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Pohlys - Glossary of Health Care Terms
Category: Health and Medicine > Health Care
Date & country: 13/09/2007, USA
Words: 949

A legal agreement between a payer and a subscribing group or individual which specifies rates, performance covenants, the relationship among the parties, schedule of benefits and other pertinent conditions. The contract usually is limited to a 12-month period and is subject to renewal thereafter. Contracts are not required by statute or regulation, and less formal agreements may be made.

Contract Provider
Any hospital, physician, skilled nursing facility, extended care facility, individual, organization, or agency licensed that has a contractual arrangement with an insurer for the provision of services under an insurance contract.

Contract Year
A period of twelve (12) consecutive months, commencing with each Anniversary Date. May or may not coincide with a calendar year.

Contributory Program
Program where the employee and the employer or the union shares the cost of group coverage.

In group health insurance, the opportunity given the insured and any covered dependents to change his or her group insurance to some form of individual insurance, without medical evaluation upon termination of his group insurance

Conversion Factor (CF)
The dollar amount used to multiply the Relative Value Schedule (RVS) of a procedure to arrive at the maximum allowable for that procedure.

Conversion Factor Update
Annual percentage change to a conversion factor, either set annually by the government or by the formula reflecting actual expenditure growth from two years falling below or above the original target rate. See Conversion Factor, Sustainable Growth Rate, Sustainable Growth Rate System.

Conversion Privilege
The right of an individual insured under a group policy to certain kinds of individual coverage, without a medical examination, upon termination of his association with the group.

Coordinated Care Plans (CCPs)
The Medicare+Choice delivery option that includes HMOs (with or without a point-of-service component), preferred provider organizations (PPOs), and provider-sponsored organizations (PSOs).

Coordination of Benefits (COB)
Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. A coordination of benefits, or 'non-duplication,' clause in either policy prevents double payment by making one insurer the primary payer, and assuring that not more than 100 percent of the cost is covered. Standard rules determine which of two or more plans, each having COB provisions, pays its benefits in full and which becomes the supplementary payer…

Coordination of Care
This term is often used as a synonym for managed care. To some, coordinated care sounds less intrusive or directive than managed care, although in practice, the policies are the same.

See Comprehensive Outpatient Rehabilitation Facility.

Corporate Compliance Committee
The hospital or MCO committee that monitors and guides all compliance activities, including appointment of a corporate compliance officer, approval of compliance program policies and procedures, review of the organization's annual compliance plan, evaluation of internal and external audits to identify potential risks, and implementation of corrective and preventive actions.

Corporate Compliance Director
An executive level health plan manager who is responsible for overseeing the plan's compliance with state and federal laws.

Cost Consequence Analysis (CCA)
A form of analysis that compares alternative interventions or programs in which the components of incremental costs and consequences are listed without aggregation.

Cost Containment
Control of inefficiencies in the consumption, allocation, or production of health care services that contribute to higher than necessary costs. Inefficiencies are thought to exist in consumption when health services are inappropriately utilized; inefficiencies in allocation exist when health services could be delivered in less costly settings without loss of quality; and, inefficiencies in production exist when the costs of producing health services could be reduced by using a different combinat…

Cost Contract
An arrangement between a managed health care plan and CMS under Section 1876 or 1833 of the Social Security Act, under which the health plan provides health services and is reimbursed its costs. A TEFRA contract payment methodology option by which CMS pays for the delivery of health services to members based on the HMO's or hospital`s reasonable cost. The plan or hospital receives an interim amount derived from an estimated annual budget, which may be periodically adjusted during the course of t…

Cost Effectiveness (Evaluation)
The efficacy of a program in achieving given intervention outcomes in relation to the program costs. Follow-up studies, outcome studies and TQM programs attempt to assess treatment efficacy, while cost effectiveness would provide a ratio of this measurement with costs. This analysis may determine the costs and effectiveness of certain interventions compared to similar alternative interventions, determining the relative costs and degree to which they will obtain desired health outcomes.

Cost Minimization Analysis (CMA)
An assessment of the least costly interventions among available alternatives that produce equivalent outcomes.

Cost of Illness Analysis (COI)
An assessment of the economic impact of an illness or condition, including treatment costs.

Cost Outlier
A case that is more costly to treat compared with other patients in a particular diagnosis related group. Outliers also refer to any unusual occurrence of cost, cases that skew average costs or unusual procedures.

Cost Sharing
Payment method where a person is required to pay some health costs in order to receive medical care. The general set of financing arrangements whereby the consumer must pay out-of-pocket to receive care, either at the time of initiating care, or during the provision of health care services, or both. This includes deductibles, coinsurance and copayments, but not the share of the premium paid by the person enrolled.

