care plan administration for use by physicians and hospitals who subscribe to the service. MHIS information is available as a software program and database, Web-based application, as well as in publications. 

MANAGEMENT SERVICES ORGANIZATION
Provides practice management services to physician groups and hospitals.  An MSO typically controls the business assets of the group it serves.

MARRIAGE, FAMILY, AND CHILD COUNSELOR 
A person qualified and duly licensed in the state in which the person lives to practice marriage, family, and child counseling and who has a Master's Degree from an accredited institution of higher learning. 

MASTER PATIENT INDEX, MASTER PERSON INDEX (MPI)
A software database program that collects a patient’s various hospital identification numbers, perhaps from the blood lab, radiology, admission, and so on, and keeps them under a single, enterprisewide identification number.

MAXIMUM 
The limit of coverage for a patient. The limit may be either a number of services, the number of visits, the number of days, or a dollar amount. 

MAXIMUM SCHEDULED ALLOWANCE 
A predetermined dollar amount which is the upper limit of reimbursement for a given service, before applicable co-payments and incentive withhold are subtracted. 

MB (MEGABYTE)
About 1 million bytes or 1,000 KB.

MEDICAL (MEDICAID) 
Health-care benefits that a person is receiving under Title XIX of the Social Security Act of 1965 as amended. 

MEDICAL ADVISOR 
A health care professional who is retained by an insurer, network, employer, or payor as a consultant to assist in the determination of current standards of practice, medical necessity, propriety of care and other professional matters. 

MEDICAL ANTHROTONIC SYSTEMS
Health monitoring instruments.

MEDICAL EMERGENCY 
Those services required for the treatment of a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate care could reasonably result in: 

1. permanently placing the member's health in jeopardy;
2. causing other serious medical consequences;
3. causing serious impairment to bodily functions; or
4. causing serious and permanent dysfunction of any body organ or part. See Emergency Services 

MEDICAL INFORMATION BUS (MIB)
Part of the Institute of Electrical and Electronics Engineers (IEEE) P1073 standard, the MIB seeks to provide open integration standards for connecting electronic patient monitoring devices with information systems.

MEDICAL NECESSITY 
A. Services and supplies which are medically necessary include only those which have been established as safe and effective and are furnished in accordance with generally accepted professional standards to treat an illness or injury, and which, as determined by insurer are:

1. Consistent with the symptoms or diagnosis in treatment of the illness or injury; and 
2. Necessary and consistent with generally accepted professional medical standards; and
3. Not furnished primarily for the convenience of the patient, the attending physician or other provider; and 
4. Furnished at the most appropriate level which can be provided safely and effectively to the patient. 

B. Hospital in-patient services and supplies which are medically necessary include only those services and supplies which satisfy the above requirements, require the acute bed patient (overnight) setting, and which could not have been provided in a physician's office, the out-patient department of a hospital, or in another lesser facility without adversely affecting the patient's condition or the quality of medical care rendered. In-patient services or supplies which are not medically necessary include: 

1. Hospitalization for diagnostic studies that could have been provided on an out-patient basis;
2. Hospitalization for medical observation or evaluation;
3. Hospitalization to remove the patient from his customary work or home environment or for personal comfort; and
4. Hospitalization in a pain management center to treat or cure chronic pain. 

MEDICAL POLICY GUIDELINES 
Managed care plans generally have medical advisors or committees to develop policies to assist the insurer in payment and benefit determination. These policies can cover a broad range of medical criteria used in managing the care of the plan's members. Each insurer or network has developed its own policies base upon the past experience of the plan and the experience of the physicians advising the plan. Therefore the medical policy guidelines of the plans are often different.

The medical policy guidelines play an important role in determining the administrative programs of an insurer, network, payor or plan. The guidelines impact the utilization review policies and other cost containment programs of the plan.

MEDICAL SAVINGS ACCOUNT
A private equity fund, much like an individual retirement account, set up to help cover future healthcare expenses, forming medical financial security regardless of workplace health plans.  Medical savings accounts have received new attention since the Health Insurance Portability and Accountability Act went into effect in January 1997.

MEDICAL SERVICES 
Services covered by a managed-care plan provided by a physician or other authorized medical professional. 

MEDICAL SERVICE ORGANIZATION (MSO)
An agreement between a group of doctors and a hospital or hospital organization, to administer managed care contracts for hospitals.

MEDICARE 
Medicare Part A and Medicare Part B health-care benefits that a person is receiving under Title XVIII of the Social Security Act of 1965 as amended. Part A benefits cover inpatient services and limited amounts of long-term care. Part B benefits cover outpatient services, and diagnostic tests or images, and usually require a 20 percent co-payment.

