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

See National Committee for Quality Assurance.

See National Drug Code.

Neonatal Intensive Care Unit (NICU)
A hospital unit with special equipment for the care of premature and seriously ill newborn infants.

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.

Network Model HMO
This type of HMO contracts with more than one physician group and may contract with single or multi-specialty groups as well as hospitals and other health care providers. A health plan that contracts with multiple physician groups to deliver health care to members. Generally limited to large single or multi-specialty groups. Distinguished from group model plans that contract with a single medical group, IPA's that contract through an intermediary, and direct contract model plans that contract wi…

New Business Underwriting
The risk evaluation an MCO performs when it first issues coverage to a group.

See Newborns' and Mothers' Health Protection Act.

No Balance Billing Provision
A provider contract clause which states that the provider agrees to accept the amount the plan pays for medical services as payment in full and not to bill plan members for additional amounts (except for copayments, coinsurance, and deductibles).

Non-Formulary Drugs
Drugs not on a plan-approved drug list. See also Formulary.

Non-Group Market
A market segment that consists of customers who are covered under an individual contract for health coverage or enrolled in a government program.

An ethical principle which, when applied to managed care, states that managed care organizations and their providers are obligated not to harm their members.

Non-Plan Provider
A health care provider without a contract with an insurer. Same as Non-Participating Provider.

Nosocomial Infections
Infections that are acquired while a patient is in a hospital are referred to as nosocomial infections; a term derived from 'nosos' the Greek word for 'disease'. Often nosocomial infections become apparent while the patient is still in the hospital but in some cases symptoms may not show up until after the affected patient is discharged. About one patient in ten acquires an infection as a direct result of being hospitalized. Infection control can be very cost-effective. Approximately one third o…

See National Practitioner Data Bank.

A term used by CMS for a proposed standard identifier for health plans. CMS had previously used the terms PayerID and PlanID for the health plan identifier.

Nurse Practitioner (NP)
A registered nurse qualified and specially trained to provide primary care, including primary health care in homes and in ambulatory care facilities, long-term care facilities, and other health care institutions. Normally, NPs are licensed and possess masters degrees. Nurse practitioners generally function under the supervision of a physician but not necessarily in his/her or her presence. In some states, NPs are able to provide basic medical services without requiring MD or DO supervision. They…

Occupational Health
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 consultation…

Office for Civil Rights
This office is part of HHS. Its HIPPA responsibilities include oversight of the privacy requirements.

Office of Inspector General (OIG)
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, and Dept. of Justice.

Ombudsperson or Ombudsman
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.…

Open Access
A term describing a member's ability to self-refer for specialty care. Open access arrangements allow a member to see a participating provider without a referral from another doctor. Health plan members' abilities, rights or invitation to self refer for specialty care. Also called Open Panel.

Open Enrollment Period
A period during which subscribers in a health benefit program have an opportunity to select among health plans being offered to them, usually without evidence of insurability or waiting periods. 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.

Open Formulary
The provision that drugs on the preferred list and those not on the preferred list will both be covered by a PBM or MCO. Also see Formulary.

Open Panel
An HMO in which any physician who meets the HMO's standards of care may contract with the HMO as a provider. These physicians typically operate out of their own offices and see other patients as well as HMO members.

Open PHO
A type of physician-hospital organization that is available to all of a hospital's eligible medical staff.

Organized Care System
Often used to discuss a more evolved form of IDSs and CCNs, this relatively new term describes the result of mergers and alliances between and among physicians, health systems, and managed care organizations. These systems often have the same performance imperatives as IDSs and CCNs: improve health status, integrate delivery, demonstrate value, improve efficiency of care delivery and prevention, and meet patient and community needs.

Original Medicare Plan
A fee-for-service health plan that lets enrollees go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. The enrollee must pay the deductible. Medicare pays its share of the Medicare-approved amount, and the enrollee pays a share (coinsurance). In some cases the enrollee may be charged more than the Medicare-approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Out of Area Benefits
Benefits supplied to a patient by a payer or managed care organization when the patient needs services while outside the geographic area of the network. MCOs often attempt to negotiate a case-by-case discount with providers when patients utilize their services while 'out of area'.

Out of Network Benefits
With most HMOs, a patient cannot have any services reimbursed if provided by a hospital or doctor who is not in the network. With PPOs and other managed care organizations, there may exist a provision for reimbursement of 'out of network' providers. Usually this will involve higher copay or a lower reimbursement. See also point of service plans.

Out of Pocket Limit
A cap placed on out of pocket costs, after which benefits increase to provide full coverage for the rest of the year. It is a stated dollar amount set by the insurance company, in addition to regular premiums.

