Guide to Managed Healthcare
By
Joseph A. Velky
[ Table of Contents]
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[10] [Glossary]
Provider
Health insurance
network directory
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:
- Co-payments and deductibles;
- Any expenditures or reductions in benefit coverage resulting from a
member's failure to comply with the managed-care program;
- Expenses for covered services in excess of the negotiated rates schedule;
or
- 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:
- 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
- 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,
- All bodily injuries sustained in any one
accident will generally be considered one disability;
- All illnesses existing simultaneously which are due to the same or related
causes will be considered one disability;
- 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:
- permanently placing the member's health in
jeopardy;
- causing other serious medical consequences;
- causing serious impairment to bodily functions; or
- 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:
- The date the covered person is no longer
totally disabled;
- The last day of the twelfth month following the month in which coverage
terminated; and
- 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:
- permanently placing the member's health in
jeopardy;
- causing other serious medical consequences;
- causing serious impairment to bodily functions; or
- 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:
- Consistent with the symptoms or diagnosis in
treatment of the illness or injury; and
- Necessary and consistent with generally accepted professional medical
standards; and
- Not furnished primarily for the convenience of the patient, the attending
physician or other provider; and
- 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:
- Hospitalization for diagnostic studies that
could have been provided on an out-patient basis;
- Hospitalization for medical observation or evaluation;
- Hospitalization to remove the patient from his customary work or home
environment or for personal comfort; and
- 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. Peripherals,
programs, and applications can be shared by the network users.
NETWORK MODEL HMO
A health maintenance organization that contracts with multiple groups of
physicians for care delivery. Compare
staff model, Independent Practice Association, and group model.
NII
-See NATIONAL INFORMATION
INFRASTRUCTURE
NIST
-See NATIONAL
INSTITUTE FOR STANDARDS AND TECHNOLOGY
NLM
-See NATIONAL LIBRARY OF MEDICINE
NODE
A connection point on a network. Each
node has its own address and can process and forward data to other nodes.
NON-CONTRACTING PROVIDERS
A provider that has not signed a contract to participate in the preferred
provider or managed care network.
NON-COVERED SERVICES
Health-care services which are not benefits under the Subscriber's Evidence of
Coverage/Disclosure form.
NON-PAR
Non-participating; a provider not on the managed care provider panel; a
non-member provider.
NPI
-See NATIONAL PROVIDER IDENTIFIER
O
OBJECT REQUEST BROKER (ORB)
The messenger at the heart of the CORBA framework. ORBs act as relay stations for requests between the
client’s software and the server. Since
ORBs work across multiple platforms, the user doesn’t have to know each
server’s protocol before communicating.
OCCUPATIONAL, VOCATIONAL, EDUCATION,
RECREATIONAL, ART, DANCE, AND MUSIC THERAPIES
Sometimes used as aids to the psychotherapeutic process and can help the patient
work toward improved mental health and social adjustment. These modes of therapy
are not central to the psychotherapeutic treatment process but should be
coordinated with it to maximize effectiveness. In and of themselves, these
therapies do not constitute treatment of an illness, injury or bodily
malfunction. Post plans do not cover these therapies.
OFFICE OF
HEALTH MAINTENANCE ORGANIZATIONS (OHMO)
An abbreviation for Office of Health Maintenance Organizations This is the old
name for the federal agency that oversees federal qualification and compliance
for HMOs.
OFFICE OF PREPAID HEALTHCARE
(OPHC)
An abbreviation for Office of Prepaid Healthcare. This is new name for the
federal agency that oversees federal qualification and compliance for HMOs.
OHMO
-See OFFICE
OF HEALTH MAINTENANCE ORGANIZATIONS
OPEN ENROLLMENT
A designated period when people may enroll in a health insurance plan or HMO or
change to an alternative form of coverage. Usually open enrollment periods are
held for one month every year or two.
OPERATING SYSTEM
The program that provides the brain power and basis functions to run all the
other applications. The OS manages
input, output, memory, and the ordering of tasks.
OPHC
-See OFFICE
OF PREPAID HEALTHCARE
ORB
-See OBJECT REQUEST BROKER
ORGAN TRANSPLANTS
Surgery intended to prolong life by transplanting a viable organ from a donor.
