Access: The ability to obtain needed medical care.
Admission Review: Assessment of the appropriateness of urgent or emergency admissions within a limited period after hospitalization.
Ancillary Services: Supplemental services such as laboratory, radiology, and physical therapy that are provided in conjunction with medical care.
Appropriate Care: Care which is clinically justified; sometimes used interchangeably with necessary care and sometimes used only to refer to whether the use of a particular site of care (for example, hospital) is justified.
Business Coalitions: Regionally based groups of employers and/or providers, insurers, and labor representatives who may disseminate information on health care issues, collect and analyze data, and provide other services for members.
Capitation: A fixed rate of payment to cover a specified set of health services. The rate is usually provided on a per member per month basis.
Claim: A bill for health services submitted to a health benefits plan for payment.
Coinsurance: The percentage of a covered medical expense that a beneficiary must pay (after the deductible is paid).
Concurrent Review: See Continued-stay review.
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Page 288 Appendix G Glossary and Acronyms Glossary A Access: The ability to obtain needed medical care. Admission Review: Assessment of the appropriateness of urgent or emergency admissions within a limited period after hospitalization. Ancillary Services: Supplemental services such as laboratory, radiology, and physical therapy that are provided in conjunction with medical care. Appropriate Care: Care which is clinically justified; sometimes used interchangeably with necessary care and sometimes used only to refer to whether the use of a particular site of care (for example, hospital) is justified. B Business Coalitions: Regionally based groups of employers and/or providers, insurers, and labor representatives who may disseminate information on health care issues, collect and analyze data, and provide other services for members. C Capitation: A fixed rate of payment to cover a specified set of health services. The rate is usually provided on a per member per month basis. Claim: A bill for health services submitted to a health benefits plan for payment. Coinsurance: The percentage of a covered medical expense that a beneficiary must pay (after the deductible is paid). Concurrent Review: See Continued-stay review.
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Page 289 Continued-Stay Review: Assessment of the need for continued inpatient care for a hospitalized patient. Cost-Sharing: The share of health expenses that a beneficiary must pay, including the deductibles, copayments, coinsurance, and extra bill. Criteria: Bases for assessing the necessity or appropriateness of a medical service; explicit criteria are written. Current Procedural Terminology (CPT): A listing of descriptive terms and identifying codes for reporting physician services and procedures. Deductible: The amount of medical expense that must be incurred and paid by an individual before a third party will assume any liability for payment of benefits. Discharge Planning: The process of ensuring that patients are discharged as soon as medically appropriate, with follow-up care planned and arranged as needed. E Effectiveness: Probability of benefit to patients from a specific medical service under average conditions of use. Efficacy: Probability of benefit to patients from a specific medical service under ideal conditions of use. Efficiency: Level of benefit from a fixed level of input or amount of input cost to achieve a defined level of benefit. Encounter: In the health maintenance organization setting, generally refers to an outpatient visit to a physician or allied health professional. Enrollee: Individual covered by a health benefit plan. F Feedback Approaches: Programs in which physicians' patient care decisions are reviewed based on medical records, claims, or other documents of care, with the results shared with the physician. Fee-for-Service: A method of paying practitioners on a service-by-service rather than a salaried or capitated basis. G Gatekeeper: Primary care provider who is responsible for coordinating all medical treatment rendered to an enrollee of a health plan. Group Model Health Maintenance Organization: A health maintenance organization that contracts with a primary care or multispecialty medical practice for delivery of health services. H Health Maintenance Organization (HMO): An entity that accepts responsibility and financial risk for providing specified services to a defined population during a defined period of time at a fixed price. High-Cost Case Management: A process for identifying high-cost patients and facilitating the development and implementation of less costly appropriate courses of care.