Out-of-Network Provider
A health care provider with whom a managed care organization does not have a contract to provide health care services. Because the beneficiary must pay either all of the costs of care from an out-of-network provider or their cost-sharing requirements are greatly increased, depending on the particular plan a beneficiary is in, out-of-network providers are generally not financially accessible to Medicaid beneficiaries.

Outcome or Outcome Measures
Healthcare quality indicators that gauge the extent to which healthcare services succeed in improving or maintaining satisfaction and patient health. A clinical outcome is the result of medical or surgical intervention or nonintervention, or the results of a specific health care service or benefit package. The valued results of care as experienced primarily by the patient but also by physicians and all other participants in the processes contributing to the outcomes.

Outcomes Management
Providers and payers alike wish to find a method of managing care in a way that would produce the best outcomes. Managed care organizations are increasingly interested in learning to manage the outcome of care rather than just managing the cost of care. It is thought that through a database of outcomes experience, caregivers will know better which treatment modalities result in consistently better outcomes for patients. Outcomes management may lead to the development of clinical protocols. A cli…

Outcomes Measurement
System used to systematically track clinical treatment and responses to that treatment. The methods for measuring outcomes are quite varied among providers. Much disagreement exists regarding the best practice or tools to utilize to measure outcomes. In fact, much disagreement exists in the medical field about the definition of outcome itself. A tool to assess the impact of health services in terms of improved quality and/or longevity of life and functioning.

Outcomes Research
Research on measures of changes in patient outcomes, that is, patient health status and satisfaction, resulting from specific medical and health interventions. Attributing changes in outcomes to medical care requires distinguishing the effects of care from the effects of the many other factors that influence patients' health and satisfaction. With the elimination of the physician's fiduciary responsibility to the patient, outcomes data is gaining increasing importance for patient advocacy and co…

A patient whose length of stay or treatment cost differs substantially from the stays or costs of most other patients in a diagnosis related group. Under DRG reimbursement, outliers are given exceptional treatment subject to peer review and organization review.

Outlier thresholds
The day and cost cutoff points that separate inlier patients from outlier patients.

Outpatient Care
Care given a person who is not bedridden. Also called ambulatory care. Many surgeries and treatments are now provided on an outpatient basis, while previously they had been considered reason for inpatient hospitalization. Some say this is the fastest growing segment of healthcare.

Outpatient Hospital Care
Medical or surgical care furnished by a hospital to a patient if that patient has not been admitted as an inpatient but is registered on hospital records as an outpatient. If a doctor orders that a patient be placed under observation, it may be considered outpatient care, even if the patient stays under observation overnight.

See Programs of All-Inclusive Care for the Elderly.

Paid Claims Loss Ratio
Paid claims divided by premiums. See also Loss Ratio.

Part A Medicare
Refers to the inpatient portion of benefits under the Medicare Program, covering beneficiaries for inpatient hospital, home health, hospice, and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and copayments. Part A services are financed by the Medicare HI Trust Fund, which consists of Medicare tax payments. See also Medicare.

Part B Medicare
Refers to the outpatient benefits of Medicare. Medicare Supplementary Medical Insurance (SMI) under Part B of Title XVII of the Social Security Act covers Medicare beneficiaries for physician services, medical supplies, and other outpatient treatment. Beneficiaries are responsible for monthly premiums, copayments, deductibles, and balance billing. Part B services are financed by a combination of enrollee premiums and general tax revenues. See also Medicare.

Part D Medicare
A stand-alone drug plan, offered by insurers and other private companies to beneficiaries that receive their Medicare Part A and/or B benefits through the Original Medicare Plan; Medicare Private Fee-for-Service Plans that don`t offer prescription drug coverage; and Medicare Cost Plans offering Medicare prescription drug coverage. These stand-alone plans add prescription drug coverage to the Original Medicare Plan and to some Medicare Cost Plans and Medicare Private Fee-for-Service Plans. Manage…

Partial Capitation
A contract between a payer and a sub-capitor, provider or other payer whereby payments made are a combination of capitated premiums and fee for service payments. The proportion of the ratios determines the amount of risk. Sometimes certain outliers are paid as fee for service (difficult childbirth, cardiac care, cancer) while routine care (preventative, family, simple surgeries and common diagnoses) are capitated.

Partial Risk Contract
A contract between a purchaser and a health plan, in which only part of the financial risk is transferred from the purchaser to the plan. Forms of this are often seen in 'self-funded' plans, competitive bidding arrangements and new health plans.

Participating Physician
A primary care physician in practice in the payer's managed care service area who has entered into a contract.