Whether the organ transplant is considered experimental or not depends on the
proven value or consensus evidenced relating to the efficacy of the procedure.
Successful transplants substitute the function of the partial loss or total
absence of the malfunctioning organ or body tissue.
OUTCOMES
An assessment of a treatment’s effectiveness by considering its success as
a care solution as well as its cost, side effects, and risk.
Outcome data is a crucial component of an organization’s performance
measurements. Building outcomes
archives also can serve as a valuable resource for use in decision support
systems.
OUTPATIENT
An individual receiving hospital services under the direction of a physician,
but not as an in-patient.
OUTSOURCING
Electronic processing capabilities that are not inherent in the system and
so are arranged through or given over to a third-party administrator.
P
PAR (PARTICIPATING)
Participating; a participating provider, or one who is a member of the provider
panel.
PARTICIPATING FACILITY
A facility that has entered into a contract with
the managed-care plan to provide covered services to members.
PARTICIPATING PRACTITIONER
A plan to provide covered services to
members.
PARTICIPATING PROVIDER
A participating practitioner or participating
facility
PAT
-See PRE-ADMISSION
TESTING
PATIENT ACCOUNTING SYSTEM
Software that records charges to patients, creates billing forms and
maintains payment records.
PATIENT EDUCATION
Health and wellness information available to the patient in electronic,
video, or print forms. Although
patient education includes general health sources (i.e. a wellness Web site or a
self-help booklet), the current emphasis is on delivering patient-specific
information, often directly from the physician.
PATIENT INFORMATICS
Previously and all-encompassing term, patient informatics now is more
commonly broken into consumer informatics and patient education.
PAYOR
An insurer, employer, union, or third-party administrator that is responsible
for the cost and payment of health services for an enrollee in a medical
plan.
PBM
-See PRESCRIPTION BENEFITS
MANAGER
PCP
-See PRIMARY
CARE PHYSICIAN
PER DIEM
An established rate per day, agreed to in advance by the hospital and insurer.
The hospital will accept the per diem as payment in full, including deductibles
and co-payments for covered in-patient services provided to subscribers.
PERFORMANCE MEASUREMENTS
The collected results of a healthcare organization’s actual performance
over a specified time. The Joint
Commission on Accreditation of Healthcare Organizations and the National
Committee for Quality Assurance have developed performance measurement
standards. Performance data usually
is a major factor in an organization’s accreditation process.
See HEDIS.
PER MEMBER PER MONTH (PMPM)
An abbreviation for Per Member Per Month. Revenue
or expense is calculated as an average for each enrolled member each month.
PET
-See POSITRON EMISSION TOMOGRAPHY
PHind
The name of the MHIS application. PHind means Provider
Health insurance network
directory.
PHO
-See PHYSICIAN
HEALTH ORGANIZATION
-See PHYSICIAN
HOSPITAL ORGANIZATION
PHYSICAL HANDICAP
A physical or mental impairment that results in
anatomical, physiological, or psychological abnormalities which are demonstrable
by medically acceptable clinical or laboratory diagnostic techniques and which
are expected to last for a continuous period of time not less than 12 months in
duration.
PHYSICIAN
A health care-professional licensed to practice as one of the following: doctor
of medicine, clinical psychologist, research psychoanalysts, dentist, clinical
social worker, optometrist, chiropractor, podiatrist, or audiologist.
PHYSICIAN
HEALTH ORGANIZATION (PHO)
An agreement between a group of doctors and a
hospital or hospital organization, to administer managed care contracts for
hospitals.
PHYSICIAN HOSPITAL ORGANIZATION
(PHO)
A system where a hospital and its physician groups jointly own the
organization. The PHO as an entity
then assumes the responsibility of arranging contracts with managed care plans
and care facilities.
PHYSICIAN MEMBER
A doctor of medicine who has enrolled with
insurer as a physician member.
PHYSICIAN PRACTICE ORGANIZATION
(PPO)
-See PREFERRED PROVIDER
ORGANIZATION
PHYSICIAN MEDICAL GROUP (PMG)
An agreement between a group of doctors and a
hospital or hospital organization, to administer managed care contracts for
hospitals.
PLAN
A health-benefit plan with specified benefits, exclusions, and limitations: an
EPO, HMO, PPO, insurance policy, or pre-paid benefit plan.
