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The patient's ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care. An individual's ability to obtain appropriate health care services. Barriers to access can be financial (insufficient monetary resources), geographic (distance to providers), organizational (lack of available providers) and sociological (e.g., discrimination, language barriers). Efforts to improve access often focus on providing/improving health coverage.
The process by which an organization recognizes a program of study or an institution as meeting predetermined standards. Two organizations that accredit managed care plans are the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO).
The assumptions that an insurer uses when calculating the expected costs and revenues of a health care plan (i.e. utilization rates, gender of enrollees, costs of medical services).
When the premiums collected by an insurer more than offset the reimbursement payments that insurer disburses to providers.
Medical services provided for an immediate and severe episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Unlike chronic care, acute care is often necessary for only a short time.
Costs not linked directly to the provision of medical care, such as marketing, claims processing, billing, and medical record keeping.
When individuals who have potentially higher medical costs than the general population continues with an insurer or initially enrolls in an insurance plan.
A federally-supported, state-administered program that provides cash welfare to children under the age of 18 who have been deprived of parental support and some households that provide care for such child. The Personal Responsibility & Work Responsibility Act of 1996 replaced AFDC with Temporary Assistance for Needy Families (TANF).
Health services provided to patients who do not require overnight hospitalization at the health care facility.
A national, not-for-profit organization that administers and coordinates voluntary standardization and conformity assessment system for private and public sector organizations based on its requirements for openness, balance, consensus and due process.
Supplemental services that are provided in conjunction with medical or hospital care, including laboratory work, X-rays, and anesthesia.
A set of laws that protect consumers from anti-competitive actions by health care provider networks. Some hospital mergers, physician and hospital joint ventures, and hospital purchasing arrangements may be considered anti-competitive.
Laws requiring managed care organizations to contract for the delivery of health care services with all willing and qualified health care providers in their geographic coverage areas. New York State does not have such laws.
The extent to which a particular procedure, treatment, test, or service is clearly indicated, not excessive, adequate in quantity, and provided in the setting best suited to a patient's needs.
The physician responsible for managing all or most of a patient’s health needs. The PCP is considered a patient’s attending physician unless, as is often the case during hospitalization, another physician or specialist assumes responsibility for a patient’s management.
When persons enrolled in a health insurance plan, usually Medicaid, are assigned to a plan by the state because they did not choose a contracted plan within a specified time frame.
Refers to the average length of stay per inpatient hospital visit.
The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made. Under Medicare, the excess amount cannot be more than 15 percent above the approved charge.
An individual who is either using or eligible for a health plan’s benefits.
The services offered by or through an insurer or health plan to enrollees covered under the terms of health insurance contract.
Health and other services and treatments that are guaranteed to an enrollee by or through the health plan.
Fees submitted by a health care provider for health services or treatment rendered to an enrollee.
A clinician who has passed a national examination (oral and written) in his or her particular specialty or field and has been certified by that specialty board.
A clinician who is eligible to take the specialty board examination by virtue of graduation from an approved medical school and completion of specific training.
An arrangement under which employees may choose their own benefit structure. Sometimes these are varying benefit plans or add-ons provided through the same insurer or 3rd party administrator, other times this refers to the offering of different plans or HMOs provided by different managed care or insurance companies.
Capital costs usually involve equipment and physical plant costs, not consummable supplies. Included in these costs can be interest, leases, rentals, taxes and insurance on physical assets like plant and equipment. Capital costs are usually reimbursed to cost based facilities through submission of these costs on annual cost reports to the HCFA intermediaries. Depreciation schedules apply.
Specified amount paid periodically to health provider for a group of specified health services, regardless of quantity rendered. Amounts are determined by assessing a payment "per covered life" or per member. The method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered. The cost of providing an individual with a specific set of services over a set period of time, usually a month or a year. A payment system whereby managed care plans pay health care providers a fixed amount to care for a patient over a given period. Providers are not reimbursed for services that exceed the allotted amount. The rate may be fixed for all members or it can be adjusted for the age and gender of the member, based on actuarial projections of medical utilization.
