Access – A client’s means to afford medical care when needed.
Accreditation – A method of inspecting a healthcare facility’s procedures and policies in order to ensure compliance with assigned standards set by the designated entity – and to ensure the assigned degree of excellence.
Acf – Ambulatory Care Facility
Acquisition – The physical takeover of one facility or group by another.
Acr – Adjusted Community Rating
Actuaries – Risk and loss analysts who gauge by numerical and operational calculation, the setting of insurance payment rates.
Adjusted Community Rating (Acr) – A rating based on demographic facts such as makeup of family – age, size, etc – and the setting these groups the same payment. The group plan must exclude any consideration of experience or grade in setting these rates.
Administrative Services Only (Aso) – The legal agreement between an employer and an insurance company providing payment.
Adverse Selection – Antiselection
Agent – An employee who represents an insurer or insurance company in designated functions of managed care contracts, such as negotiation, selling and service.
Aggregate Stop-Loss Coverage – A kind of stop-loss insurance plan that will come into place when a group’s total claims have reached the stated limit.
Ambulatory Care Facility (Acf) – A medical care facility providing health care services of a large nature – including preventive care, such as surgery and outpatient care in one location. Also known as an outpatient medical center or medical clinic.
Ancillary Services – Supportive or ancillary services – such as diagnostic services – home health services – physical therapy – and occupational therapy – used to substantiate diagnosis and treatment of a patient’s illness.
Annual Maximum Benefit Amount – The yearly financial limit set by an MCO. This dollar amount is the maximum the plan pays for healthcare for the subscriber in a calendar year.
Antitrust Laws – Laws created to regulate business in illegal holdings in trade – unjust distinction – unfair pricing – lesser contesting and singular status of commerce. See also Sherman Antitrust Act – Clayton Act – and Federal Trade Commission Act.
Appropriate Care – A medical evaluation whose measured outcome of health will supersede its medical risks by a large enough span to ensure reasonable success of the procedure.
Appropriateness Review – A gauge of patient services that will show essential procedures were provided and that no non – essential measures were used.
Aso Contract – Administrative Services Only Contract
Associate Medical Director – Administrator whose work is explained as secondary to the general work of the medical director.
At-Risk – A phrase that explains a provider group is responsible for risk of insurance plan procedures given to a patient.
Autonomy – A standard of care which mandates that medical administrators and providers in a specific plan must be aware that subscribers have the right to be apprised of and implement a plan of action in their care.
Behavioral Healthcare – Those premium plans that implement and carry out psychiatric applications.
Beneficence – A moral principle utilized in managed care. It mandates that patient’s care must reflect their values, treatment plan and that providers of care must have their best interests as a base.
Benefit Design – An evaluation of benefits that will be most effective and affordable for the members of a medical plan. This review would take into account the best way for members to receive care.
Blended Rating – For plan groups with little exposure to claims – a procedure that projects a group’s premium expense, calculated in measure on an MCO’s monetary tables and on their records.
Brand – A trademark or label – an identifying sign of a company for their products.
Broker – One who holds a certification to market and manage several health premiums or insurers – and who is usually seen as an advocate for the purchaser.
Business Integration – A method of merging several applications of a corporate entity into one function outside of a clinical area.
Deductible – A specified payment that a group member must pay prior to payment for services rendered.
Demand Management – Methods used to discourage demand and use of medical services – including benefits that encourage preventive care – and proper usage of health services.
Dental Health Maintenance Organization – A medical group that supplies dental services within a network of providers to members of a group plan who issue a prepayment.
Dental Point Of Service (Dental Pos – A dental care plan that gives the members the choice of using a DHMO (in network) dentist, or using a dentist that is not in the network (HMO). This choice is made at the time of the appointment, and if the latter choice is made, will usually involve more expense to the member.
Dental Pos Option – Dental Point Of Service Option
Dental Ppo – Dental Preferred Provider Organization
Dental Preferred Provider Organization – A group of dentists offering care through a network. The cost of service is discounted.
Dhmo – Dental Health Maintenance Organization
Diagnostic And Treatment Codes – An individual number of combinations that designate one diagnosis or treatment per code.
Direct Response Marketing – Direct Marketing
Disease Management (Dm) – A prescribed program that addresses prevention, diagnostic and therapeutic methods designed to provide cost effective and quality healthcare to those who either have or are at risk for a certain chronic illness or medical condition.
