Term
| utilization management (utilization review) |
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Definition
| method of con¬trolling health care costs and quality of care by review¬ing the appropriateness and necessity of care provided to patients prior to the administration of care |
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Term
utilization review organization (URO) |
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Definition
| entity that establishes a utilization management program and performs external utilization review services. |
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Term
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Definition
| also called covered lives; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans |
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Term
customized sub-capitation plan (CSCP)
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Definition
| managed care plan in which health care expenses are funded by insurance coverage; the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium; each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider (called a sub-capitation payment). |
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Term
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Definition
| customized sub-capitation plan |
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Term
direct contract model HMO |
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Definition
| contracted health care services delivered to subscribers by individual physicians in the community. |
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Term
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Definition
| involves arranging appropriate health care services for the discharged patient (e.g., home health care). |
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Term
exclusive provider organization (EPO) |
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Definition
| managed care plan that provides benefits to subscribers if they receive services from network providers. |
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Term
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Definition
exclusive provider organization |
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Term
external quality review organization (EQRO) |
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Definition
| responsible for reviewing health care provided by managed care organizations. |
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Term
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Definition
| external quality review organization |
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Term
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Definition
| certified to provide health care services to Medicare and Medicaid enrollees. |
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Term
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Definition
| reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services (e.g., brand-name vs. generic pre¬scription medication |
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Term
flexible spending account (FSA) |
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Definition
| tax-exempt account offered by employers with any number of employees, which individuals use to pay health care bills; participants enroll in a relatively inexpensive, high-deductible insurance plan, and a tax-deductible savings account is opened to cover current and future medical expenses; money deposited (and earnings) is tax-deferred, and money is withdrawn to cover qualified medical expenses tax-free; money can be withdrawn for purposes other than health care expenses after payment of income tax plus a 15 percent penalty; unused balances "roll over" from year to year, and if an employee changes jobs, the FSA can continue to be used to pay for qualified health care expenses; also called health savings account (HSA) or health savings security account (HSSA). |
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Term
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Definition
| flexible spending account |
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Term
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Definition
| prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services. |
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Term
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Definition
| primary care provider for essential health care services at the lowest possible cost, avoiding non-essential care, and referring patients to specialists. |
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Term
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Definition
| contracted health care services delivered to subscribers by participating physicians who are members of an independent multispecialty group practice. |
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Term
group practice without walls (GPWW) |
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Definition
| contract that allows physicians to maintain their own offices and share services (e.g., appointment scheduling and billing). |
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Term
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Definition
| group practice without walls |
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Term
health care reimbursement account (HCRA)
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Definition
| tax-exempt account used to pay for health care expenses; individual decides, in advance, how much money to deposit in an HCRA (and unused funds are lost). |
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Term
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Definition
| health care reimbursement account |
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Term
health reimbursement arrangement (HRA) |
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Definition
| tax-exempt accounts offered by employers with more than 50 employees; individuals use HRAs to pay health care bills; HRAs must be used for qualified health care expenses, require enrollment in a high-deductible insurance policy, and can accumulate unspent money for future years; if an employee changes jobs, the HRA can continue to be used to pay for qualified health care expenses. |
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Term
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Definition
health reimbursement arrangement |
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Term
independent practice association (IPA) HMO |
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Definition
also called individual practice association (IPA); type of HMO where contracted health services are delivered to subscribers by physicians who remain in their independent office settings.
