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

RVU
See Relative Value Unit.

Sanction
Reprimand that gives binding force to a law or rule, or secures obedience to it, as the penalty for breaking it, or a reward for carrying it out. The government and its agencies can sanction hospitals, providers and health plans. Health plans sometimes seek to sanction hospitals and physicians. Medical staffs sometimes seek sanctions against its members.

SCH
See Sole Community Hospital.

SCHIP
See State Children's Health Insurance Program, below.

SCR
See Standard Class Rate.

Second Opinion
This is when another doctor gives his or her view about what another doctor has said a patient has and how it should be treated.

Secondary Care
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.

Secondary Coverage
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. See Secondary Payer.

Secondary Payer
An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation and may or may not be Supplemental Insurance.

Section 1115 Medicaid Waiver
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 m…

Section 1915(b) Medicaid Waiver
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. …

Self-Funding or Self-Funded Plan
Employer or organization assumes complete responsibility for health care losses of its covered employees. This usually includes setting up a fund against which claim payments are drawn and claims processing is often handled through an administrative services contract with an independent organization. In this case, the employer does not pay premiums to an insurance carrier, but, rather pays administrative costs to the insurance company or health plan, and, in essence, treats them as a third party…

Self-Insurance or Self-Insured
An individual or organization that assumes the financial risk of paying for health care. This term is usually used to describe the type of insurance that an employer provides. When an employer is self-insured, this means that the payer or managed care company manages the employer's funds whether than requiring the employer to pay premiums. Many employers choose to self-insure because they are then exempted from certain insurance laws and also think that they will spend less money in the short ru…

Sentinel Event
Adverse health events that may have been avoided through appropriate care or alternate interventions. Providers are required to alert JCAHO and often state licensing authorities of all sentinel events, including a review of risk factors, preventative measures and case analysis.

Service Area
The area where a health plan accepts members. For plans that require enrollees to use certain doctors and hospitals, it is also the area where services are provided. The plan may disenroll a member who moves out of the plan's service area. Service area is also a term used by hospitals to describe the geographic or catchment area from which the hospital may receive referrals or admissions. Also see Disenrollment.

Service Category Definition
A general description of the types of services provided under the service and/or the characteristics that define the service category.

Shadow Pricing
Within a given employer group, pricing of premiums by HMO based upon the cost of indemnity insurance coverage, rather than strict adherence to community rating or experience rating criteria.

Shared Savings
A provision of most prepaid health care plans where at least part of the providers' income is directly linked to the financial performance of the plan. If costs are lower than projections, a percentage of these savings are referred to the providers.

SHIP
See State Health Insurance Assistance Program.

SHMO
See Social Health Maintenance Organization.

Significant Break in Coverage
Generally, a significant break in coverage is a period of 63 consecutive days during which an individual has no creditable coverage. In some states, the period is longer if the individual`s coverage is provided through an insurance policy or HMO. Days in a waiting period during which you had no other health coverage cannot be counted toward determining a significant break in coverage. This definition relates to Creditable Coverage and Pre-Existing Illnesses that are considered when an individual…

Single-Stream Funding
The consolidation of multiple sources of funding into a single stream. For example, this is a key approach used in some progressive mental health systems to ensure that 'funds follow consumers.'

Site Appropriateness Listings
A resource for the review of surgery and certain nonsurgical interventions that indicates the most appropriate settings for common procedures.

Site-of-Service Differential
The difference in the monies paid when the same service is performed in different practice setting or by a different provider. One example would be an examination in an ER versus in a family doctor's office.

Skilled Care
A type of health care given when a patient needs skilled nursing or rehabilitation staff to manage, observe, and evaluate care. Generally refers to a level of care that is lower, or less intense, than inpatient hospital care.

Skilled Nursing Care
A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).

SLMB
See Specified Low-Income Medicare Beneficiaries.

Small Group
Although each MCO's size limit may vary, generally a group composed of 1 to 99 members for which the group sponsor provides health coverage.

Small Group Market
The insurance market for products sold to groups that are smaller than a specified size, typically employer groups. The size of groups included usually depends on state insurance laws and thus varies from state to state, with 50 employees the most common size, and typically ranging from 2 to 99 members.

SMI
See Supplemental Medical Insurance.

SNF
See Skilled Nursing Facility.