Participating Provider
Any provider licensed in the state of provision and contracted with an insurer. Usually this refers to providers who are a part of a network. That network would be a panel of participating providers. Payers assemble their own provider panels.

Patient Liability
The dollar amount that an insured is legally obligated to pay for services rendered by a provider. These may include co-payments, deductibles and payments for uncovered services.

Patient Origin Study
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.

Pay-for-Performance Programs
A program of financially structured incentives for practitioners and providers in exchange or as reward for the achievement of certain benchmarks of performance. The hope is that by offering positive rewards both for reaching thresholds of performance and for making continuous strides in improving the quality of health care high quality health care will be delivered on a consistent basis. This approach acknowledges the reality that financial rewards are among the most powerful tools for bringing…

Payer (usually Third Party Payer)
The public or private organization that is responsible for payment for health care expenses. Payers may be insurance companies or self-insured employers.

See Pharmacy Benefit Manager or Pharmacy Benefit Management Plan.

See Prescription Benefit Plan.

See Primary Care Case Management.

See Primary Care Network.

Primary care physician who often acts as the primary gatekeeper in health plans. That is, often the PCP must approval referrals to specialists. Particularly in HMOs and some PPOs, all members must choose or are assigned a PCP. See Primary Care Case Management or Primary Care Physician.

PCP Capitation
A reimbursement system for healthcare providers of primary care services who receive a pre-payment every month. The payment amount is based on age, sex and plan of every member assigned to that physician for that month.

See Physician Contingency Reserve.

See Prescription Drug Plan.

Peer Review
The mechanism used by the medical staff to evaluate the quality of total health care provided by the Managed Care Organization. The evaluation covers how well all health personnel perform services and how appropriate the services are to meet the patients' needs. Evaluation of health care services by medical personnel with similar training. Generally, the evaluation by practicing physicians or other professionals of the effectiveness and efficiency of services ordered or performed by other member…

Peer Review Committee
The hospital, clinic or MCO committee that reviews cases of health care services delivery in which the quality of care is questionable or problematic.

Peer Review Organization (PRO)
An organization established by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 to review quality of care and appropriateness of admissions, readmissions, and discharges for Medicare and Medicaid. These organizations are held responsible for maintaining and lowering admission rates, reducing lengths of stay, while insuring against inadequate treatment. PROs can conduct review of medical records and claims to evaluate the appropriateness of care provided. PROs also exist within privat…

Penalty (on Medicare Premium)
An amount added to a senior citizen's monthly premium for Medicare Part B, or for a Medicare Prescription Drug Plan, if the citizen does not join the Medicare Plan(s) when they are first able to. The senior citizen pays this higher amount as long as the citizen has Medicare. There are some exceptions.

Pended Authorization
An authorization decision that is delayed.

Per Diem Rates
A form of payment for services in which the provider is paid a daily fee for specific services or outcomes, regardless of the cost of provision. Per diem rates are paid without regard to actual charges and may vary by level of care, such as medical, surgical, intensive care, skilled care, psychiatric, etc. Per diem rates are usually flat all-inclusive rates.

Per Member Per Month (PMPM)
Applies to a revenue or cost for each enrolled member each month. The number of units of something divided by member months. Often used to describe premiums or capitated payments to providers, but can also refer to the revenue or cost for each enrolled member each month. Many calculations, other than cost or premium, use PMPM as a descriptor.

Performance Gap
The occurrence, trend, or incident that shows that a clinician's performance falls short of expected performance levels, particularly when the clinician ignores accumulated scientific evidence supporting other clinical interventions or when the clinician does not reach benchmarked targets.

Performance Improvement
See Quality Improvement

Performance Measurement
Measures and results that describe the health care being provided and the outcomes. Performance may be stated in terms of health outcome, quality of care, timeliness, correctness, percentage of goals attained or percentage of mistakes made. Performance measures may also indicate whether a health plan or provider has appropriately provided certain services expected to lead to desirable outcomes. Closely related to Continuous Quality of Improvement (CQI) and Utilization Review (UR).

Performance Standards
Standards set by the MCO or payer that the provider will need to meet in order to maintain it`s credentialing, renew its contract or avoid penalty. These will vary from payer to payer, and contract to contract. Standards an individual provider is expected to meet, especially with respect to quality of care. The standards may define volume of care delivered per time period. Thus, performance standards for obstetrician/gynecologist may specify some or all of the following office hours and office v…

Personal Care Physician
See Primary Care Physician.

Personal Representative
A person authorized under state or other law to act on behalf of the individual in making health-related decisions. Examples include a court-appointed guardian with medical authority, a health care agent under a health care proxy, and a parent acting on behalf of an un-emancipated minor (with exceptions where state law gives minors the right to make health decisions). For a decedent, the personal representative may be an executor, administrator, or other authorized person.