An insurer; an underwriter of risk, that finances health care. Also refers to any organization which underwrites or administers life, health or other insurance programs.
Practice of excluding specific services from a managed care organization's capitated rate. In some instances, the same provider will still provide the service, but they will be reimbursed on a fee-for-service basis. In other instances, carved out services will be provided by an entirely different provider. A payer strategy in which a payer separates ("carves-out") a portion of the benefit and hires an MCO to provide these benefits. Common carve outs include such services as psychiatric, rehab, chemical dependency and ambulatory services. Increasingly, oncology and cardiac services are being carved out. This permits the payer to create a seperate health benefits package and assume greater control of their costs. Many HMOs and insurance companies adopt this strategy because they do not have in-house expertise related to the service "carved out." A "carve-out" is typically a service provided within a standard benefit package but delivered exclusively by a designated provider or group. This process may or may not seem transparent to the subscriber, but, it often means that seperate UR and pre-certification entities are involved as well as different payers and providers. Carve-outs are also called sub-contractors, sub-capitators or junior capitation contracts.
Method designed to accomodate the specific health services needed by an individual through a coordinated effort to achieve the desired health outcome in a cost effective manner. The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services. The process by which all health-related matters of a case are managed by a physician or nurse or designated health professional. Physician case managers coordinate designated components of health care, such as appropriate referral to consultants, specialists, hospitals, ancillary providers and services. Case management is intended to ensure continuity of services and accessibility to overcome rigidity, fragmented services, and the misutilization of facilities and resources. It also attempts to match the appropriate intensity of services with the patient's needs over time.
Insurance for medical conditions with total costs that are expected to exceed an amount designated by the insurance company or health maintenance organization.
Persons who are eligible for Medicaid coverage because they are disabled (as defined under the Supplemental Security Income program), or are members of a family with dependent children where one parent is absent, incapacitated, or unemployed (as defined under the Aid to Families with Dependent Children program).
Issued by state governments, the certificate grants health maintenance organizations (HMOs) and insurance companies its license to operate within the state.
Outlines the terms of coverage and benefits available in a carrier's health plan.
In some states, an agency must review and approve certain proposed capital expenditures, changes in health services provided, and purchases of expensive medical equipment. New York State distributes Certificates of Need.
The published prices for services and treatments rendered by a facility.
Formerly called Children’s Medicaid, this program provides medical coverage for children who are under the age of 19 and eligible for Medicaid. The program covers medical services including regular medical check-ups, specialty services, dental care, prescription drugs, and hospital care.
A New York State insurance program that provides medical services for children under the age of 19 who are not eligible for Child Health Plus A and do not have private health insurance. The cost to parents/guardians depends on household income and size. Families whose income is less that 160% of the Federal Poverty Level pay nothing.
Part of New York State’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), this program provides early and periodic screenings to children who are under the age of 21 and eligible for Medicaid.
Long-term care of individuals with long standing, persistent diseases or conditions. In addition to care specific to the problem, chronic care includes measures to encourage self-care, promote health, and prevent loss of function.
The separation of data from the computer application that allows entry or editing of data.
A patient with an atypically long length of stay compared with other patients in a particular diagnosis related group.
A standard unit of measurement of utilization. Refers to an annualized use of the hospital or other institutional care. It is the number of hospital days that are used in a year for each thousand covered lives. The formula used to calculate days per thousand is as follows: (# of days/member months) x (1000 members) x (# of months). An indicator calculated by taking the total number of days (for inpatient, residential, or partial hospitalization) or visits (for outpatient) received by a specific group for a specific period of time (usually one year). A measure used to evaluate utilization management performance.
