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
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