Disease State Management – Disease Management
Dm – Disease Management
Drive Time – An assessment of an area that is accessible to members, based on how long they must drive to see a primary care provider.
Drug Cards – Pharmaceutical Cards
Drug Utilization Review (Dur) – Method and standard that reviews and directs the safe and efficacious use of drugs.
Due Process Clause – A contract clause set up to offer appeal rights to those providers who are terminated with cause.
Dur – Drug Utilization Review
Federal Employee Health Benefits Pr – An offering of a health benefit plan that is managed by the Office of Personnel Management for persons employed by the federal government – retirees – and their dependents and survivors.
Federal Trade Commission Act – A federal law, creating the Federal Trade Commission, giving it the power to interact with the Department of Justice in order to actuate the Clayton Act. The main duty of the FTC is regulation of unfair competition and deceitful business methods, which, within the act, are shown. Because of these procedures, the FTC will pursue those who violate the Sherman Antitrust Ace. Antitrust Laws
Fee-For-Service (Ffs) Payment System – A method of payment that will allow a medical plan to pay the provider or the group member for services provided, after those services have been utilized.
Fee Allowance – Fee Schedule
Fee Maximum – Fee Schedule
Fee Schedule – A listing of accepted fees or established allowances for certain medical procedures. It represents the maximum amounts the program will pay for these procedures, known as fee allowance – fee maximum- – or capped fee.
Fehbp – Federal Employee Health Benefits Plan
Ffs Payment System – Fee-For-Service Payment System
Finance Committee – Arm of directing body that carries out the duty of examining finances and sanction budgets, setting and approving outlay of monies, examining an annual audit, and examining and approving external financing.
Finance Director – Person charged with all financial operations – billing, MIS operations, enrollment data, as well as assuming financial responsibility, accounting and budget data and fiscal reporting.
Formulary – A database of drugs that are categorized by their actions or use and that are set up to be prescribed as preferred by the MCO’s providers.
Fully Funded Plan – A benefit plan which is paid for by the insurer or the MCO. This entity will cover all incurred procedures, if covered by the plan.
Functional Status – A patient’s status of functioning on a daily basis.
Funding Vehicle – A bank account that holds funds an employee and employer would usually pay premiums to an insurer or MCO. This account holds the funds until expenses are paid.
Generic Substitution – The administration of a drug that is the basic equal of another drug on the pharmacy formulary plan. This drug us usually dispensed without contacting the physician.
Geographic Accessibility – Determined by the time needed to drive to a provider’s location or by how many primary care providers are located in a particular service area.
Gpww – Group Practice Without Walls
Grievances – Methods used by an MCO to resolve issues in which a patient needs resolution of a dissatisfactory episode.
Group Market – A demographic of groups of two or more which is a part of a group contract with an MCO. The MCO is responsible for medical coverage to the group.
Group Model Hmo – Physicians in a varied specialty group and who are employed by the group practice, which is an HMO. Often called a group practice model HMO.
Group Practice Model Hmo – Group Model Hmo
Group Practice Without Walls (Gpww) – A physician group that as a group can operate as its own legal group, or can facilitate member practices for the group or the managing group. This group may provide services for the managing group, or arrange for another entity to do so.
Guaranteed Issue – Benefit which allows all persons who are eligible for coverage, and who meet regulations, to receive an insurance policy.
Ibnr Claims – Incurred But Not Reported Claims
Ids – Integrated Delivery System
Incorporation By Reference – A way of incorporating evidence into a contract by referencing it within the contract.
Indemnity Wraparound Policy – The providing of services not normally covered by an HMO in contract with an insurance company.
Independent Agents – Persons who market a number of medical plans or insurers.
Independent Practice Association (I – An MCO model in which the MCO contracts with a group who has an agreement with individual physicians.
Individual Market – That demographic that is ineligible tor Medicare or Medicaid and who are covered by an individual medical contract.
Individual Stop-Loss Coverage – Insurance that pays for charges that are above the stated amount in a certain period.
Integrated Delivery System (Ids) – A consolidated provider group made up of physician services – medical services – hospital and support services.
Integration – Two or more providers uniting to form a collective business, or the uniting of two or more businesses, when they were independent before that time.
Ipa Model Hmo – An HMO delivery model that has an agreement with a physician organization that contracts with individual physicians. These physicians contract to give medical services to the HMO patients.
