| Benchmark |
For
particular indicator or performance goal, the industry measure of
best performance. The benchmarking process identifies the best performance
in the industry (healthcare or non-healthcare) for a particular
process or outcome, determines how that performance is achieved, and
applies the lessons learned to improve performance. |
| Capitation |
A
method of paying for medical services on a per-person rather than
a per-procedure basis. Under capitation, an HMO pays a participating
doctor a fixed, predetermined amount in advance of the delivery of
service for every HMO member he or she takes care of, regardless of
how many times the member uses the service. |
| Carve-outs |
One
or more services an HMO may separate (or "carve-out") from
those they require to be provided under the capitation rates. These
services may be paid on a fee-for-service or other basis. |
| Claim |
A
request by an individual (or his or her provider) to an individual's
insurance company for the insurance company to pay for services obtained
from a healthcare professional. |
| Copayment |
A
fixed payment the patient pays (often between $5 to $25) each time
he or she visits a health plan physician or clinician or receives
a covered service. |
| Credentialing |
A
process of review to approve a provider who applies to participate
in a health plan. Specific criteria and prerequisites are applied
in determining initial and ongoing participation in the health plan. |
| Deductible |
More
typical in traditional health insurance, a fixed amount the patient
must pay each year before the insurer will begin covering the cost
of care. |
| Exclusions |
Specific
conditions or circumstances listed in the contract or employee benefit
plan for which the policy or plan will not provide benefit payments. |
|
Fee-for-service
|
The
traditional method of paying for medical services. A doctor charges
a fee for each service provided, and the insurer pays all or part
of that fee. Sometimes the patient pays a copayment for each visit
to the doctor. |
| HMO
(health maintenance organization) |
A
public or private organization that provides healthcare in return
for pre-set monthly payments. Most HMOs provide care through a network
of doctors, hospitals and other medical professionals that their members
must use to be covered for that care. |
| IPA
(independent physicians association) |
IPAs
generally include large numbers of individual private practice physicians
who are paid either a fee or a fixed amount per patient to care for
the IPA's members. |
| Managed
Care |
A
system of healthcare delivery that influences the utilization and
cost of services and measures performance. The goal is a system that
delivers value by giving people access to quality, cost-effective
healthcare. |
| Network |
The
doctors, clinics, health centers, medical group practices, hospitals,
and other providers that an HMO, PPO, or other managed care network
plan has selected and contracted with to care for its members. |
| Open
enrollment period |
A
time during which members in a health benefit program have an opportunity
to re-enroll or select an alternate health plan being offered to them,
usually without evidence of insurability or waiting periods. |
|
Outcome
measurement
|
A
process of systematically measuring individual or collective clinical treatment
and response to that treatment. |
| Out-of-network |
Not
in the HMO's network of selected and approved doctors and hospitals.
HMO members who get care out-of-network (sometimes called out-of-area)
without getting permission from the HMO to do so may have to pay for
all or most of that care themselves. Exceptions are usually made for
extreme emergencies or urgent care needed when traveling away from
home. |
| PPO
(preferred provider organization) |
A
network of doctors and hospitals that provides care at a lower costs
than through traditional insurance. PPO members get better benefits
(more coverage) when they use the PPO's network, and pay higher out-of-pockets
costs when they receive care outside the PPO network. |
| Practice
guidelines |
Carefully
developed information on diagnosing and treating specific medical
conditions. Practice guidelines --- usually based on clinical literature
and expert consensus --- are designed to help physicians and patients
make decisions, and to help a health plan evaluate appropriateness
and medical necessity of care. |
| Pre-existing
condition (PEC) |
Any
medical condition that has been diagnosed or treated within a specified
period immediately preceding the covered person's effective date of
coverage under the master group contract. |
| Preventive
care |
Care
designed to prevent disease altogether, to detect and treat it early,
or to manage its course most effectively. Examples of preventive care
include immunization and regular screenings (such as Pap smears or
cholesterol checks). |
| Primary
care physician (PCP) |
A
physician --- usually an internist, pediatrician, or family physician
--- devoted to general medical care of patients. Most HMOs require
members to choose a primary care physician, who is then expected to
provide or authorize all care for that patient. |
| Prior
authorization |
The
process of obtaining prior approval as to the appropriateness of a
service or medication. Prior authorization does not guarantee coverage. |
| Referral |
A
formal process that authorizes an HMO member to get care from a specialist
or hospital. To assure coverage, an HMO patient generally must get
a referral from his or her primary care doctor before seeing a specialist. |
| Specialist |
A
doctor or other health professional whose training and expertise are
in a specific area of medicine, like cardiology or dermatology. Most
HMOs require members to get a referral from their primary care physician
before seeing a specialist. |
| Utilization
review (UR) |
Health
care services and treatment plans are formally assessed according
to the medical necessity, efficiency, or appropriateness on a prospective,
concurrent, or retrospective basis. |