Cost Shifting
Charging one group of patients more in order to make up for underpayment by others. Most commonly, charging some privately insured patients more in order to make up for underpayment by Medicaid or Medicare.

Cost Utility Analysis
A form of effectiveness analysis where outcomes are rated in terms of utility, or quality of life.

The guarantee against specific losses provided under the terms of an insurance policy.

Covered Benefit
A medically necessary service that is specifically provided for under the provisions of an Evidence of Coverage. A covered benefit must always be medically necessary, but not every medically necessary service is a covered benefit. For example, some elements of custodial or maintenance care, which are excluded from coverage, may be medically necessary, but are not covered.

Covered Employee
An individual who is (or was) provided coverage under a group health plan through an employer or job.

Covered Entity
Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction. For purposes of the HIPAA Privacy Rule, health care providers include hospitals, physicians, and other caregivers, as well as researchers who provide health care and receive, access or generate individually identifiable health care information.

Covered Services
Services provided within a given health care plan. Health care services provided or authorized by the payer's Medical Staff or payment for health care services.

See Customary, Prevailing, and Reasonable.

See Current Procedural Terminology.

See Continuous Quality Improvement.

CR and CRC
See Community Rating and Community Rating by Class.

Review procedure where a potential or existing provider must meet certain standards in order to begin or continue participation in a given health care plan, on a panel, in a group, or in a hospital medical staff organization. The process of reviewing a practitioners credentials, i.e., training, experience, or demonstrated ability, for the purpose of determining if criteria for clinical privileging are met. The recognition of professional or technical competence. The credentialing process may inc…

Credible Coverage
Health coverage an individual has had in the past, such as group health plan (including COBRA continuation coverage), an HMO, an individual health insurance policy, Medicare or Medicaid, and this prior coverage was not interrupted by a significant break in coverage. The time period of this prior coverage must be applied toward any pre-existing condition exclusion imposed by a new health plan. Proof of creditable coverage may be shown by a certificate of creditable coverage or by other documents …

Creditable Coverage
Health coverage that a new enrollee has had in the past that gives the enrollee certain rights when he or she applies for new coverage. See also Certificate of Creditable Coverage. Certain kinds of previous health insurance coverage, such as group plan coverage, that can be used to shorten a pre-existing condition waiting period under a new plan.

Critical Access Hospital
A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.

Cure Provision
A provider contract clause which specifies a time period (usually 60-90 days) for a party that breaches the contract to remedy the problem and avoid termination of the contract.

Current Dental Terminology (CDT)
A medical code set of dental procedures, maintained and copyrighted by the American Dental Association (ADA), and adopted by the Secretary of HHS as the standard for reporting dental services on standard transactions.

Custodial Care
Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, health plans and Medicare don't pay for custodial care.

Customary Charge
One of the factors determining a physician's payment for a service under Medicare. Calculated as the physician's median charge for that service over a prior 12-month period.

Data Condition
A description of the circumstances in which certain data is required.

Data Content
Under HIPAA, this is all the data elements and code sets inherent to a transaction, and not related to the format of the transaction.

Data Mapping
The process of matching one set of data elements or individual code values to their closest equivalents in another set of them. This is sometimes called a cross-walk.

Data Use Agreement (DUA)
HIPAA Regulation states that a health care entity may use or disclose a 'limited data set' if that entity obtains a data use agreement from the potential recipient and can only be used for research, public health or healthcare operations. Relates to privacy rules of HIPAA. A satisfactory assurance between the covered entity and a researcher using a limited data set that the data will only be used for specific uses and disclosures. The data use agreement is required to include the following infor…

Data Warehouse
A specific database (or set of databases) containing data from many sources that are linked by a common subject (e.g., a plan member).

Database Management System (DBMS)
The separation of data from the computer application that allows entry or editing of data.

Day Outlier
A patient with an atypically long length of stay compared with other patients in a particular diagnosis related group.

Days (Or Visits) Per Thousand
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 …

See Database Management System

See Duplicate Coverage Inquiry

Deceased individuals. Afforded privacy rights under the HIPAA Privacy Rule, even though not considered 'human subjects' protected under the Common Rule. As is the current practice, all research protocols involving the review of medical records of deceased subjects or of living and deceased subjects require review and approval by the HRC/IRB and can be conducted without informed consent and authorization only if the protocol satisfies the criteria for a waiver. If the research includes access to …

Decision Support Systems
Computer technologies used in healthcare that 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.

