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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.


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.


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

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