PLAN HOSPITAL
A hospital licensed under applicable state law,
contracting with networks, insurers, employers, unions, or payors specifically
to provide plan benefits to members under a particular plan.
PMG
-See PHYSICIAN
MEDICAL GROUP
PMPM
-See PER
MEMBER PER MONTH
POINT
OF SERVICE (POS)
The offering of a traditional insurance plan, PPO,
HMO and/or EPO by one carrier. Also called a POS plan, triple option, or
open-ended HMO. Note that the benefit level changes when the patient selects
different types of providers or non preferred providers.
POPULATION HEALTH MANAGEMENT
Also called community-based healthcare.
The coordination of care delivery across a population to improve clinical
and financial outcomes. True
population management includes all aspects of disease management, case
management, and demand management.
POS
-See POINT
OF SERVICE
POSITRON EMISSION TOMOGRAPHY (PET)
A nuclear medicine diagnostic imaging technology for observing the functions
of organs and tissue rather than physical structure. PET scans can differentiate between damaged and healthy
tissue, or show which parts of an organ are not functioning properly.
PPO
-See PREFERRED
PROVIDER ORGANIZATION
PRE-ADMISSION REVIEW
A review of an inpatient admission prior to the
date of admission required by an insurer or managed health care plan.
PRE-ADMISSION TESTING (PAT)
Lab services and x-rays are to be performed on an
out-patient basis prior to admission to a hospital.
PRE-EXISTING CONDITION
An illness or injury which existed prior to the
effective date of the member's coverage under the health plan. A disability
shall be considered to have been in existence prior to the effective date of
coverage if during that time:
- Any professional advice or treatment by a
physician, or any medical supply, including but not limited to prescription
drugs or medicines, was obtained for that disability; or
- The disability was manifest to the member.
PREFERRED HOSPITAL
A hospital under contract to insurer which has
agreed to furnish services and accept reimbursement at negotiated rates and
which has been designated as a preferred hospital by insurer.
PREFERRED PROVIDER
A physician member, a hospital or any other
health care professional who has contracted with insurer to furnish services
under the insurer's preferred plan.
PREFERRED
PROVIDER ORGANIZATION (PPO)
The entity that has arranged for contracts with a
preferred providers is the preferred provider organization.
The preferred provider contracts specify the role
and responsibility of the preferred provider with respect to care provided to
patients who are covered by health benefits plans that utilize the preferred
provider network.
The entities that organize a PPO take several
different forms. Some large insurers have formed exclusive networks that cover
only patients of that insurer. Some PPOs have been formed by entities who then
contract with many different insurers to allow those insurers' enrollees access
to the network. Some insurers have relationships with several PPO networks, but
their groups enroll with the insurer and a specific (single) PPO network.
PREMIUM
The amount of money paid monthly in advance for membership in an health benefit
coverage.
PRESCRIPTION BENEFITS MANAGER (PBM)
A company that manages provider and health plan prescription costs by
negotiating with drug rates and reimbursements. Two of the largest are Merck-Medco and PCS Health Systems.
PREVAILING FEE
A fee which falls within a range of charges which
includes at least the majority of all charges for the same service, beginning
with the lowest charges, as submitted to insurer by physicians within a
geographical area determined by insurer.
PRIMARY CARE NETWORK
A group of primary care physicians who contract among themselves and/or with
health plans. Providers in the
group usually share financial responsibilities and risks.
PRIMARY
CARE PHYSICIAN (PCP)
A general practitioner, board-certified, or
eligible family practitioner, internist, obstetrician-gynecologist, or
pediatrician who has contracted with a network, insurer, employer, union, payor,
or PPO to provide benefits to members and to refer, authorize, supervise, and
coordinate the provision of all benefits to members in accordance with their
health-services contract.
Note: Some plans exclude some of the indicated
specialties in their definition of PCP. Also, some plans do not require board
certification for a primary care physician.
PRIMARY CARRIER
The insurer who is primary is determined by rules
established by coordination of benefits. Most insurers have adopted the birthday
rule to determine the primary and secondary carriers. The subscriber with the
earlier birth date in a year determines the primary carrier. Other factors to
consider in determining the primary carrier are: Does one or both policies have
a COB provision? What is the patients relationship to the subscriber? If the
patient is a child, are the child's parents divorced? Is one of the plans from a
government agency? Is one of the plans an HMO?