Sole Community Hospital (SCH)
A hospital which (1) is more than 50 miles from any similar hospital, (2) is 25 to 50 miles from a similar hospital and isolated from it at least one month a year as by snow, or is the exclusive provider of services to at least 75 percent of its service area populations, (3) is 15 to 25 miles from any similar hospital and is isolated from it at least one month a year, or (4) has been designated as an SCH under previous rules. The Medicare DRG program makes special optional payment provisions for…

Solo Practice, Solo Practitioner
A physician who practices alone or with others but does not pool income or expenses. This form of practice is becoming increasingly less common as physicians band together for contracting, overhead costs and risk sharing.

SPD
See Summary Plan Description.

Special Election Period
A term used by CMS to describe a set time that a beneficiary can change health plans or return to the Original Medicare Plan, such as: when the citizen moves outside the service area, if a Medicare+Choice organization violates its contract with the citizen, if the organization does not renew its contract with CMS, or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP). See Election Periods, Enrollment, Penalty, or Spec…

Special Enrollment Period
A set time when a senior citizen can sign up for Medicare Part B, without penalty, if the citizen did not take Medicare Part B during the Initial Enrollment Period because the citizen or the citizen's spouse were working and had group health plan coverage through an employer or union. The citizen can sign up at anytime while he or she is covered under the group plan based on current employment status. The last eight months of the Special Enrollment Period starts the month after the employment en…

Special Needs Plan
A special type of plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.

Specialist
A doctor who treats only certain parts of the body, certain health problems, or certain age groups. Normally, a specialist has received advanced training in a specialty field. For example, some doctors treat only heart problems. Some health plans require enrollees to obtain a referral from a primary care provider prior to seeing a specialist in order for the specialist care to be reimbursed. Also see Referral or Primary Care Physician.

Specific Stop Loss Coverage
The form of excess risk coverage that provides protection for the employer against high claim on any one individual. This is protection against abnormal severity of a single claim rather than abnormal frequency of claims in total. Also see Reinsurance, Stop Loss, and Individual Stop-Loss Coverage.

Specified Disease Insurance
This kind of insurance pays benefits for only a single disease, such as cancer, or for a group of diseases. Specified Disease Insurance doesn't fill gaps in Medicare coverage but may do so when combined with other types of health plan coverage.

Spend Down
A term used in Medicaid for persons whose income and assets are above the threshold for the state's designated medically needy criteria, but are below this threshold when medical expenses are factored in. The amount of expenditures for health care services, relative to income, that qualifies an individual for Medicaid in States that cover categorically eligible, medically indigent individuals. Eligibility is determined on a case-by-case basis.

Spider Graphs-Charts
A technique or tool developed by Ernst & Young, to combine analyses of a market's level of managed care evolution with an internal readiness review.

Sponsor
An entity that sponsors a health plan or makes one available to members of a group. This can be an employer, a union, or some other entity.

SSI
See Supplemental Security Income.

Staff Model HMO
A closed-panel HMO whose physicians are employees of the HMO. A model in which the HMO hires its own physicians. All premiums and other revenues accrue to the HMO, which, in turn, compensates physicians. Very much like the group model, except the doctors are employees of the HMO. Generally, all ambulatory health services are provided under one roof in the staff model.

Standard Class Rate (SCR)
Base revenue requirement per member multiplied by demographic information to determine monthly premium rates.

Standard Community Rating
A type of community rating in which an MCO considers only community-wide data and establishes the same financial performance goals for

Standard of Care
A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.

Standards
According to the Institute of Medicine, Standards are authoritative statements of: (1) minimum levels of acceptable performance or results, (2) excellent levels of performance or results, or (3) the range of acceptable performance or results.

Standing Referral
A referral to a specialist provider that covers routine visits to that provider. It is a common practice to permit the gatekeeper to make referrals for only a limited number of visits (often 3 or fewer). In cases where the medical condition requires regular visits to a specialist, this type of referral eliminates the need to return to the gatekeeper each time the initial referral expires.

State Insurance Department
A state agency that regulates insurance and can provide information about Medigap policies and other private insurance. HMOs and other managed care entities may require permission from this department in order to operate in a given state.

State Medical Assistance Office
A state agency that is in charge of the state`s Medicaid program and can give information about programs that helps pay medical bills for people with low incomes.

State Pharmacy Assistance Program
A state program that provides people assistance in paying for drug coverage, based on financial need, age or medical condition and not based on current or former employment status. These programs are run and funded by the states.

State Survey
A process that varies by state and is responsible for assuring that hospitals or other health providers comply with Medicare, Medicaid, fire safety or other rules and regulations.

Statutory Solvency
An MCO's ability to maintain at least the minimum amount of capital and surplus specified by state insurance regulators.