Computer technologies used in healthcare which allow providers to collect and analyze data in more sophisticated and complex ways. Activities supported include case mix, budgeting, cost accounting, clinical protocols and pathways, outcomes, and actuarial analysis.
Charge incurred during the last three months of a year that may be applied to the deductible and which may be carried over into the next year.
Amounts required to be paid by the insured under a health insurance contract, before benefits become payable.
EPSDT program covers screening and diagnostic services to determine physical or mental defects in recipients under age 21, as well as health care and other measures to correct or ameliorate any defects and chronic conditions discovered.
The use of economic criteria unrelated to quality of care or professional competency in determining an individual's qualifications for initial or continuing hospital medical staff membership or privileges. Economic credentialling has become a controversial topic involving much concern about ethics, yet, economic credentialing remains the most powerful form of controlling the behavior of doctors. Other forms of control include utilization review, certification, exclusive provider panels and more.
The date on which a policy's coverage of a risk goes into effect.
A digital representation of a medical bill generated by a provider or by the provider's billing agent for submission using telecommunications to a health insurance payer.
The automated exchange of data and documents in a standardized format. In health care, some common uses of this technology include claims submission and payment, eligibility, and referral authorization.
This technology, when fully developed, meets provider needs for real-time data access and evaluation in medical care. Together with clinical workstations and clinical data repository technologies, the EMR provides the mechanism for longitudinal data storage and access. A motivation for healthcare entities to implement this technology derives from the need for medical outcome studies, more efficient care, speedier communication among providers and management of health plans.
Selection of subscribers or covered lives based on data which shows a tendency for utilization of health services in that population group to be lower than expected or estimated.
As an agency under the DOJ, the FBI investigates violations of federal criminal law and provides law enforcement assistance to federal, state, local and international agencies. The FBI has investigated hospitals for fraud and abuse. (see Fraud)
A status designated by HCFA after conducting an extensive evaluation of an HMO's organization and operations. An organization must be federally qualified or be designated as a competitive medical plan (CMP) to be eligible to participate in Medicare and cost and risk contracts. Federal designation that allows an organization to participate in certain Medicare cost and risk contracts.
A federal payment option that enables qualified providers in medically underserved areas to receive cost-based Medicare and Medicaid reimbursement and allows for the direct reimbursement of nurse practitioners, physician assistants and certified nurse midwives. Many outpatient clinics and specialty outreach services are qualified under this provision which was enacted in 1989.
A prepaid health plan that has met strict federal standards and has been granted qualification status. A federally-qualified HMO is eligible for loans and loan guarantees not available to non-qualified plans. Employers of 25 or more workers were, until recently, required to offer a federally-qualified HMO if the plan requested to be included in the company's health benefits program.
Physicians and caregivers discussing their charges with patients prior to treatment.
A provision of a contract between a managed care organization and a health care provider that restricts the amount of information a provider may share with a beneficiary or that limits the circumstances under which a provider may recommend a specific treatment option.
A primary care physician or managed care entity responsible for determining when and what services a patient can access and receive reimbursement for. A PCP is involved in overseeing and coordinating all aspects of a patient's medical care. In order for a patient to receive a specialty care referral or hospital admission, the PCP must preauthorize the visit, unless there is an emergency. The term gatekeeper is also used in health care business to describe anyone (EAP, employer based casemanager, UR entity, etc.) which makes the decision of where a patient will recieve services.
Limits placed on categories of health spending. A method of hospital cost containment in which participating hospitals must share a prospectively set budget. Method for allocating funds among hospitals may vary but the key is that the participating hospitals agree to an aggregate cap on revenues that they will receive each year. Global budgeting may also be mandated under a universal health insurance system.
A total charge for a specific set of services, such as obstetrical services that encompass prenatal, delivery and post-natal care. Managed care organizations will often seek contracts with hospitals which contain set global fees for certain sets of services. Outliers and carve-outs will be those services not included in the global negotiated rates.