Deductible Carry Over Credit
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. Different components of a health plan may have separate deductibles. Usually expressed in terms of an 'annual' amount.

Defensive Medicine
Doctors in recent years have admitted to and have been accused of prescribing additional tests or procedures to justify their care, strengthen support for their decisions or simply to corroborate their diagnosis. This defensiveness is a result of lawsuits, malpractice claims and the onslaught of external UR entities questioning care decisions. Defensive medicine is said to be one of the primary causes of the increasing cost of health care. Many physicians and the AMA fight for tort reform to red…

Defined Care
An umbrella term used for Defined Contribution, Consumer-Driven and Self-Directed health plan arrangements and other consumer-centered initiatives.

Defined Contribution Coverage
A payment process for procurement of health benefit plans whereby employers contribute a specific dollar amount toward the costs of insurance coverage for their employees. Sometimes this includes an undefined expectation of guarantee of the specific benefits to be covered.

Defined Contribution Health Plan
Health Plans that involve employer funding of a fixed (as opposed to variable) dollar amount for health benefits, which employees may then use to purchase benefits from an employer arranged funding mechanism. The benefits could either be group benefits packaged and arranged by the employer, or purchased individually by the employees. See also Variable Contribution Health Plan.

Under the HIPAA Privacy Rule, data are deidentified if either (1) an experienced expert determines that the risk that certain information could be used to identify an individual is 'very small' and documents and justifies the determination, or (2) the data do not include any of the following eighteen identifiers (of the individual or his/her relatives, household members, or employers) which could be used alone or in combination with other information to identify the subject: names, geographic su…

Dental POS
A dental service plan that allows a member to use either a DHMO network dentist or to seek care from a dentist not in the HMO network. Members choose in-network care or out-of-network care at the time they make their dental appointment and usually incur higher out-of-pocket costs for out-of-network care. See also Point of Service.

Dental PPO
An organization that provides dental care to its members through a network of dentists who offer discounted fees to the plan members. See also Preferred Provider Organization.

Department of Justice (U.S. DOJ)
The federal agency that enforces the law and handles criminal investigations. As the nation's largest law firm, the DOJ protects citizens through effective law enforcement, crime prevention and crime detection. It is the agency that prosecutes those in the health care system guilty of proven 'fraudulent' activity. Also see Fraud and FBI.

Person covered by someone else's health plan. In a payer's policy of insurance, a person other than the subscriber eligible to receive care because of a subscriber's contract.

Designated Mental Health Provider
Person or place authorized by a health plan to provide or suggest appropriate mental health and substance abuse care.

Designated Record Set
A health care provider's medical and billing records about individuals and any records used by the provider to make decisions about individuals. Individuals, including research subjects, have the right under the HIPAA Privacy Rule to access and amend protected health information in a Designated Record Set.

See Dental Health Maintenance Organization.

Diagnosis Related Groups (DRGs)
An inpatient or hospital classification system used to pay a hospital or other provider for their services and to categorize illness by diagnosis and treatment. A classification scheme used by Medicare that clusters patients into 468 categories on the basis of patients' illnesses, diseases and medical problems. Groupings of diagnostic categories drawn from the International Classification of Diseases and modified by the presence of a surgical procedure, patient age, presence or absence of signif…

Diagnostic and Treatment Codes
Special codes that consist of a brief, specific description of each diagnosis or treatment and a number used to identify each diagnosis and treatment. Also see Coding.

Direct Contracting
Providing health services to members of a health plan by a group of providers contracting directly with an employer, thereby butting out the middleman or third party insurance carrier. This can be provider heaven, since middleman-MCO-is cut out and provider gets some portion of the money usually made by it. Key is to price services correctly, since provider is usually at full risk in this situation. Takes a strong IDS, MSO or AHP to do this successfully.

Direct Payment Subscriber
A person enrolled in a prepayment plan who makes individual premium payments directly to the plan rather than through a group. Rates of payment are generally higher, and benefits may not be as extensive as for the subscriber enrolled and paying as a member of the group.

When a payer declines to pay for all or part of a claim submitted for payment.

Discharge Planning
Required by Medicare and JCAHO for all hospital patients. A procedure where aftercare services are determined for after discharge from the inpatient facility. See also Case Management.

Refers to the release of identifiable health information, regarding a patient or patient(s). Disclosure involves the release of information to anyone or any entity outside of the covered entity. See also HIPAA Privacy Rule.

