Community Service


To deal effectively with today's health care system, it is essential for patients to understand the language used by managed care companies, hospitals, and physicians. This glossary provides definitions of important terms.

All entries are listed alphabetically:
click on the letters below to view section listings


To locate a specific term,
select "Edit" and then "Find"

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a patient's ability to obtain medical care determined by factors such as the availability of medical services, their acceptability to the patient, facility location, transportation, hours of operation, and the cost of care

Accountable Health Plans (AHPs)
a collaboration between health care providers and insurance companies (similar to HMOs, PPOs, and other group practices) to provide high-quality, low-cost care and insurance as a single product

an official authorization or approval to an organization determined by industry-derived standards

the purchase by cash or other compensation or the receipt by exchange or gift of majority voting control of a corporation or all or substantially all the assets of a corporation

activities of daily living (ADLs)
a set of basic tasks used to measure an individual's level of functional impairment

adult day care
supervised programs for elderly and/or disabled adults generally offered Monday through Friday during daytime hours

services that are administered following hospitalization or rehabilitation that are individualized for each patient's needs

all-payer system
a plan that dictates uniform prices on medical services for all payers

ambulatory care
health services that don't require hospitalization of the patient

ambulatory surgery
surgery that doesn't require an overnight hospital stay; also called outpatient surgery or same-day surgeryclick here for information about ambulatory surgery at Stony Brook

ancillary services
additional services offered in combination with medical care, such as lab work, imaging studies and pharmacy

any willing provider
state requirements that a network accept any provider who meets the network's credentialing requirements and is willing to accept the network's contractual terms

average length of stay
the average period that patients are in a hospital or health care institution receiving inpatient care; calculated by dividing total patient days by the number of admitted patients

assisted living facility
accommodations for the elderly or disabled where staff is always available to provide care


total number of beds in a hospital

behavioral health care
treatment of mental and psychoactive substance abuse disorders

the value which is conveyed to a plan participant under a health plan

board-certified surgeon
a surgeon who has met the standards of excellence established and maintained by the American Board of Surgery (ABS); only those surgeons who have completed their specialty training in an ABS-accredited residency program in general surgery, such as Stony Brook's surgical residency, can apply to be board certified in surgery

bond insurance
issuers of health care bonds purchase this coverage to lower their interest rate to make the bonds more attractive to investors; bonds with insurance typically are rated AAA-the highest rating

book of business
the range of business contracts held by a corporation, whether between insurer and employer or between provider and insurer

Boren Amendment
Part of the Medicaid law, this amendment provides that state payment rates for hospitals and nursing facilities must be reasonable and adequate to meet the costs incurred by efficiently and economically operated facilities to provide care and services meeting state and federal standards


total number of patients a hospital or system can accommodate

capitation or prepayment
negotiated per capita rate to be paid periodically, usually monthly, to a health care provider to cover services required by the covered person under the conditions of the provider contract

a comprehensive care documentation tool that incorporates a timeline, a critical path, an index of problems with intermediate and outcome criteria, and a variance record; used to plan, deliver and analyze patient care (CareMap® is a registered trademark of The Center for Case Management, South Natick, MA)

case management
the identification of patient needs and the development of a plan to efficiently achieve the optimum patient outcome in the most cost-effective manner

case manager
the health care professional who coordinates the services necessary to carryout a case management plan

case mix
categories of patients classified by disease, procedure, method of payment, or other characteristics in an institution at a given time, usually measured by counting or aggregating groups of patients sharing one or more characteristics

centers of excellence
a network of health care facilities or a specific clinical program (i.e., neurology, cardiology, oncology) that provides specific clinical services based on providers' experience, outcomes, efficiency and effectiveness

certificate of need (CON)
a document, provided by a state governing board to a health care institution at the institution's request, which allows the institution to build additional physical facilities and/or add equipment or new services

the official authorization for use of services

chief information officer
the senior information management position responsible for information strategy and overall information management

clinical paths/clinical guidelines
strategies used to manage patients' clinical care; they encompass basic elements such as recommended schedules for childhood immunizations to the more complex areas of drug protocols and pathways for disease management

the portion of a medical bill not covered by insurance and payable by the patient

Consolidated Omnibus Budget Reconciliation Act (COBRA)
a federal law requiring employers to offer at cost continued health insurance coverage to certain employees and their beneficiaries whose group health coverage has been terminated

community health assessment
process of formally assessing and documenting the health status of a community; normally culminates in a formal, published report leading to a strategic plan; an assessment can be segmented by numerous characteristics and can be undertaken by an individual or an organization

community health information network (CHIN)
an integrated collection of computer and telecommunications capabilities that facilitates communication of patient, clinical and payment information among multiple providers, payers and related health care entities within a community

community health status
the overall level and quality of health in a community, taking into account the composite status of all individuals and groups within that community and the health services available to them, as well as the environmental conditions in that area

community rating
a method of determining a premium structure based on the expected benefit utilization by an entire population, rather than by specific groups

competitive medical plan
a health care plan that has been approved by the federal government to obtain Medicare risk contracts

comprehensive outpatient rehabilitation facility (CORF)
a facility that provides complete outpatient rehab treatments for patients

computer-based patient record
an electronic record of a patient's illnesses and treatments

combining the assets and operations of two or more organizations into a single new entity

continuing medical education (CME)
a process of ongoing education on the part of individual physicians, who often in the context of professional requirements in specialty fields take courses, read medical journals, attend teaching programs and take self-study courses to keep up with medical improvements, procedures, drugs, etc.; CME programs are provided by organizations including medical schools, professional organizations and hospitals

continuous quality improvement/ total quality management
a philosophy that promotes the ongoing search for methods to enhance the systemic quality of products and services, and the overall improvement of system operations