PRIOR AUTHORIZATION
Authorization given by insurer, payor, or agent
authorizing the provision of the services.
PROSPECTIVE PAYMENT
A payment plan where reimbursements are based on set rates for pre defined
groups of services. Unlike the
previous Medicare reimbursement system, prospective payment pays hospitals
according to what a care episode should cost regardless of the actual expenses,
placing new emphasis on materials management and the accuracy of diagnostic,
evaluation and procedural coding.
PROTECTED HEALTH INFORMATION
Any individually identifiable health information that is used or circulated
by an entity that falls under the governance of HIPAA.
The privacy regulations will mandate safe-guards for protected health
information, and the responsibility for maintaining them also may be extended to
third-party business partners.
PROTOCOL
A way of doing things that has become an agreed-upon convention, or
“rule.” In electronic
communication, if several systems use the same protocols, they operate in a
similar way and can easily exchange data. Standard
protocols have evolved on a national and international basis for data exchange,
language translation, and use of the Internet, to name a few.
PROVIDER
Any practitioner(individual, group), facility, organization who or which is
qualified and duly licensed or certified by the state in which the provider is
located to furnish health services to member (e.g. physicians, medical groups,
hospitals).
PROVIDER PROFILE
An examination of services provided, claims filed, and benefits allocated by
healthcare facilities, physicians and other providers to assess quality of care
and cost management.
PSYCHOLOGICAL INJURY
Damage to a person inflicted by a traumatic event
or chronic exposure to adverse conditions.
PSYCHOTHERAPY
The use of psychological
methods in a clinical relationship to assist a person to modify feelings,
conditions, attitudes, and behavior which are emotionally, intellectually, or
socially ineffectual or maladjustive.
Q
QUALITY ASSURANCE
An assessment of the delivery portion of healthcare plans to make sure patients
are receiving high quality care when and where they need it.
The National Committee for Quality Assurance is a key agency in
evaluating the performance of managed care plans
QUALITY-ASSURANCE PROGRAM
The policies and
procedures adopted by the managed-care plan from time to
time for evaluating and enhancing the quality of covered
services rendered to members in accordance with the terms
and conditions of the group enrollment agreement.
R
REASONABLE FEE
A fee is "reasonable" when it is justifiable, considering the
special circumstances of the case, in the opinion of either a duly
constituted professional review panel of the medical society where
services were rendered or an appropriate professional review panel
designated by insurer.
RECIPROCITY
An agreement between a managed health care plan to provide care and payment for
patients enrolled in a related managed care plan. Under the provider agreement,
each provider is subject to the network reciprocity agreement. Under the
reciprocity clause, if a provider provides approved referral services to an
enrollee of the network the provider will accept payment at the contractual
rates.
For
example IPAs who agree to provide services to patients who are enrolled in the
HMO but whose capitation is paid to another IPA will be reimbursed for care
provided such an enrollee under a reciprocity agreement. Blue Cross and Blue
Shield have included reciprocity agreements for enrollees of plans from other
states.
REFERRAL
The process by which the PCP, 'gate keeper', or other provider directs a
member to seek and obtain covered services from other health
professionals. Some plans have forms that must be used for a valid
referral. A referral in an HMO or EPO plan generally requires an
authorization. In many cases the PCP can authorize the referral, but in
some cases and for some services authorization must also be obtained
from an IPA, PMG, or from the HMO or EPO.
REFERRAL PROVIDER
Any health professional or facility to whom a member is referred.
REFERRAL SERVICE
A covered health service performed by a referral provider.
REHABILITATION SERVICE
A health service provided by an eligible provider, such as a physical
therapist, an occupational therapist, or a speech therapist that can be
expected to result in significant improvement.
RE-INSURANCE
Insurance purchased by insurance carriers to protect against significant
financial loss, above a specified limit, for catastrophic medical and
hospital expenses.
RELATIONAL DATABASE
A database where all information is arranged in tables containing predefined
fields. Using structured query
language, reports, and comparisons can be generated by selecting fields of
interest from the original database and crating new tables. Changing a field in one record automatically changes the same
record in all related databases, allowing for easy global updating.
