Copy of `Pohlys - Glossary of Health Care Terms`

The wordlist doesn't exist anymore, or, the website doesn't exist anymore. On this page you can find a copy of the original information. The information may have been taken offline because it is outdated.

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

Triage Providers
Medical personnel who classify ill or injured persons by severity of condition. When providers or insurance companies manage triage on the telephone, this service may be referred to as pre-authorization center, crisis center, call center or information line. Providers may also manage triage in emergency rooms, walk-in centers, disaster scenes or outreach centers.

TRICARE
A health care program for active duty and retired uniformed services members and their families.

TRICARE Extra
A reduced fee-for-service (FFS) plan similar to the network portion of a PPO.

TRICARE for Life (TFL)
Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses.

TRICARE Prime
An enrollment-based managed care option designed to provide coordinated care managed by a primary care manager, who is similar to a primary care provider in a commercial HMO.

TRICARE Standard
A fee-for-service plan that allows participants to use TRICARE authorized providers or non-network providers.

Triple Option Plan
A plan (usually offered by a single carrier or a joint venture between two or more carriers) that gives subscribers or employees a choice among HMO, PPO and traditional indemnity plans. Also see Cafeteria Plan.

Two-Tier Copayment Structure
A pharmacy benefit copayment system under which a member is required to pay one copayment amount for a generic drug and a higher copayment amount for a brand-name drug. See Tiered Formulary.

U.S. Per Capita Cost (USPCC)
The national average cost per Medicare beneficiary, calculated annually by CMS`s Office of the Actuary. See also Capitation or CMS.

UCR
See Usual, Customary and Reasonable.

UM
See Utilization Management.

Unassigned Claim
A claim submitted for a service or supply by a provider who does not accept assignment. Also see Assignment of Benefits.

Unbundling
A coding inconsistency that involves separating a procedure into parts and charging for each part rather than using a single code. 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. Unbundling is disallowed by many MCOs.

Uncompensated Care
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.

Underinsured
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.

Underwriting
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.

Underwriting Impairments
Factors that tend to increase an individual's risk above that which is normal for his or her age.

Underwriting Manual
A document that provides background information about various underwriting impairments and suggests the appropriate action to take if such impairments exist.

Underwriting Requirements
Requirements, sometimes relating to group characteristics or financing measures, that MCOs at times impose in order to provide healthcare coverage to a given group and which are designed to balance a health plan's knowledge of a proposed group with the ability of the group to voluntarily select against the plan. Also see Antiselection.

Uninsured
People who lack public or private health insurance.

Universal Access
The right and ability to receive a comprehensive, uniform, and affordable set of confidential, appropriate, and effective health services. Universal service is a reality in countries with national medicine programs or socialized healthcare, such as the UK, Canada, France and most countries in the world. Few countries have the private insurance programs as the primary form of healthcare, as in the US. See Universal Coverage.

Universal Coverage
A type of government sponsored health plan that would provide healthcare coverage to all citizens. This is an aspect of Clinton's original health plan in the mid 1990s and is an attribute of national health insurance plans similar to those offered in other countries such as the UK or Canada. While government sponsored health care is not likely to be universal, politicians in Washington continuously discuss the concept of providing healthcare to all Americans. Expect to see more and more discussi…

Upcoding
A coding inconsistency that involves using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider.

Update Factor
The year-to-year increase in base payment amounts for PPS and excluded hospitals and dialysis facilities. The update factors generally are legislated by the Congress after considering annual recommendations provided by ProPAC and HHS.

UR
See Utilization Review.

Urgent Services
Benefits covered in an Evidence of Coverage that are required in order to prevent serious deterioration of an insured's health that results from an unforeseen illness or injury.

Urgently Needed Care
A CMS term, it refers to care that an enrollee receives for a sudden illness or injury that needs medical care right away, but is not life threatening. Primary care doctor generally provides urgently needed care if the enrollee is in a Medicare health plan other than the Original Medicare Plan. If the enrollee is out of your plan's service area for a short time and cannot wait until returning home, the health plan must pay for urgently needed care.