Ipa – Independent Practice Association
Joint Venture – A limited business group in which several groups unit in order to reach a goal. The groups own and control the business, but keep and maintain their own businesses.
National Accounts – Large group plans that are comprised of employees in several geographic areas and have a single national health benefit plan.
National Practitioner Data Bank (Np – A national roster held by the federal government that lists data on medical providers who have settled malpractice claims or have had other disciplinary actions taken against them.
Network Model Hmo – An HMO that has an agreement with several provider groups or specialty groups.
Network – An organized group of physicians, hospitals and other health care providers working under a health plan to offer care at negotiated rates.
Newborns’ And Mothers’ Health Protection – A federal mandate that regulates hospital stays for childbirth, stating that these confinements cannot be less than 48 hours for normal deliveries, or 96 hours for cesarean births.
Nmhpa – Newborns’ And Mothers’ Health Protection Act
No Balance Billing Provision – An agreement between the provider and benefit plan group that mandates the provider’s acceptance of a specific payment for services as payment in full. The provider must not bill for any additional amounts, with the exception of copayments, coinsurance and deductibles.
Non-Group Market – A member group that has medical coverage under an individual contract, or has coverage under a government program.
Non-Maleficence – A standard that states, under managed care organizations regulations, that providers agree to do no harm to members.
Npdb – National Practitioner Data Bank
Qm Committee – Group within a Managed Care Organization whose work centers around reviewing a quality management program, including setting levels of care, reviewing data, communicating information to providers, following up, sanctioning, and assessing quality of care.
Qm – Quality Management
Quality Management (Qm) – A company procedure of gauging and increasing the quality of care provided by a MCO.
Quality Program – A group wide mandate to review and increase the service and medical service provided by a MCO.
Quality – The ability of an MCO to provide benefits in a managed care plan for its members.
Termination Provision – A contract provision stating circumstances that would allow dissolving an agreement.
Termination With Cause – A standard clause in a provider contract that will allow an MCO or provider to dissolve a contract if duties of the agreement are not fulfilled.
Termination Without Cause – A clause in a contract that permits an MCO or a provider to end an agreement with no explanation or appeal.
Therapeutic Substitution – The distribution of a generic drug in the same class of a drug on a MCOs formulary. Physician’s permission for this is always needed.
Third Party Administrator (Tpa) – An organization that administers health insurance plans to MCOs or self-funded health groups.
Tpa – Third Party Administrator
Treatment Codes – Diagnostic And Treatment Codes
Tricare – A medical plan administered to more than 6 million military personnel and families, managed by private companies selected through a bidding process. Civilian Health And Medical Program Of The Uniformed Services
Ucr Fee – Usual – Customary – And Reasonable Fee
Um – Utilization Management
Underwriting Impairments – Health issues affecting a patient’s risk beyond the norm for his or her age.
Underwriting Manual – Evidence that contains background data regarding underwriting constricts, and that suggests the proper remedy in such cases.
Underwriting Requirements – Process of examining group data or finances that MCOs might institute to provide healthcare coverage to a group, and that which are created for balance in a plan.
Underwriting – A method of locating and grouping the risk of a patient or group.
Ur – Utilization Review
Uro – Utilization Review Organization
Usual – Customary – And Reasonable – The usual and customary medical fee in a geographic region. These fees are used by traditional medical insurance plans as the standard for provider reimbursement.
Utilization Management (Um) – The monitoring and controlling of medical services provided to a particular patient population to assure cost effective, quality care.
Utilization Review (Ur) – Examination of necessary, effective and appropriate medical care and treatment plans.
Utilization Review Committee – Group that examines and approves or sanctions utilization concerns brought by a medical director. Utilization patterns of providers and reviewing coverage policy is one of the duties of this group.
Utilization Review Organization (Ur – A group of outside examiners who assure that a proposed course of treatment is appropriate. The value and quality of treatment and services is thus assured.
Variances – In the equation of the difference between actual results and expected results, the differential number.
Withhold – A portion of a provider’s profit that is on hold during the plan year as an offset of payment for any cost overruns for referral or facility services. If these monies are not used, they are disseminated to providers.
Workers’ Compensation Indemnity Benefits – Insurance payments that provide an employee wages during an injury or illness that prevents employment.
Workers’ Compensation – When an employee is injured or is ill due to an on-the-job occurrence, this is a state insurance program that will issue benefits for healthcare costs and lost wages if the employee and dependents qualify.