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HC233

Essentials of Managed Care Terminology

TermDefinition
Capitation Method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount for each person enrolled without regard to the actual number or nature of services provided or number of persons served.
Carve-out Contracts that separate out services or populations of patients or clients to decrease risk and costs.
Case management Coordination of individuals’ care over time and across multiple sites and providers, especially in complex and high-cost cases. Goals include continuity of care, cost-effectiveness, quality, and appropriate utilization.
Consumer-Directed Health Plans Specific set of health insurance arrangements in which individuals have a high-deductible health plan coupled with a personal health account (PHA) that they can use to pay health care expenses not covered by insurance.
Cost sharing Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; a cost-control mechanism.
Disease management Program focused on preventing exacerbations of chronic diseases and on promoting healthier lifestyles for patients and clients with chronic diseases.
Eligibility Set of stipulations that qualify a person to apply for healthcare insurance, examples include percentage of the appointment or duration of employment.
Enrollee Covered member or covered member’s dependent of a health maintenance organization (HMO).
Enrollment Initial process in which new individuals apply and are accepted as members of healthcare insurance plans.
Fee-for-service (FFS) reimbursement Healthcare payment method in which providers retrospectively receive payment for each service rendered.
Group practice Type of integrated delivery system in which the individual physicians share administrative systems but maintain their separate practices and offices distributed over a geographic area.
Health Insurance Portability and Accountability Act (HIPAA) of 1996 Significant piece of legislation aimed at improving healthcare data transmission among providers and insurers; designated code sets to be used for electronic transmission of claims.
Health maintenance organization (HMO) A health insurance organization to which subscribers pay a predetermined fee in return for a range of medical services from physicians and healthcare workers registered with the organization.
Health reimbursement arrangement (HRA) Combination of an employee-benefit health insurance plan and a separate arrangement to reimburse employees for all or a portion of the qualified medical expenses not paid by the health insurance policy.
Individual (single) coverage Healthcare insurance benefits that cover only one individual, the member.
In-network Set of physicians, hospitals, and other providers who have formal agreements with health insurers under which patients and clients receive services at a discounted rate
Insurance Reduction of a person’s (insured’s) exposure to risk of loss by having another party (insurer) assume the risk.
Insured Individual or entity that purchases healthcare insurance coverage.
Integrated provider organization (IPO) Corporate, managerial entity that includes one or more hospitals, alarge physician group practice, other healthcare organizations, or various configurations of these businesses.
Malpractice Element of the relative value unit (RVU); costs of the premiums for professional liability insurance
Managed Care Payment method in which the third-party payer has implemented some provisions to control the costs of healthcare while maintaining quality care.
Managed care organization (MCO) Entity that integrates the financing and delivery of specified healthcare services.
Management (medical) service organization (MSO) Specialized entity that provides management services and administrative and information systems to one or more physician group practices or small hospitals.
Measurement Systematic process of data collection, repeated over time or at a single point in time.
Medicaid Part of the Social Security Act, a joint program between state and federal governments to provide healthcare benefits to low-income persons and families.
Medical necessity Healthcare services & supplies that are proved/ acknowledged to be effective in the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms and to be consistent with the community’s accepted standard of care.
Medicare Federally funded healthcare benefits program for those persons 65 years old and older, as well as for those entitled to Social Security benefits.
Micro-hospitals A community hospitals that is licensed facilities that offer emergency medical care, inpatient care, surgery, laboratory and radiology services. Designed to create more accessible, cost-effective access points and alternative delivery models.
Network Physicians, hospitals, and other providers who provide healthcare services to members of a managed care organization. Providers may be associated through formal or informal contracts and agreements.
Network model Type of health maintenance organization (HMO) in which the HMO contracts with two or more medical groups and reimburses the groups on a fee-for-service or capitation basis
Out-of-pocket Payment made by the policyholder or member.
Policy Binding contract issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to treat illness or injury
Policyholder Individual or entity that purchases healthcare insurance coverage
Primary care physician Physician who provides, supervises, and coordinates the healthcare of a member. Family and general practitioners, internists, pediatricians, and obstetricians/gynecologists are primary care physicians.
Primary care provider (PCP) Healthcare provider who provides, supervises, and coordinates the healthcare of a member. The PCP makes referrals to specialists and for advanced diagnostic testing.
Prospective payment system (PPS) Method of reimbursement in which payment rates for healthcare services are established in advance for a specific time period. The predetermined rates are based on average levels of resource use for certain types of healthcare.
Referral Process in which a primary care provider or physician makes a request to a managed care plan on behalf of a patient to send that patient to receive medical care from a specialist or provider outside the managed care plan.
Reimbursement Compensation or repayment for healthcare services already rendered.
Risk Probability of incurring loss.
Unbundling The fraudulent process in which individual component codes are submitted for reimbursement rather than one comprehensive code.
Universal healthcare coverage Minimum level of healthcare insurance that includes coverage for preventive and primary care, hospitalization, mental health benefits, and prescription drugs.
Utilization management Program that evaluates the healthcare facility’s efficiency in providing necessary care to patients in the most effective manner.
Utilization review Process of determining whether a patient’s medical care is necessary according to established guidelines and regulations.
Withhold Portion of providers’ capitated payments that managed care organizations deduct and hold to create an incentive for efficient or reduced use of healthcare services
Created by: kredding