Step Protocol
see Step Therapy below.

Stop Loss Insurance
Insurance purchased by an insurance company or health plan from another insurance company to protect itself against losses. A type of insurance coverage that enables provider organizations or self-funded groups to place a dollar limit on their liability for paying claims and requires the insurer issuing the insurance to reimburse the insured organization for claims paid in excess of a specified yearly maximum. Reinsurance purchased to protect against the single overly large claim or the excessiv…

Structural Integration
The unification of previously separate providers under common ownership or control.

Subrogation
Procedure where insurance company recovers from a third party when the action resulting in medical expense (e.g. auto accident) was the fault of another person. The recovery of the cost of services and benefits provided to the insured of one health plan when other parties are liable.

Subscriber
Employment group or individual that contracts with an insurer for medical services. Person or group responsible for payment of premiums, or person whose employment is the basis for membership in a health plan. Usually synonymous with enrollee, covered individual or member.

Subscriber Contract
A written agreement that describes the individual's health care policy. Also called subscribe certificate or member certificate.

Subsidy
A monetary grant paid by the government to a private person or company to assist an enterprise deemed advantageous to the public.

Summary Plan Description (SPD)
In self-funded plans, a written explanation of the eligibility for and benefits available to employees required by ERISA.

Supplemental Insurance
Any private health insurance plan held by a Medicare beneficiary or commercial beneficiary, including Medigap policies and post-retirement health benefits. Supplemental usually pays the deductible or co-pay and sometimes will pay the entire bill when the primary carrier's benefits are exhausted. See Secondary Payer.

Supplemental Payer
Any private health insurance plan held by a Medicare beneficiary or commercial beneficiary, including Medigap policies and post-retirement health benefits. Supplemental usually pays the deductible or co-pay and sometimes will pay the entire bill when the primary carrier's benefits are exhausted. See Secondary Payer.

Supplemental Security Income (SSI)
A federal cash assistance program for low-income aged, blind and disabled individuals established by Title XVI of the Social Security Act. States may use SSI income limits to establish Medicaid eligibility.

Supplemental Services
Optional services a health plan covers or provides.

Supplier
Generally, any company, person, or agency that provides supplies (such as medicines, linens or prostheses) to medical providers or that provides medical items or services, like wheelchair or walkers, directly to patients.

Surplus
The amount that remains when an insurer subtracts its liabilities and capital from its assets.

Surplus Lines Ta
xA tax imposed by state law when coverage is placed with an insurer not licensed or admitted to transact business in the state where the risk is located. Unlike premium tax for admitted insurers, the surplus lines tax is not included in the premium and must be collected from the policyholder and remitted to the state.

Termination Date
Date that a group contract expires or an individual is no longer eligible for benefits.

Termination Provision
A provider contract clause that describes how and under what circumstances the parties may end the contract.

Termination With Cause
A contract provision, included in all standard provider contracts, that allows either the MCO or the provider to terminate the contract when the other party does not live up to its contractual obligations.

Tertiary Care
Services provided by highly specialized providers such as neurosurgeons, thoracic surgeons and intensive care units. These services often require highly sophisticated technology and facilities.

TFL
See TRICARE for Life.

Therapeutic Alternatives
Drug products that provide the same pharmacological or chemical effect in equivalent doses. Also see Formulation Substitution.

Therapeutic Equivalency
Drug products that provide the same pharmacological or chemical effect in equivalent doses. Also see Formulation Substitution.

Therapeutic Substitution
The dispensing of a different chemical entity within the same drug class of a drug listed on a pharmacy benefit management plan's formulary. Therapeutic substitution always requires physician approval.

Third Party Administrator (TPA)
An independent organization that provides administrative services including claims processing and underwriting for other entities, such as insurance companies or employers. Often insurance companies will contract as TPAs with other insurance companies or health plans. TPAs are not always insurance companies. TPAs are organizations with expertise and capability to administer all or a portion of the claims process. Self-insured employers will often contract with TPAs to handle their insurance func…

Third-Party Payer
Any organization, public or private that pays or insures health or medical expenses on behalf of beneficiaries or recipients. An individual pays a premium for such coverage in all private and in some public programs; the payer organization then pays bills on the individual's behalf. Such payments are called third-party payments and are distinguished by the separation among the individual receiving the service (the first party), the individual or institution providing it (the second party), and t…

Third-Party Payment
Payment by a financial agent such as an HMO, insurance company or government rather than direct payment by the patient for medical care services. The payment for health care when the beneficiary is not making payment, in whole or in part, in his own behalf.