RELATIONSHIP
CODE
A code assigned by an insurer or managed care plan to identify the relationship
of the patient to the subscriber.
REMITTANCE ADVICE
A notice of payment due, either in paper form or as a notice of an
electronic data interchange financial transaction. See explanation of benefits.
RETENTION
1.
The result when members remain on a health plan from one year to the
next.
2.
The percentage of a premium that a health plan keeps for internal costs
or profit.
RETURN ON INVESTMENT (ROI)
For information technology, it’s the estimated profit or cost
efficiency of one system or infrastructure compared to that of another.
ROI considerations should include the total cost of ownership (hardware,
software, implementation, initial training, operations staff, maintenance staff
and services, and connectivity fees) as well as less tangible issues such as
care delivery speed and quality, workload management, and patient satisfaction.
REVIEW AGENCY
The organization that reviews the medical treatment plan, assigns the length of
stay, or coordinated the other cost containment programs of the insurer or
managed care plan.
RIDER
An optional benefit or set of benefits, in addition to basic coverage, for which
additional premium is collected.
RISK SHARING
Common in a health maintenance organization setting, this arrangement
combines the risk of financial losses for all care providers in a business
entity such as a hospital or physician group.
One provider’s losses are shared by all, but gains also are shared.
ROBOTICS
A form of artificial intelligence, robotic systems are used in healthcare in
two main forms: they process sensory input from haptic interfaces and/or allow
surgeons to act with more accuracy than the unassisted human hand.
Robotic system with miniaturized cameras and precision laser surgical
instruments are now used to conduct minimally invasive surgery, right down to
the cellular level.
ROI
-See RETURN ON INVESTMENT
S
SATISFACTION SURVEY
A survey sent to members of a health plan to allow feedback on the
organization’s service and quality. The
current HEDIS standard requires such surveys as part of performance
measurements.
SCHEDULE
OF BENEFITS
The summary of covered services, exclusions, limitations, co-payment,
deductibles, co-insurance amounts, co-insurance limits, annual-benefit maximums
and, lifetime benefit maximums applicable to a health-benefits program.
SEARCH ENGINE
A tool for finding information quickly from a variety of sources on the
Internet or the World Wide Web. Users
can enter keywords or narrow their search using Boolean language, and the search
engine will list as many relevant sources as it can find.
Not all engines are designed the same way; some gather information by
keyword registry, and others use a “bot”—robot program that wanders the
Web and scans the first few hundred words of each Web site it encounters.
SECONDARY COVERAGE
The health plan that is determined to be secondary under the coordination of
benefit rules. See definition of primary carrier.
SECOND OPINION
A review of surgical procedures recommended or not recommended by a physicians
for treatment of a medical condition of a patient. Many managed care plans have
second opinion programs. These programs may be mandatory or voluntary. Some
payors have created a list of procedures for which they require a second
opinion. Other payors have established criteria which indicate that a second
opinion is appropriate.
SELF
FUNDED
An employer or other organization that chooses to be responsible for the cost of
health care benefits or worker's compensation. The organization chooses to self
insurer the liabilities rather then purchase insurance. A self insured
organization may hire an third party administrator (TPA) to process its claims
and review care. Several insurers have set up departments and subsidiary
organizations to serve as TPAs for self insured employers. Some self insured
employers have selected PPOs to administer their health program.
SELF-INSURED
A company that creates and maintains its own health plan for its employees,
instead of contracting with and outside insurance provider.
Also called self-funded.
SELF-INSURED
OR SELF-FUNDED PLAN
A health plan where the risk for medical cost is assumed by the company rather
than an insurance company or managed care plan.
SKILLED NURSING FACILITY
A place for patients who need the scheduled medical care of a nurse but
don’t need to stay in a hospital. A
health facility holding a valid license issued by the California State
Department of Public Health as a "skilled nursing facility" or any
similar institution licensed under the laws of any other state, territory. or
foreign country.
SMART CARD
A portable, updateable card that can be used to store personal
identification, medical history, and insurance information.
Because it has its own micro processing chip, a smart card can store
thousands more bits of information than a magnetic stripe card, although it does
requires a special card reading device.