See Private Fee-for-Service Plans.

Pharmaceutical Cards
Identification cards issued by a pharmacy benefit management plan to plan members. These cards assist PBMs in processing and tracking pharmaceutical claims. Also known as drug cards or prescription cards. See Drug Plan.

Pharmacy Benefit Manager (PBM)
PBMs are third party administrators of prescription drug benefits.

See Physician-Hospital Organization.

See Partial Hospitalization Program.

See Prepaid Health Plan.

Physician Attestation
The requirement that the attending physician certify, in writing, the accuracy and completion of the clinical information used for DRG assignment.

Physician Contingency Reserve (PCR)
Portion of a claim deducted and held by a health plan before payment is made to a capitated physician. Revenue that is withheld from a provider's payment to serve as an incentive for providing less expensive service. A typical withhold is approximately 20 percent of the claim. This amount can be paid back to the provider following analysis of his/her practice and service utilization patterns. See also Withhold.

Physician Organization
This term describes physician linkages and alliances that allow physicians to manage risk and capitation. Information systems, physician relationships, and financial integration allow these organizations to be more integrated than the traditional solo practice or IPA relationship between healthcare providers and/or managed care organizations that are working to develop a 'seamless' continuum of healthcare services. Sometimes physician organizations are simply group practices or professional orga…

Physician Payment Review Commission
Established by Congress in 1986 to advise it on reforms of Medicare policies for paying physicians. Submits a report to Congress annually.

Physician Services
Services provided by an individual licensed under state law to practice medicine or osteopathy. Physician services given while in the hospital that appear on the hospital bill are not included in this definition.

See Performance Improvement

Plan Administration
A term often used to describe the management unit with responsibility to run and control a managed care plan includes accounting, billing, personnel, marketing, legal, purchasing, possibly underwriting, management information, facility maintenance, servicing of accounts. This group normally contracts for medical services and hospital care. If an insurance company is the underwriter, it may serve as its own administrator or may contract to a 3rd party administrator. The plan administrator is a pe…

Plan Document
The document that contains all of the provisions, conditions, and terms of operation of a pension or health or welfare plan. This document may be written in technical terms as distinguished from a summary plan description (SPD) that, under ERISA, must be written in a manner calculated to be understood by the average plan participant.

Plan Funding
The method that an employer or other payer or purchaser uses to pay medical benefit costs and administrative expenses.

Plan Sponsor
An entity that sponsors a health plan. This can be an employer, a union, or some other entity.

Play or Pay
Proposal to make employers provide health care coverage for employees or pay a special government tax.

See Per Member Per Month.

Combining risks for groups into one risk pool. The practice of underwriting a number of small groups as if they constituted one large group. Also see Risk.

Requirement that health plans guarantee continuous coverage without waiting periods for persons moving between plans. The ability for an individual to transfer from one health insurer to another health insurer with regard to pre-existing conditions or other risk factors. This is a new protection for beneficiaries involving the issuance of a certificate of coverage from previous health plan to be given to new health plan. Under this requirement, a beneficiary who changes jobs is guaranteed covera…

See Point-of-Service Plan.

See Physician Practice Management Company.

See Preferred Provider Organization.

PPS Inpatient Margin
A measure that compares DRG based operating and capital payments with Medicare-allowable inpatient operating and capital costs. It is calculated by subtracting total Medicare-allowable inpatient operating and capital costs from total PPS operating and capital payments and dividing by total PPS operating and capital payments.

PPS Operating Margin
A measure that compares PPS operating payments with Medicare-allowable inpatient operating costs. This measure excludes Medicare costs and payments for capital, direct medical education, organ acquisition, and other categories not included among Medicare-allowable inpatient operating costs. It is calculated by subtracting total Medicare-allowable inpatient operating costs from total PPS operating payments and dividing by total PPS operating payments.

PPS Year
A designation referring to hospital cost reporting periods that begin during a given Federal fiscal year, reflecting the number of years since the initial implementation of PPS. For example, PPS1 refers to hospital fiscal years beginning during Federal fiscal year 1984, which was the first year of PPS. For a hospital with a fiscal year beginning July 1, PPS 1 covers the period from July 1, 1984, through June 30, 1985. (See also Fiscal Year)

Practical Nurses
Practical nurses, also known as vocational nurses, provide nursing care and treatment of patients under the supervision of a licensed physician or registered nurse. Licensure as a licensed practical nurse (L.P.N.) or in California and Texas as a licensed vocational nurse (L.V.N.) is required.