Requirement that health plans offer coverage to all businesses during some period each year.
The Health Care Finance Administration's standard form for submitting provider service claims to third party companies or insurance carriers.
The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It is recognized, however, that health has many dimensions (anatomical, physiological, and mental) and is largely culturally defined. The relative importance of various disabilities will differ depending upon the cultural milieu and the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms or morbidity and mortality.
The services and products a health plan offers.
The federal government agency within the Department of Health and Human Services which directs and oversees the Medicare and Medicaid programs (Titles XVIII and XIX of the Social Security Act) and conducts research to support those programs. Generally it oversees the state's administrations of Medicaid, while directly administering Medicare.
Public or private organizations which secure health insurance coverage for the workers of all member employers. The goal of these organizations is to consolidate purchasing responsibilities to obtain greater bargaining clout with health insurers, plans and providers, to reduce the administrative costs of buying, selling and managing insurance policies. Private cooperatives are usually voluntary associations of employers in a similar geographic region who band together to purchase insurance for their employees. Public cooperatives are established by state governments to purchase insurance for public employees, Medicaid beneficiaries, and other designated populations.
A data interchange protocol for health care computer applications that simplifies the ability of different vendor-supplied IS systems to interconnect. Although not a software program in itself, HL7 requires that each healthcare software vendor program HL7 interfaces for its products.
In epidemiology, the number of cases of disease, infection, or some other event having their onset during a prescribed period of time in relation to the unit of population in which they occur. Incidence measures morbidity or other events as they happen over a period of time. Examples include the number of accidents occurring in a manufacturing plant during a year in relation to the number of employees in the plant, or the number of cases of mumps occurring in a school during a month in relation to the number of pupils enrolled in the school. It usually refers only to the number of new cases, particularly of chronic diseases. Hospitals also track certain risk management or quality problems with a system called incidence reporting.
Refers to a financial accounting of all services that have been performed but, as a result of a short period of time, have not been invoiced or recorded. Estimates of costs for medical services provided for which a claim has not yet been filed. Refers to claims which reflect services already delivered, but, for whatever reason, have not yet been reimbursed. These are bills "in the pipeline." This is a crucial concept for proactive providers who are beginning to explore arrangements that put them in the role of adjudicating claims--as the result, perhaps, of operating in a sub-capitated system. Failure to account for these potential claims could lead to some very bad decisions. Good administrative operations have fairly sophisticated mathematical models to estimate this amount at any given time.
All claims with dates of service within a specified period.
Incurred claims divided by premiums.
To make good a loss.
Managed care, particularly HMO and capitation, has evolved away from the indemnity method. Yet, many people are still covered under indemnity plans. Insurance program in which covered person is reimbursed for covered expenses. Health insurance benefits provided in the form of cash payments rather than services. An indemnity insurance contract usually defines the maximum amounts which will be paid for covered services. Indemnity insurance plans may have a PPO option, UR and case management features, or include a network or other preferred provider restrictions, but, will not have an HMO plan. Indemnity is the traditional form of insurance.
This refers to a little known performance-based program with incentives for the purpose of attracting, motivating and retaining key individuals or small groups.
System that isolated claims above a certain level and charges them to a pool funded by charges of all groups who share the pool. Designed to help stabilize significant premium fluctuations.
An urban statistical region with population of one million or more.
Computer applications, both hardware and software, which have been inherited through previous acquisition and installation. Most often, these systems run business applications which are not integrated with each other. Newer systems which stress open design and distributed processing capacity are gradually replacing such systems.
Drug that the law says can only be obtained by prescription.
The maximum amount that a non-participating physician is permitted to charge a Medicare beneficiary for a particularly defined procedure or bundled service. These limits are published by the individual state intermediaries for Medicare and HCFA and are usually combined in reports with the allowed charges and regional payment schedules. In 1993, the limiting charge was set at 115 percent of the Medicare-allowed charge. However, this does not reflect what the physician will be paid.