URO
See Utilization Review Organization.

Use
Under HIPAA, this term refers to the sharing of individually identifiable health information within a covered entity. For Partners' purposes, a use is the sharing of such information within the Partners affiliated covered entity.

Utilization
Use of services and supplies. Utilization is commonly examined in terms of patterns or rates of use of a single service or type of service such as hospital care, physician visits, and prescription drugs. Measurement of utilization of all medical services in combination is usually done in terms of dollar expenditures. Use is expressed in rates per unit of population at risk for a given period such as the number of admissions to the hospital per 1,000 persons over age 65 per year, or the number of…

Utilization Management (UM)
The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria. Evaluation of the necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities. UM usually includes new actions or decisions based on the overall analysis of the utilization. See also Case Management.

Utilization Management Committee
The MCO committee that reviews and updates the MCO's utilization management program, establishes utilization review protocols, reviews referral and utilization patterns, and reviews utilization decisions for medical appropriateness.

Utilization Review (UR)
A formal review of utilization for appropriateness of health care services delivered to a member on a prospective, concurrent or retrospective basis. In a hospital, this includes review of the appropriateness of admissions, services ordered and provided, length of a stay, and discharge practices, both on a concurrent and retrospective basis. A peer review group, or a public agency can do utilization review. UR is a method of tracking, reviewing and rendering opinions regarding care provided to p…

Utilization Risk
The risk that actual service utilization might differ from utilization projections. Validation The process by which the integrity and correctness of data are established. Validation processes can occur immediately after a data item is collected or after a complete set of data is collected. A key concept in transmittal of electronic health records and HIPAA rules.

Variable Contribution Health Plan
In contrast to a fixed contribution plan, a variable contribution involves employers committing to a specified level of benefits funding for its employees, regardless of the actual benefit price. Employers are thus locked into variable contribution arrangements because they are committed to funding a certain benefit structure without knowing what the future costs may be if premiums are raised. See also Fixed Contribution Health Plan.

Vertical Disintegration
A practice of selling off health plan subsidiaries or provider activities. Vertical disintegration was a trend in the late 1990s.

Vertical Integration
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…

Vital Statistics
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. An individual patient's vital statistics in a health care setting may also refer simply to blood pressure, temperature, height and weight, etc.

Volume and Intensity of Services
The quantity of health care services per enrollee, taking into account both the number and the complexity of the services provided.

Volume Performance Standards (VPS)
A mechanism to adjust updates to fee-for-service payment rates based on actual aggregate.

Waiting Periods
The length of time an individual must wait to become eligible for benefits for a specific condition after overall coverage has begun. Also refers to the period that must pass before an employee or dependent is eligible to enroll (becomes covered) under the terms of the group health plan. If the employee or dependent enrolls as a late enrollee or on a special enrollment date, any period before the late or special enrollment is not a waiting period. If a plan has a waiting period and a pre-existin…

Waiver
Approval that the Centers for Medicare and Medicaid Services (CMS, formerly called 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…

Waiver of Authorization
Under HIPAA, under limited circumstances, a waiver of the requirement for authorization for use or disclosure of private health information may be obtained from the IRB by the researcher. A waiver of authorization can be approved only if specific criteria have been met. See Authorization also.

Wellness
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 lifes…

WHCRA
See Women's Health and Cancer Rights Act.

Withhold
Used as an incentive to encourage providers to reduce utilization of services, a percentage of a provider's payment is 'held back' during the plan year to offset or pay for any cost overruns for referral or hospital services. 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…

Withhold Pool
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, and Shared Risk.

Workers' Compensation
Insurance that employers are required to have to cover employees who get sick or injured on the job. 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. Some employers pay premiums to the state or to insurance companies for this coverage. Others ar…

Zero-Sum Budgeting
A 'deficit neutral' budget process in which new expenditures are paid through cuts in existing programs or increases in revenue. The end result is the same bottom line and no increase in the deficit (if governmental) or debt (if referring to private or public corporation or company).