Three-Tier Copayment Structure
A pharmacy benefit copayment system under which a member is required to pay one copayment amount for a generic drug, a higher copay-ment amount for a brand-name drug included on the health plan's formulary, and an even higher copayment amount for a nonformulary drug. Also see Tiered Formulary.

Tiered Formulary
List of preferred prescription drugs in which different drugs have different co-pays, according to the policies of Drug Plans or Prescription Drug Benefits. Each drug is assigned to a specific ‘tier` within the formulary. The most cost-effective drugs, often generic drugs, belong to the most preferred tier and typically have the lowest co-pay, whereas the least cost effective drugs belong to the least preferred tier and have the highest co-pay. Tiered formularies encourage consumers to be cost-c…

Tiers
To have lower costs, many Prescription Drug Plans place drugs into different 'tiers,' which cost different amounts. Each plan can form their tiers in different ways. Here is an example of how a plan might form its tiers. One example may be: Tier 1Generic drugs, Tier 2 Preferred brand-name drugs, Tier 3 Non-preferred brand-name drugs. See also Prescription Drug Plan.

Title XIX (Medicaid)
The title of the Social Security Act that contains the principal legislative authority for the Medicaid program and therefore a common name for the program. See also Medicaid.

Title XVIII (Medicare)
The title of the Social Security Act that contains the principal legislative authority for the Medicare program and therefore a common name for the program. See also Medicare.

Tort Reform
Legislative limits or changes or judicial reform of the rules governing medical malpractice lawsuits and other lawsuits. Tort simply refers to lawsuit. Reform implies that limits can be placed on individual rights to sue or on the amounts or situations for which they can seek relief. Tort is considered to be by some as the primary cause of the rising costs of health care. Reform, then, would lower health care costs. On the other hand, patient advocates are against tort reform, claiming that the …

Total Budget
Otherwise known as a 'global' budget, a cap on overall health spending.

Total Margin
A measure that compares total hospital revenue and expenses for inpatient, outpatient, and non-patient care activities. The total margin is calculated by subtracting total expenses from total revenue and dividing by total revenue.

Total Quality Management (TQM)
Related to quality management, TQM identifies required system elements to measure, design, and select processes that consistently deliver superior outcomes. These fundamentals make up the basis for TQM. See also Quality Improvement.

TPA
See Third Party Administrator.

TQM
See Total Quality Management.

Tracking of Disclosures
The HIPAA Privacy Rule gives individuals the right to request an accounting of disclosures of protected health information over the previous six years. If an individual authorizes uses or disclosures for research, the disclosures do not need to be tracked, but disclosures must be tracked if the researcher receives an IRB-approved waiver of authorization. The accounting of disclosures generally must include: the date of the disclosure, the name of the entity or person (and address if known) who r…

Transaction
Usually refers to the exchange of information for administrative or financial purposes such as health insurance claims or payment. Under HIPAA, this is the exchange of information between two parties to carry out financial or administrative activities related to health care.

Transfer
Movement of a patient between hospitals or between units in a given hospital. In Medicare, a full DRG rate is paid only for transferred patients that are defined as discharged. In managed care, transfers are often suggested by UR entities to move patients to lower cost care facilities.

Treatment
The provision of health care by one or more health care providers. Treatment includes any consultation, referral or other exchanges of information to manage a patient's care. The HIPAA Privacy Notice explains that the HIPAA Privacy Rule allows Partners and its affiliates to use and disclose protected health information for treatment purposes without specific authorization.

Treatment Episode
The period of treatment between admission and discharge from a modality, e.g., inpatient, residential, partial hospitalization, and outpatient, or the period of time between the first procedure and last procedure on an outpatient basis for a given diagnosis. Many healthcare statistics and profiles use this unit as a base for comparisons.

Trending
Methods of estimating future costs of health services by reviewing past trends in cost and utilization of these services. Also see Actuarial.

Triage
Triage is the act of categorizing patients according to acuity and by determining that need services first. Most commonly occurs in emergency rooms, but, can occur in any healthcare setting. Classification of ill or injured persons by severity of condition. Designed to maximize and create the most efficient use of scarce resources of medical personnel and facilities.

Triage Center
Managed care organizations, health plans and provider systems are setting up programs or clinics called 'triage centers'. These centers serve as an extension of the utilization review process, as diversions from emergency room care or as case management resources. These triage centers also serve to steer patients away from more costly care (for example, a child with a cold is steered away from an emergency room). Triage can also be handled on the telephone and be called a pre-authorization cente…