Policies designed to help offset the heavy medical expenses resulting from catastrophic or prolonged illness or injury. They generally provide benefits payments for 75 to 80 percent of most types of medical expenses above a deductible paid by the insured.
Insurance against the risk of suffering financial damage due to professional misconduct or lack of ordinary skill. Malpractice requires that the patient prove some injury and that the injury was the result of negligence on the part of the professional. A practitioner is liable for damages or injuries caused by malpractice.
A program of managed care specific to psychiatric or behavioral health care. This usually is a result of a "carve-out" by an insurance company or managed care organization (MCO). Reimbursement may be in the form of sub-capitation, fee for service or capitation. See also Carve-Out.
Systems and techniques used to control the use of health care services. Includes a review of medical necessity, incentives to use certain providers, and case management. The body of clinical, financial and organizational activities designed to ensure the provision of appropriate health care services in a cost-efficient manner. Managed care techniques are most often practiced by organizations and professionals which assume risk for a defined population (e.g., health maintenance organizations) but this is not always the case. Managed care is a broad term and encompasses many different types of organizations, payment mechanisms, review mechanisms and collaborations. Managed care is sometimes used as a general term for the activity of organizing doctors, hospitals, and other providers into groups in order to enhance the quality and cost-effectiveness of health care. Managed Care Organizations (MCO) include HMO, PPO, POS, EPO, PHO, IDS, AHP, IPA, etc. Usually when one speaks of a managed care organization, one is speaking of the entity which manages risk, contracts with providers, is paid by employers or patient groups, or handles claims processing. Managed care has effectively formed a "go-between", brokerage or 3rd party arrangement by existing as the gatekeeper between payers and providers and patients. The term managed care is often misunderstood, as it refers to numerous aspects of healthcare management, payment and organization. It is best to ask the speaker to clarify what he or she means when using the term "managed care". In the purest sense, all people working in healthcare and medical insurance can be thought of as "managing care." Any system of health payment or delivery arrangements where the plan attempts to control or coordinate use of health services by its enrolled members in order to contain health expenditures, improve quality, or both. Arrangements often involve a defined delivery system of providers with some form of contractual arrangement with the plan. See Health Maintenance Organization, Independent Practice Association, Preferred Provider Organization.
A health plan that seeks to manage care. Generally, this involves contracting with health care providers to deliver health care services on a capitated (per-member per-month) basis. (For specific types of managed care organizations, see also health maintenance organization and independent practice association.
A HCFA data reporting system that combines both Part A and Part B claims in a common file. The NCH system became fully operational in 1991.
A non-profit organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers, and the public sector.
Classification system for drug identification, similar to UPC code.
Proposal by politicians to make government the single payer for all health care, similar to Great Britain or Canada. Providers like some aspects of this idea because it provides for "universal coverage" for all citizens. However, businesses and providers (as businesses themselves) dislike the idea of the government administering a program that they will either have to fund or be funded by. Proposals for national health insurance are surely to be debated by politicians for many years to come. See also Universal Coverage.
A computerized data bank maintained by the federal government that contains information on physicians against whom malpractice claims have been paid or certain disciplinary actions have been taken. Hospitals and other agencies pay a fee to access these records. Many regulatory agencies now require hospitals to utilize the NPDB prior to credentialing physicians at their facilities.
An affiliation of providers through formal and informal contracts and agreements. Networks may contract externally to obtain administrative and financial services. A list of physicians, hospitals and other providers who provide health care services to the beneficiaries of a specific managed care organization. See also IDS, PPO, PHO or Hospital Alliances.
