| Term | Definition |
|---|
| ancillary services | Supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests. |
| buffing | A physicians justifying the transference of sick, high-cost patients to other physicians in a managed care plan. |
| capitation | System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan. |
| carve outs | Medical services not included within the capitation rate as benefits of a managed care contract and may be contracted for separately. |
| churning | When physicians see a high volume of patients--more than medically necessary-- to increase revenue. May be seen in fee-for-service or managed care environments |
| claims-review type of foundation | A type of foundation that provides peer review by physicians to the numerous fiscal agents or carriers involved in its area. |
| closed panel program | A form of HMO that limits the patient's choice o personal physicians to those doctors praticign in the HMO group practice within the geographic location or facility. A physician must meet very narrow criteria to join a closed panel. |
| comprehensive type of foundation | A type of foundation that designs and sponsors prepaid health programs or sets minimum benefits |
| copayment | A patient's payment of a portion of the cost at the time the service is rendered. |
| deductible | A specific dolla a ount that must be paid by the insured before a medical insurance plan or government program begins covering health care costs. |
| direct referral | Certain services in a managed care plan may not require preauthorization. the authorization request form is completed and signed by the physician and handed to the patient to be done directly. |
| disenrollment | A member's voluntary cancellation of membership in a managed care plan. |
| exclusive provider organization | EPO, A type of managed health care plan that combines features of HMOs and PPOs. it is referred to as "exclusinve" because it is offered t large employers who agree not to contract with any other plan. EPOs are regulated under state health insurance laws. |
| fee-for-service | a method of payment in shich the patient pays the physician for each professional service performed from an established schedule of fees. |
| formal referral | An authorization request (telephone, fax, or completed form) required by the managed care organization contract to determine medical necessity and grant permission before services are rendered or procedures performed |
| foundation for medical care | An organizatoin of physicians sponsored by a state or local meical associatoin concerned with the development and delivery of medical services and the cost of health care. |
| gatekeeper | In the managed care system, this is the physician who controls patient access to specialists adn diagnostic testing services. |
| health maintenance organization | HMO, The oldest of all prepaid health plans. A comprehensive health care financing and delivery organization that provides an wide range of health care services with an emphais on preventive medicine to enrollees within a geographic area through a panel of providers. Primary care physicion "gatekeepers" are usually reimbursed via capitation. In geneal, enrollees do ot receive coverage for the services form providers who are not in the HMO network, except for emergency services. |
| in-area | Within the geographic boundaries defined by an HMO as the area in which it will provide mecial services to its members. |
| independent practice association | IPA, A type of HMO in which a program administrator contracts with a number of physicinas who agreee to provide treatment to subscribers in their own offices. Physicians are not employees of the managed care organization and are not paided salaries. They receive reimbursement on a capitatin or fee-for-service basis |
| managed care organizations | MCOs, A generic term applied to a managed care plan. May apply to EPO, HMO, PPO integrated delivery system or other different managed care arrangement. MCOs are usually prepaid group plans, physicians are typically paid by the capitation method |
| participating physicians | A physician woh agrees to accept payemnt from Medicare (80% of the apprved charges) plus payment from the patient (20% of approved charges) after the $100 deductible has been met. |
| per capita | see capitation |
| physician provider group | PPG, A physician-owned business that hs the flexibility to deal with all forms of contract medicine and still offer its own packages to business groups, unions, and the general public. |
| point-of-service plan | POS plan, A managed care plan in which members are given a choice as to how to receive services whether through an HMO PPO, or fee-for-service plan. The decision is made at thetime the service is needed (e.g. "at the point of service"); somtimes referred to as open-emded HMOs, swing-out HMOs self-referral options, or multiple option plans. |
| preferred provider organization | PPO, A type of health benefit program in which enrollees receive the highest level of benefits when they obtain services from a physician, hospital, or other health care provider desinated by their program as a "preferred provider". Enrollees may receive substantial although reduced, benefits when they obtain care from a provider of their own choosing who is not designated as "preferredprovider" by their program. |
| prepaid group practice model | A plan under which specified health services are rendered by participating physicians to an enrolled group of persons, with fixed periodic payemnts made in advance, by or on behaldf of each person or family. If a health insurance carrier is involved it contracts to pay in advance for athe full range of heatlh services to which the insured is entitled under the terms of the health insurance contract. Such a plan is one for of a health maintenance organization. |
| primary care physician | PCP, Physician who oversees care of patients in a managed health care plan and refers patients to specialists services as needed. Also known as a gatekeeper. |
| self-referral | A patient in a managed care plan that refers himself to a specialist. The patient may be required to inform the primary care physician. |
| service area | The geographic area defined by an HMO as the locale in which it will provide health care services to its members directly through its own resources or arrangements with other providers in the area. |
| staff model | The type of HMO in which the health plan hires physicians directly and pays them a salary. |
| stop-loss | An agreement between a managed care company and a reinsurer in which absorptoin of pre-paid patient expenses is limited; or limiting losses on an individual expensive hospital claim or professional services claim; form of reinsurance by which the managed care program limits the losses of an individual expensive hospital claim. |
| tertiary care | Services requested by a specialist from another specialist (e.g. neurosurgeons, intensive care units). |
| turfing | Transferring the sickest, high-cost patients to other physicians so the provider appears as a low-utilizer in a managed care setting. |
| utilization review | UR, A process, based on established criteria of reviewing and controlling rhe medical necessity for services and providers' use of medcial resources. Reviews are carried out by allied health personnel at predetermined times during the hospital stay to assess the need for the full facilities of an acute care hospital. In managed care systems, such as an HMO, reviews are done to establish medical necessity, thus curbing costs. Also called utilization or management control. |
| verbal referral | A primary care physician informs the patient and telephones to the referring physician that the patient is being referred for an appointment. |
| withold | A portion of the monthly capitaton payment to physicians retained by the HMO until the end of the year to create an incentive for efficient care. If the physicain exceeds utitlization norms, he or she will not receive it. |
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