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Term
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Definition
| independent practice association |
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Term
integrated delivery system (IDS) |
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Definition
| organization of affiliated provider sites (e.g., hospitals, ambulatory surgical centers, or physician groups) that offer joint health care services to subscribers. |
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Term
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Definition
integrated delivery system |
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Term
integrated provider organization (IPO) |
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Definition
| manages the delivery of health care services offered by hospitals, physicians employed by the IPO, and other health care organizations (e.g., an ambulatory surgery clinic and a nursing facility). |
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Term
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Definition
| integrated provider organization |
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Term
managed care organization (MCO) |
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Definition
| responsible for the health of a group of enrollees; can be a health plan, hospital, physician group, or health system. |
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Term
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Definition
managed care organization |
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Term
| managed health care (managed care) |
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Definition
| combines health care delivery with the financing of services provided. |
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Term
| management service organization (MSO) |
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Definition
| usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual physician practices. |
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Term
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Definition
| management service organization |
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Term
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Definition
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Term
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Definition
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Term
| medical savings account (MSA) |
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Definition
| tax-exempt trust or custodial account established for the purpose of paying medical expenses in conjunction with a high-deductible health plan; allows individuals to withdraw tax-free funds for health care expenses, which are not covered by a qualifying high-deductible health plan. |
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Term
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Definition
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Term
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Definition
| nonprofit organization that contracts with and acquires the clinical and business assets of physician practices; the foundation is assigned a provider number and manages the practice's business. |
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Term
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Definition
| CMS agency that facilitates innovation and competition among Medicare HMOs. |
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Term
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Definition
| health care provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO. |
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Term
| National Committee for Quality Assurance (NCQA) |
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Definition
| a private, not-for-profit organization that assesses the quality of managed care plans in the United States andreleases the data to the public for its consideration when selecting a managed care plan. |
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Term
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Definition
| contracted health care services provided to subscribers by two or more physician mul-tispecialty group practices |
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Term
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Definition
| physician or health care facility under contract to the managed care plan. |
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Term
quality assessment and performance improvement (QAPI)
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Definition
| program implemented so that quality assurance activities are performed to improve the functioning of Medicare Advantage organizations. |
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Term
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Definition
| quality assessment and performance improvement |
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Term
quality assurance program |
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Definition
| activities that assess the quality of care provided in a health care setting. |
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Term
Quality Improvement System for Managed Care (QISMC)
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Definition
established by Medicare to ensure the accountability of managed care plans in terms of objective, measurable standards. |
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Term
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Definition
| Quality Improvement System for Managed Care |
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Term
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Definition
| requires managed care plans that contract with Medicare or Medicaid to disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval. |
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Term
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Definition
| include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services (e.g., discharge an inpatient from the hospital more quickly) to save money for the managed care plan. |
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Term
physician-hospital organization (PHO)
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Definition
| owned by hospital(s) and physician groups that obtain managed care plan contracts; physicians maintain their own practices and provide health care services to plan members. |
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Term
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Definition
physician-hospital organization |
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Term
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Definition
| delivers health care services using both an HMO network and traditional indemnity coverage so patients can seek care outside the HMO network. |
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Term
| preadmission certification (PAC) |
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Definition
| review for medical neces¬sity of inpatient care prior to the patient's admission. |
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Term
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Definition
| preadmission certification |
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Term
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Definition
| review for medical necessity of inpatient care prior to the patient's admission. |
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Term
Preferred Provider Health Care Act of 1985 |
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Definition
| eased restrictions on preferred provider organizations (PPOs) and allowed subscribers to seek health care from providers outside of the PPO. |
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Term
preferred provider organization (PPO) |
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Definition
| network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee. |
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Term
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Definition
| preferred provider organization |
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Term
primary care provider (PCP) |
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Definition
| responsible for supervising and coordinating health care services for enrollees and preauthorizing referrals to specialists and inpatient hospital admissions (except in emergencies). |
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Term
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Definition
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Term
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Definition
| reviewing appropriateness and necessity of care provided to patients prior to administration of care. |
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Term
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Definition
| usually offered by either a single insurance plan or as a joint venture among two or more insurance carriers, and provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans; also called cafeteria plan or flexible benefit plan. |
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Term
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Definition
| contains data regarding a managed care plan's quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control. |
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Term
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Definition
| reviewing appropriateness and necessity of care provided to patients after the administration of care. |
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Term
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Definition
| an arrangement among providers to provide capitated (fixed, prepaid basis) health care services to Medicare beneficiaries. |
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Term
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Definition
| created when a number of people are grouped for insurance purposes (e.g., employees of an organization); the cost of health care coverage is determined by employees' health status, age, sex, and occupation. |
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Term
second surgical opinion (SSO) |
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Definition
| second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery (e.g., outpatient clinic or doctor's office versus inpatient hospitalization). |
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Term
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Definition
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Term
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Definition
| voluntary process that a health care facility or organization (e.g., hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law. |
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Term
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Definition
| covering members who are sicker than the general population. |
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Term
| Amendment to the HMO Act of 1973 |
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Definition
| legislation that allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be par¬tially reimbursed. |
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Term
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Definition
| also called triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party administrator. |
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Term
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Definition
| provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually one year). |
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Term
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Definition
| development of patient care plans to coordinate and provide care for complicated cases in a cost-effective manner. |
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Term
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Definition
| submits written confirmation, authorizing treatment, to the provider. |
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Term
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Definition
| health care is provided in an HMO-owned center or satellite clinic or by physicians who belong to a specially formed medical group that serves the HMO. |
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Term
| competitive medical plan (CMP) |
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Definition
| an HMO that meets federal eligibility requirements for a Medicare risk contract, but is not licensed as a federally qualified plan. |
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Term
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Definition
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Term
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Definition
| review for medical necessity of tests and procedures ordered during an inpatient hos-pitalization. |
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Term
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Definition
| utilization review organization |
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Term
| subscribers (policyholders) |
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Definition
| person in whose name the insurance policy is issued |
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