OSHA, county health departments and regulatory bodies oversee occupational health hazards in workplaces, including hospitals. Occupational health programs include the employer activities undertaken to protect and promote the health and safety of employees in the workplace, including minimizing exposure to hazardous substances, evaluating work practices and environments to reduce injury, and reducing or eliminating other health threats. Many health providers offer occupational health consultations as well as occupational health screenings, treatments and case-management. Employers and health providers often enter agreements whereby health providers will provide these services as well as managed the related workers compensation case management and rehabilitation programs. Employers seek to remain in compliance with regulations and reduce costs associated with employee injury and benefit utilization. Often, EAPs and drug prevention or drug testing programs are also combined under this category.
The office responsible for auditing, evaluating and criminal and civil investigating for HHS, as well as imposing sanctions, when necessary, against health care providers. (see also Fraud, FBI, Dept. of Justice)
A person within a managed care organization or a person outside of the health care system (such as an appointee of the state) who is designated to receive and investigate complaints from beneficiaries about quality of care, inability to access care, discrimination, and other problems that beneficiaries may experience with their managed care organization. This individual often functions as the beneficiary's advocate in pursuing grievances or complaints about denials of care or inappropriate care.
Health plan members' abilities, rights or invitation to self refer for specialty care. Also called Open Panel.
A period of time which eligible subscribers may elect to enroll in, or transfer between, available programs providing health care coverage. Under an open enrollment requirement, a plan must accept all who apply during a specific period each year.
Paid claims divided by premiums. See also Loss Ratio.
A primary care physician in practice in the payer's managed care service area who has entered into a contract.
Simply refers to a provider under a contract with a health plan. A physician or hospital that has agreed to provide services for a set payment provided by a payer, or who agrees to other arrangements, or who agrees to provide services to a set of covered lives or defined patients. Also refers to a provider or physician who signs an agreement to accept assignment on all Medicare claims for one year. See also Assignment, Preferred Provider or Network.
The dollar amount which an insured is legally obligated to pay for services rendered by a provider.
A study, generally undertaken by an individual health program or health planning agency, to determine the geographic distribution of the residences of the patients served by one or more health programs. Such studies help define catchment and medical trade areas and are useful in locating and planning the development of new services.
Can be defined as a measure of the degree to which delivered health services meet established professional standards and judgments of value to the consumer. Quality may also be seen as the degree to which actions taken or not taken maximize the probability of beneficial health outcomes and minimize risk and other untoward outcomes, given the existing state of medical science and art. Quality is frequently described as having three dimensions: quality of input resources; quality of the process of services delivery (the use of appropriate procedures for a given condition); and quality of outcome of service use (actual improvement in condition or reduction of harmful effects). Quality programs are commonly called QA, TQM, QI, CQI and other acronyms, all referring to the process of monitoring quality in systematic ways.
Activities and programs intended to assure the quality of care in a defined medical setting. Such programs include peer or utilization review components to identify and remedy deficiencies in quality. The program must have a mechanism for assessing its effectiveness and may measure care against pre-established standards.
A process developed by the Health Care Financing Administration to develop a health care quality improvement system for Medicaid managed care plans.
Also called performance improvement (PI). This is the more commonly used term in healthcare, replacing QA. QI implies that concurrent systems are used to continuously improve quality, rather than reacting when certain baseline statistical thresholds are crossed. Quality improvement programs usually use tools such as cross functional teams, task forces, statistical studies, flow charts, process charts, pareto charts, etc.
The allowable variation in insurance premiums as defined in state regulations. Acceptable variation may be expressed as a ratio from highest to lowest (e.g., 3:1) or as a percent from the community rate (e.g., +/-20%). Usually based on risk factors such as age, gender, occupation or residence.
Review by a government or private agency of a hospital's budget and financial data, performed for the purpose of determining the reasonableness of the hospital rates and evaluating proposed rate increases.
Measurement of an economic amount corrected for change in price over time (inflation), thus expressing a value in terms of constant prices. A common term in economics.
The process of sending a patient from one practitioner to another for health care services. Health Plans may require that designated primary care providers authorize a referral for coverage of specialty services.