MEDICARE RISK CONTRACT
Instead of paying the premium for portions of Medicare, the patient pays a flat fee to the Medicare risk contract, which then assumes responsibility for delivering healthcare.  Like an HMO, most risk contracts cover only the services delivered by listed providers.

MEMBER 
This term is used synonymously with the terms Patient and Covered Insured. A member is any individual or dependent who is enrolled in and covered by a managed healthcare plan.

MEMBER MONTHS 
The total of all months that each member is covered by a plan. A plan with 1,000 members in January and 1,200 members in February has year-to-date 2,200 member months as of March 1. Member months, and ratios calculated by member months provide the most relevant statistics for evaluating a plans financial performance. 

MENTALLY RETARDED 
Those persons, not psychotic, who are so mentally retarded from infancy or before reaching maturity that they are incapable of managing themselves and their affairs independently, with ordinary prudence, or if being taught to do so, and who require supervision, control and care for their own welfare or for the welfare of others or for the welfare of the community.

METROPOLITAN AREA NETWORK (MAN)
A system of networked computers covering the space of an average sized city.  Compare Local area network and wide area network.

MHIS
-See MANAGED HEALTHCARE INFORMATION SERVICES

MIB
-See MEDICAL INFORMATION BUS

MIDDLEWARE
A bridge between two applications, or the software equivalent of an interface.  Middleware can “translate” each side of a data exchange, allowing users to execute programs on remote servers and access databases through Web sites without having to know the other server’s language protocols.

MIXED MODEL 
An HMO that mixes two or more types of delivery systems (e.g. staff and IPA models).

M/MUMPS
Massachusetts General Hospital Utility Multi-Programming System.  A programming language for database management in systems where multiple users need to access data simultaneously.  Originally designed for medical records, MUMPS is now used in a variety of non-healthcare industries where it is more commonly called M.

MORBIDITY
A measurement of illness or accident risk, based on categories of age, region, occupation, and others.  Morbidity describes potential or expected rates rather than actual rates.

MORTALITY
Statistical death rates, usually broken down by age or gender.

MPI
-See MASTER PATIENT INDEX/MASTER PERSON INDEX

MSO
-See MEDICAL SERVICE ORGANIZATION

N

NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA)
A non-profit organization that acts as a watchdog for the quality of care delivered by managed care plans and physician organizations.  Its accreditation process includes HEDIS and patient satisfaction surveys.

NATIONAL INFORMATION INFRASTRUCTURE (NII)
Formal name for the “information superhighway” and a main focus of the National Institute for Standards and Technology.  Once composed of four computers in the first Internet, the NII system now includes fiber optics, videography, telecommunications, cable, and satellites.  Healthcare emphases are on computer-based patient records, secure data access and telemedicine.

NATIONAL INSTITUTE FOR STANDARDS AND TECHNOLOGY (NIST)
A branch of the U.S. Department of Commerce’s technology administration.  Its Advanced Technology Program awards grants for development and commercialization of new technology ideas and products.  Although it considers projects in any technological area, it has 17 target categories, including the Information Infrastructure for Healthcare.

NATIONAL LIBRARY OF MEDICINE (NLM)
The world’s largest medical library and a branch of the National Institutes of Health.  The NLM has more than 5 million materials, and many of its databases are available to the public on the World Wide Web.  The NLM maintains several project groups, including new research in telemedicine, biotechnology, applied informatics, and next generation Internet, and sponsors fellowship and grants for healthcare IT training sites.  See United Medical Language System and Internet Grateful Med.

NATIONAL PROVIDER IDENTIFIER (NPI)
The intended replacement for the Unique Physician Identifier Number system.  Under development by the Health Care Financing Administration, the system will assign a unique eight-character ID to each provider who bills services under Medicare or as a stipulated by the Health Insurance Portability and Accountability Act.

NCQA
-See NATIONAL COMMITTEE FOR QUALITY ASSURANCE

NETWORK
A network model PPO or EPO has more than one payor who provides health benefits to enrolled patients. The payors in the PPO or EPO are insurance companies, third party administrators, or self funded employers or unions.  A network model HMO contracts with two or more group practices to provide health services to the HMOs enrollees.

In this book, we have adopted the practice of considering any managed care entity that signs a contract with a provider, group practice, medical group, or IPA as the 'Network' or 'Managed Care Network'. Under this definition every HMO is considered to be its own managed care network. Large insurers or employers that sign contracts with providers to treat their members or employees are also each considered to be a managed care network. PPO entities that sign contracts with providers are managed care networks. Payors are insurers, group practices, IPAs, and other entities that contract with a PPO, EPO, or HMO.  2. A general term for terminals, processors, and devices linked either by cable or wireless technology.