SNOMED
Systematized Nomenclature of Human and Veterinary Medicine.
A standardized vocabulary system for medical databases.
Current modules contain more that 144,000 terms and are available in at
least 12 languages. SNOMED has
potential to become the standard vocabulary for speech recognition systems and
computer-based patient records.
SOAP
A standard format for physician charting of patient examinations and a
problem-based patient record. SOAP
combines patient complaints and physician determinations: Subjective
(patient’s input), Objective (physician’s conclusions) and Plan (medical
course of action). Originating the
paper-based world, SOAP elements are now incorporated into many template-based
charting systems.
SPECIAL CASE MANAGEMENT
Some insurers have created procedures for providers to request special
consideration for special benefits normally excluded from coverage. If the
provider can effectively demonstrate the medical and financial benefits of the
care to the plan (in some cases to the employer) the special care may be
approved for payment by the plan.
SPECIALIST
A physician other than a primary-care physician. A preferred specialist has an
agreement with the network, insurer, payor, etc., to provide services to members
on referral by the PCP.
STAFF
MODEL HMO
An HMO with the physicians, who serve the HMO membership, are employed by the
HMO. The staff physicians are typically paid on a salary basis and may also
receive bonus or incentive payments based on their performance and productivity.
Also called a closed panel model. Compare
group HMO, Independent Practice Association and network model HMO.
STANDARD INDUSTRY CODE
Codes assigned to various industries and jobs. Since workforce sectors carry different levels of health
risk, the SIC is used in calculating insurance and health plan premiums.
STOP LOSS
A program limiting the financial liability of a provider for any given member.
It is a reinsurance to provide protection for medical expenses above a certain
limit, generally on a year-by-year basis.
SUBROGATION
As a condition of receiving benefits under a health benefit plan the covered
person agrees to cooperate with the plan in recovering such payment from any
person or organization who has a liability for all or part of the payment. Not
legal in all states.
SUBSCRIBER/SUBSCRIBING
MEMBER
An individual who has been enrolled and accepted by insurer as a member and has
maintained membership in accord with this contract.
SYMBOLIC REASONING
The type of “thinking” employed by artificial intelligence systems.
Symbolic reasoning relies on symbols rather than mathematical equations,
and more closely resembles human thought and decision-making skills.
T
TCP/IP
Transmission Control Protocol / Internet Protocol. The most common group of conventional rules for exchanging
packets of information among networks, including Internet.
TCP/IP has been used on the Internet since the early ‘80s and is
considered an international standard.
TELEHEALTH
A broad term describing the combined efforts of the health
telecommunication, information technology, and health education to improve the
efficiency and quality of healthcare.
TELEMEDICINE
As a segment of telehealth, telemedicine focuses on the provider aspects of
healthcare telecommunications, especially medical imaging technology.
TELERADIOLOGY
Conducting radiology image exchange and/or image interpretations
electronically, usually via videoconferencing or messaging.
TERABYTE
About 1 trillion bytes or 1,000 gigabytes (GB). A system with a terabyte of storage could hold as much as 500
computers’ with 2 GB hard drives data.
THIRD PARTY ADMINISTRATOR (TPA)
A third party administrator
processes the claims and performs other utilization review functions for a self
insured group. Most TPAs contract for access to one or more PPOs, or EPOs for
each employer group that they manage health benefits. See
out-sourcing.
THIRD PARTY LIABILITY
Another insurer or entity who has financial liability for the services provided
a patient. Illnesses or injuries that are a result of an automobile accidents,
accidents in a home or business may be covered by another casualty or liability
insurer. Homeowners, automobile, business, or worker's compensation polices
cover medical care and are referred to as third party liability carriers.
THIRD
PARTY PAYOR
An insurer, employer, union, or third-party administrator that is responsible
for the cost and payment of health services for an enrollee in a medical
plan.
TPA
-See THIRD
PARTY ADMINISTRATOR
TRIAGE
Once used solely as a way to sort disaster victims into categories of care
urgency, this method also is used to guide patients to proper services by using
an intermediary person to gather preliminary information and answer patient
questions.
TRIPLE
OPTION
The offering of a traditional insurance plan, PPO and HMO by one carrier. Also
called a point of service plan (POS).