This is a mechanism established by health plans to direct patients to approved hospitals and doctors. Often the Referral Center serves a UR function and certified or pre-certifies the care. These centers are also used by hospitals to refer patients to certain doctors, reduce use of the emergency room or to provide follow-up patient contact. Manages care organizations utilize these centers as their central hub of communications with patients and providers at the time of service.
Reprimand of a provider by a health plan.
Services provided by medical specialists who generally do not have first contact with patients (e.g., cardiologist, urologists, dermatologists). In the U.S., however, there has been a trend toward self-referral by patients for these services, rather than referral by primary care providers. This is quite different from the practice in England, for example, where all patients must first seek care from primary care providers and are then referred to secondary and/or tertiary providers, as needed.
Health plan that pays costs not covered by primary coverage under coordination of benefits rules. Any insurance that supplements Medicare coverage. The three main sources for secondary insurance are employers, privately purchased Medigap plans, and Medicaid.
The Social Security Act grants the secretary of HHS broad authority to waive certain laws relating to Medicaid for the purpose of conducting pilot, experimental or demonstration projects which are "likely to promote the objectives" of the program. Section 1115 demonstration waivers allow states to change provisions of their Medicaid programs, including: eligibility requirements, the scope of services available, the freedom to choose a provider, a provider's choice to participate in a plan, the method of reimbursing providers, and the statewide application of the program. Health plans and capitated providers can seek waivers through their state intermediaries.
Section 1915(b) waivers allow states to require Medicaid recipients to enroll in HMOs or other managed care plans in an effort to control costs. The waivers allow states to: implement a primary care case-management system; require Medicaid recipients to choose from a number of competing health plans; provide additional benefits in exchange for savings resulting from recipients' use of cost-effective providers; and limit the providers from which beneficiaries can receive non-emergency treatment. The waivers are granted for two years, with two-year renewals. Often referred to as a "freedom-of-choice waiver"
Legislation that created the target rate of increase cost based limits on reimbursements for inpatient operating costs. These limits are considered per Medicare discharges total amounts. A facility's target amount is derived from costs in its base year (1st full fiscal year of operation with application to HCFA as same) updated to the current fiscal year by the annual allowable rate of increase. Medicare payments for operating costs generally may not exceed the facility's target amount and still be paid by HCFA. These provisions apply to hospitals and units excluded from PPS and DRG. When cost reports fall short of the TEFRA limit, certain pay backs are provided. If costs exceed TEFRA, facilities can submit an exception report and may or may not be provided additional payment. Many facilities which established TEFRA limits in the early 1980s are finding they consistently exceed their TEFRA limits. Units normally under the TEFRA rules are psychiatric units, rehab units, free standing specialty hospitals, oncology outpatient clinics and others.
The use of telecommunications (i.e., wire, radio, optical or electromagnetic channels transmitting voice, data and video) to facilitate medical diagnosis, patient care, and/or medical learning. Many rural area are finding uses for telemedicine in providing oncology, home health, ER, radiology and psychiatry among others. Medicaid and Medicare provide some limited reimbursement for certain services provided to patients via telecommunication.
Date that a group contract expires or an individual is no longer eligible for benefits.
Services provided by highly specialized providers such as neurosurgeons, thoracic surgeons and intensive care units. These services often require highly sophisticated technology and facilities.
Drug products that provide the same pharmacological or chemical effect in equivalent doses. Also see Drug Formulary.
Bill form used to submit hospital insurance claims for payment by third parties. Similar to HCFA 1500, but reserved for the inpatient component of health services.
The practice of providers billing for a package of health care procedures on an individual basis when a single procedure could be used to describe the combined service.
Service provided by physicians and hospitals for which no payment is received from the patient or from third-party payers. Some costs for these services may be covered through cost-shifting. Not all uncompensated care results from charity care. It also includes bad debts from persons who are not classified as charity cases but who are unable or unwilling to pay their bill. See cost shifting.