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Page 290 I Individual Practice Association (IPA): Model Health Maintenance Organization: A health maintenance organization that contracts with private physicians who serve health maintenance organization enrollees in their offices, generally on a fee-for-service basis. Insurer: Organization that bears the financial risk for the cost of defined categories of services for a defined group of enrollees. M Medical Necessity: The need for a specific medical service based on clinical expectations that the health benefits will outweigh the health risks; sometimes used interchangeably with appropriateness. N Network Model Health Maintenance Organization: A health maintenance organization that contracts with two or more medical group practices. O Outcome: The result of a medical intervention. Outliers: Cases that are at the extremes of a distribution. P Peer Review Organization (PRO): A physician-based organization that reviews the medical necessity and the quality of care provided to Medicare beneficiaries. Per Diem: A negotiated daily payment for delivery of hospital services, regardless of the actual services provided; sometimes refers only to "room and board" charges (meals, routine nursing care, etc.), not ancillary services. Practice Guidelines: Clinical recommendations for patient care. Practice Patterns: Aggregate characteristics of a practitioner's use of medical resources over time. Practitioner: One who practices medicine; may include physicians, chiropractors, dentists, podiatrists, and physician's assistants. Preadmission Review: Assessment of the clinical justification for a proposed hospital admission. Premium: An amount paid periodically to purchase health insurance benefits. Prepaid Group Practice: A term used before the term health maintenance organization was coined to refer to multispecialty groups paid on a salaried or capitated basis. Preservice Review: Assessment of the clinical justification for a proposed inpatient or outpatient service. Prior Review/Authorization/Certification/Determination: Prior assessment by a payer or payer's agent that proposed services, such as hospitalization, are appropriate for a particular patient. Payment for services also depends on whether the patient and the category of service are covered by a benefit plan. Professional Standard Review Organization (PSRO): Medicare review organization that preceded the peer review organization.
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Page 291 Profile Analysis: Use of aggregate statistical data on an institution or practitioner to compare practice and use patterns, identify inappropriate practices, or assess other characteristics of practice. Provider: An individual or organization that provides personal health services. Q Quality Assessment: Evaluation of the technical and interpersonal aspects of medical care. Quality Assurance: An organized program to protect or improve quality of care by evaluating medical care, correcting problems, and monitoring corrective actions. R Referral: An arrangement for a patient to be evaluated and treated by another provider. Retrospective Utilization Review: Assessment of the appropriateness of medical services on a case-by-case or aggregate basis after the services have been provided. S Second-Opinion Program: An opinion about the appropriateness of a proposed treatment provided by a practitioner other than the one making the original recommendation; some health benefit plans require such opinions for selected services. Self-Insurance: When an organization bears financial risk for hazards (for example, medical costs, and property damage) that the organization itself may experience. Self-Referral: The process whereby a patient seeks care directly from a specialist without seeking advice or authorization from the primary care physician. Site of Service: Location where care is provided, for example, an inpatient facility or home. Staff Model Health Maintenance Organization: A health maintenance organization which provides health services through a multispecialty group practice, usually on a salaried basis. T Third-Party Administrator (TPA): Organization that processes health plan claims without bearing any insurance risk. Third-Party Payer: An organization other than the patient (first party) or health care provider (second party) involved in the financing of personal health services. Triple-Option Plan: An experience-rated program for an employer group in which a single insurance carrier, Blue Cross and Blue Shield plan, or health maintenance organization provides indemnity or service benefits in conjunction with various managed care or health maintenance organization plans. U Unbundle: Charging for individual services which ordinarily should have been covered under one procedure code.
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Page 292 Upcode: Using a procedure code which reflects a higher intensity of care than would normally be used for the services delivered. Utilization Management: A set of techniques used on behalf of purchasers of health benefits to manage costs through case-by-case assessments of the clinical justification for proposed medical services. W Withhold: A portion of a capitated or fee-for-service payment to a contracting physician withheld by an HMO or similar organization during the year. Depending on how revenues cover costs, the organization may retain or return some or all of the amount withheld. Acronyms AEP: Appropriateness Evaluation Protocol BCBSA: Blue Cross and Blue Shield Association CBO: U.S. Congressional Budget Office CCMC: Committee on the Costs of Medical Care CPT: Current Procedural Terminology DHHS: U.S. Department of Health and Human Services DRG: Diagnosis-related group FFS: Fee-for-service FMC: Foundation for Medical Care GAO: U.S. General Accounting Office GHAA: Group Health Association of America HCFA: Health Care Financing Administration HIAA: Health Insurance Association of America HMO: Health maintenance organization ICD-9: International Classification of Disease IMC: International Medical Centers Inc. IOM: Institute of Medicine IPA: Individual practice association ISD-A: Intensity of service, severity of illness, discharge, and appropriateness screens OBRA-86: Omnibus Budget Reconciliation Act of 1986 PCP: Primary care physician PPO: Preferred provider organization PPS: Prospective payment system (for hospitals) PRO: Peer review organization TPA: Third-party administrator