U
UB-92
The uniform hospital billing form. The current HCFA billing form used to
bill Medicare and third-party payors for reimbursement.
Also called HCFA 1450.
UCR
An abbreviation for Usual, Customary, and Reasonable Reimbursement. This is a
method used by insurers or Medicare carriers of profiling prevailing fees in an
area and reimbursing providers based on that profile.
UMLS
-See UNIFIED MEDICAL LANGUAGE
SYSTEM
UNIFIED MEDICAL LANGUAGE
SYSTEM (UMLS)
An ongoing National Library of Medicine project aimed at the expansion
and coordination of medical databases into “knowledge sources” that can be
easily accessed by multiple platforms. The
current ULMS project offers lexicon and semantic databases and medical resource
lists, including Internet Grateful Med. Under
most circumstances, the licensed use of UMLS products is free.
UNIFORM BILLING CODE
The procedural rules on patient billing, including what information should
appear on the bill and how it should be codes.
UNIQUE PHYSICIAN
IDENTIFIER NUMBER (UPIN)
A database system created in 1985 that gave a unique ID number to each
physician who billed their services under Medicare. The Health Care Financing Administration plans to replace
this system with the National Provider Identifier system, already under
construction.
UNIX
An operating system that has evolved since the 1970s into a standard for
mainframes, work stations, and other computers. Developed by Bell Laboratories and written in C programming
language, Unix became the first open system because of its versatile,
non-proprietary characteristics.
UPIN
-See UNIQUE PHYSICIAN
IDENTIFIER NUMBER
UR
-See UTILIZATION
REVIEW
USUAL,
CUSTOMARY, AND REASONABLE
Usual, customary, and reasonable charge means the amount of a provider's charge
which, as determined by the insurer (payor), does not exceed either of the
following:
-
the amount customarily billed by the provider for the particular
accommodation, service, supply, or other item; or
-
the prevailing charge in the area for the same or substantially
equivalent accommodations, supplies, or other items, or for services of the same
nature and duration performed by providers with similar training and experience.
UTILIZATION MANAGEMENT
A review process used to make sure a patient’s hospital stay, surgery,
tests, or other treatment is necessary.
UTILIZATION REVIEW (UR)
A review and approval of an in-patient hospital service or services
provided, or to be provided, to a member of a managed-care health plan. The
review determines if the care is medically necessary. The
utilization review may be performed by the managed-health-care plan or by an
organization or entity acting as an agent for the managed-care plan. The
utilization review procedures are defined by each health plan. The review must
occur within the plan's specified time period and be coordinated by the agent
selected by the plan. Generally, if the utilization review is not performed the
benefit percentage will be reduced and in some case the patient will receive no
coverage.
UTILIZATION REVIEW APPEAL
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.
V
VALUE-ADDED NETWORK (VAN)
An information exchange network between a healthcare site and its
business operations such as billing and supply offices.
A VAN merely transmits information and does not attempt to verify it.
Compare clearinghouse.
VAN
-See VALUE-ADDED NETWORK
W
WC
-See WORKER'S
COMPENSATION
WEDI
A standards group whose goal is to improve healthcare through widespread
adoption of e-commerce protocols, technologies, and tools.
WIDE AREA NETWORK (WAN)
A network that links computers over a distance, sometimes across
hundreds of miles, using digital technology or telephony.
Compare local area network and metropolitan area network.
WORKER'S
COMPENSATION (WC)
Coverage for work-related injuries and illnesses.
WORKFLOW
A process description of how tasks are done, by whom, in what order, and how
quickly. Workflow can be used in
the context of electronic systems or people, i.e. an electronic workflow system
can help automate a physician’s personal workflow.
WORKFLOW AUTOMATION
The combination of software, tools and services to automate knowledge-based
tasks, on an ad hoc or production-based level.
Technologies commonly incorporated in a workflow automation include,
document imaging and management, knowledge management, and groupware.
WORKFLOW MANAGEMENT
Tracking and prioritizing information and work tasks as they are passed from
one person or department to the next. Software
helps automate this process with priority work lists, task scheduling, and
management reporting.
WRAPAROUND PLAN
A term used to refer to an insurance or health plan coverage for co-payments and
deductibles that are not covered under a member's base plan. This term may also
be used to describe Medicare Supplemental Plans.