People with public or private insurance policies that do not cover all necessary health care services, resulting in out-of-pocket expenses that exceed their ability to pay. See cost shifting.
Process of selecting, classifying, analyzing and assuming risk according to insurability. The insurance function bearing the risk of adverse price fluctuations during a particular period. Analysis of a group that is done to determine rates or to determine whether the group should be offered coverage at all.
Organization of production whereby one business entity controls or owns all stages of the production and distribution of goods or services. In health care, vertical integration can take many forms, but, generally implies that physicians, hospitals and health plans have combined their organizations or processes in some manner to increase efficiencies, increase competitive strength or to improve quality of care. Integrated delivery systems or healthcare networks are generally vertically integrated. Also see IDS, AHP, horizontal integration.
Statistics relating to births (natality), deaths (mortality), marriages, health, and disease (morbidity). Vital statistics for the United States are published by the National Center for Health Statistics. Vital statistics can be obtained from CDC, state health departments, county health departments and other agencies. A individual patient's vital statistics in a health care setting may also refer simply to blood
pressure, temperature, height and weight, etc.
The quantity of health care services per enrollee, taking into account both the number and the complexity of the services provided.
The VPS provides a mechanism to adjust fee updates for the Medicare Fee Schedule based on how annual increases in actual expenditures compare with previously determined performance standard rates of increase.
A mechanism to adjust updates to fee-for-service payment rates based on actual aggregate.
A state-mandated program providing insurance coverage for work-related injuries and disabilities. Several states have either enacted or are considering changes to the Workers Compensation Laws to allow employers to cover occupational injuries and illnesses within their own existing group medical plans. See also Occupational Health.
The aggregate amount withheld from all providers' capitation payments as an amount to cover excess expenditures of his or a groups referral or other pool. See also risk pool, capitation or sub-capitation. See also Risk Pool, Capitation, Shared Risk.
Portion of a claim deducted and held by a health plan before payment is made to a capitated physician. A form of compensation whereby a health plan withholds payment to a provider until the end of a period at which time the plan distributes any surplus based on some measure of provider efficiency or performance. That portion of the monthly capitated payment to providers withheld by the MCO to create an incentive for efficient or reduced utilization of care or services. A provider that exceeds their withhold amount does not receive a dispersion at the end of the contract period. See also PCR or physician contingency reserve.
A dynamic state of physical, mental, and social well-being; a way of life which equips the individual to realize the full potential of his/her capabilities and to overcome and compensate for weaknesses; a lifestyle which recognizes the importance of nutrition, physical fitness, stress reduction, and self-responsibility. Wellness has been viewed as the result of four key factors over which an individual has varying degrees of control: human biology, environment, health care organization and lifestyle. Preventive medicine associated with lifestyle and preventive care that can reduce health- care utilization and costs. "Wellness" programs became popular with the advent of managed care in the 1980s, with the philosophy and business idea that health plans needed to emphasize keeping their beneficiaries well. However, there has been a drop off in these programs in the 1990s as health plans recognize the difficulty in assessing efficacy and they found that subscribers tend to change plans regularly, thus reducing benefit of keeping one population "well".
Approval that the Health Care Financing Administration (HCFA, the federal agency that administers the Medicaid program) may grant to state Medicaid programs to exempt them from specific aspects of Title XIX, the federal Medicaid law. Most federal waivers involve loss of freedom of choice regarding which providers beneficiaries may use, exemption from requirements that all Medicaid programs be operated throughout an entire state, or exemption from requirements that any benefit must be available to all classes of beneficiaries (which enables states to experiment with programs only available to special populations).
The length of time an individual must wait to become eligible for benefits for a specific condition after overall coverage has begun.
A "deficit neutral" budget process in which new expenditures are paid through cuts in existing programs or increases in revenue. The end result is no increase in the federal deficit.
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What is Health Plus?