Discounted Fee-For-Service
A financial reimbursement system whereby a provider agrees to supply services on an FFS basis, but with the fees discounted by a certain percentage from the physician's usual and customary charges. An agreed upon rate for service between the provider and payer that is usually less than the provider's full fee. This may be a fixed amount per service, or a percentage discount. Providers generally accept such contracts because they represent a means to increase their volume or reduce their chances …

Disease Management
A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition. Also known as disease state management.

The process or end result of a termination of coverage. Voluntary termination would include a member quitting because he or she simply wants out. Involuntary termination would include leaving the plan because of changing jobs. A rare and serious form of involuntary disenrollment is when the plan terminates a member's coverage against the member's will. This is usually only allowed (under state and federal laws) for gross offenses such as fraud, abuse, nonpayment of premium or copayments, or a de…

See Durable Medical Equipment

See Durable Medical Equipment Regional Carrier.

See Department of Justice.

See Diagnosis Related Groups.

Drug Card
See Prescription Drug Plan.

Drug Categories
Groupings that reflect therapeutic uses of drugs based on the International Classification of Diseases (ICD-9) diagnostic codes. For example, drugs may belong to the analgesic category or the antiparkinson category. Categories may also be based on an organ system, such as the cardiovascular category. In 2004, the United States Pharmacopeia (USP), a non-profit non-governmental organization, received directive from the Medicare Modernization Act to publish guidelines on drug categories and classes…

Drug Classes
Classes are subcomponents of drug categories and are based either on the chemical structure of the drug or on its 'mechanism of action,' i.e., how it works to achieve its results. For example, the analgesic category, or drugs which treat pain, is broken down into two classes opioids (such as codeine or morphine) and non-opioids (such as ibuprofen or aspirin). Certain classes are subdivided into an additional level of specificity. For example, the beta-adrenergic blocking agent class of the cardi…

Drug Formulary
Varying lists of prescription drugs approved by a given health plan for distribution to a covered person through specific pharmacies. Health plans often restrict or limit the type and number of medicines allowed for reimbursement by limiting the drug formulary list. The list of prescription drugs for which a particular employer or State Medicaid program will pay. Formularies are either 'closed,' including only certain drugs or 'open,' including all drugs. Both types of formularies typically impo…

Drug List
A list of drugs covered by a plan. This list is also called a formulary.

Drug Plan
When people join a Prescription Drug Plan, they use the plan member cards that are received from the plans when they go to the pharmacies to purchase prescriptions. When they use their cards, they will normally get discounts on their prescriptions. See also Prescription Drug Plan.

Drug Risk Sharing Arrangements
Provider organizations may be at partial, full or no risk for drug costs. Providers at partial risk share in the proportion of savings and / or cost overruns. Groups at full risk realize all the savings or absorb all of the losses. Groups at no risk absorb none of the profits or losses. These arrangements are normally made between HMOs and providers (doctors/hospitals) in the HMO`s attempt to discourage the overuse of drugs that will cause a loss of profit for the HMO. In a shared risk arrangeme…

Drug Utilization Review (DUR)
Review of an insured population's drug utilization with the goal of determining how to reduce the cost of utilization. Reviews often result in recommendations to practitioners, including generic substitutions, use of formularies, use of copayments for prescriptions and education. In some cases, practitioners are now penalized or rewarded depending on their drug prescription related costs and utilization. Some speculate that these incentives can adversely effect doctor decisions.

See Disproportionate Share Adjustment

Data Use Agreement

Dual Eligible
A Medicare beneficiary who also receives the full range of Medicaid benefits offered in his or her state. Medicare usually pays the charges for inpatient while Medicaid will pay the co-pay for inpatient care in hospitals. Medicare will be considered the primary insurer for inpatient care for the Care/Caid patient.

Duplicate Coverage Inquiry (DCI)
Method used by an insurance company or group medical plan to inquire about the existing coverage of another insurance company or group medical plan.

Duplication of Benefits
When a person is covered under two or more health plans with the same or similar coverage.

See Drug Utilization Review.

Durable Medical Equipment (DME)
Items of medical equipment owned or rented which are placed in the home of an insured to facilitate treatment and/or rehabilitation. Certain medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs, or hospital beds. DME generally consist of items that can withstand repeated use. DME is primarily and customarily used to serve a medical purpose and is usually not useful to a person in the absence of illness or injury. DME is paid for under both Medicare…

See Employee Assistance Program

See Extended Care Facility.

Economic Credentialing
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 credentialing 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.

EDI Translator
Used in electronic claims and medical record transmissions, this is a software tool for accepting an EDI transmission and converting the data into another format, or for converting a non-EDI data file into an EDI format for transmission. See also Electronic Data Interchange.