continuum of care
the provision of coordinated health care services that encompass preventive care, primary care, acute care, chronic care, rehabilitative care and supportive care so as to maximize the value of services received by patients

contract management firm
an organization that specializes in managing and directing an entire health care institution or a particular department, service or activity in a health care institution (such as housekeeping, food service or emergency physician care) for a set fee paid by the institution

a nominal fee charged to HMO members to offset costs of paperwork and administration for each office visit or pharmacy prescription

the degree to which a service meets a specified goal at an acceptable cost

cost contract
a contract under which Medicare pays a health plan company for the costs it incurs furnishing services to program beneficiaries enrolled with it

cost sharing
financing arrangement whereby the member of a health plan must pay some of the costs to receive care

covered life
an individual who meets eligibility requirements and has paid a premium for specified benefits of the contractual agreement

critical paths/pathways
clinical management tools that organize, sequence, and time the major interventions of nursing staff, physicians and other departments for a particular case type, subset or condition


diagnosis-related groups (DRGs)
a system of classification for inpatient hospital services based on principle diagnosis, secondary diagnosis, surgical procedures, age, sex and presence of complications; this classification system is used as a financing mechanism to reimburse hospital and selected other providers for services rendered

an out-of-pocked expense a covered person must pay annually before becoming eligible for benefits

discharge planning
the evaluation of patients' medical needs in order to arrange for appropriate care after discharge from an inpatient setting

an interruption, cessation, or disorder of body or mental functions, systems or organs

disease episode
the entire time period in which a person has a specific disease

disease management
treating and controlling the cause and spread of disease

disproportionate share hospital (DSH) adjustment
an additional payment under Medicare or Medicaid to hospitals that serve a relatively large volume of low-income patients

doctor of osteopathy (DO)
a health care practitioner whose training is similar to that of MDs; in addition to treating patients with drugs, surgery and other treatments, a DO may emphasize movement in treating problems of muscles, bones and joints

drug formulary/formulary
a listing of prescription medications that are preferred for use by a health plan, hospital or clinic and which will be dispensed through participating pharmacies to covered persons

drug utilization review
a quantitative evaluation of prescription drug use, physician prescribing patterns or patient drug utilization to determine the appropriateness of drug therapy

durable medical equipment
medical equipment that can stand repeated use and is designed for a specific medical purpose (examples: wheelchairs, hospital beds)


electronic data interchange (EDI)
the electronic exchange of business information in a standardized, structured, machine-processible format

a serious medical condition resulting from an injury, sickness or mental illness that arises suddenly and requires immediate treatment

emergency contract management
outsourcing of emergency physician and other clinical staff to a non-affiliated professional organization on the part of a hospital

emergency physician
a physician who specializes in the area of emergency medicine

emergency services
the division of a health care organization responsible for the delivery of emergency care

endoscopic surgery
see videoscopic surgery

episode of care
the range of treatments provided over time for treating a condition or illness

Employee Retirement Security Act (ERISA)
a federal law that mandates reporting and disclosure requirements for group life and health plans; ERISA effectively prevents states from regulating self-funded health plans

exclusive provider organization (EPO)
unlike a preferred provider organization that extends coverage to preferred and non-preferred providers, an EPO only provides coverage to contracted providers

experience rating
setting rates based on previous claims and projected required revenues for a future policy year for a specific demographic group

extended care facility
a nursing home-type setting that offers skilled, intermediate, or custodial care


family practitioners
MDs or DOs who specialize in providing comprehensive, continuous health care for all family members, regardless of age or sex

federally qualified HMO
an HMO that has had its entire business process extensively evaluated and approved by HCFA; an organization must be federally qualified to participate in certain Medicare cost and risk contracts

fee-for-service reimbursement
the traditional health care payment system, in which physicians and other providers are reimbursed for services provided and billed

fee schedule
a listing of codes and related services with pre-established payment amounts composed of percentages of billed charges, flat rates or maximum allowable amounts

flexible benefit plan
a benefit program that offers employees a number of benefit options, allowing them to tailor benefits to their needs

for-profit hospital
a hospital that is owned and operated by a corporation or a group of investors, and is required to produce a return on investment and pay income taxes

foundation model
a legal mechanism that allows a hospital or health system to employ physicians indirectly; the physicians are technically employed by a independently chartered organization, which then has a contract with the foundation to provide care; particularly popular in states with corporate-practice-of-medicine statutes

freestanding hospital
a hospital that is not formally tied to any other hospital or health care organization

freestanding surgical center/surgi-center
a health care facility that is physically or geographically separated from a hospital and provides surgical services to outpatients who do not require hospitalization


gatekeeper model
a method of providing health care services in which the primary care physician is the patient's initial and main contact for care and referrals

gatekeeper physician
the contact physician in a gatekeeper model; this physician is usually a family practitioner, internist, pediatrician or obstetrician/gynecologist

generic drug
a chemical equivalent of a brand-name drug whose patent has expired; usually cheaper

generic substitution
dispensing a generic drug in place of a brand name medication

a physician with specialized training in the diagnosis, treatment and prevention of disorders in older people

graduate medical education
medical education after receipt of the doctor of medicine or equivalent degree, including the education received as an intern, resident or fellow, and continuing medical education

group contract
the application and addenda signed by both the health plan and the enrolling unit, which constitutes the agreement regarding the benefits, exclusions and other conditions between the health plan and the enrolling unit

group-model HMO
a managed care delivery model involving contracts with physicians organized as a partnership, professional corporation or other association; the health plan compensates the medical group for contracted services at a negotiated rate, and that group is responsible for compensating its physicians and contracting with hospitals for care of their patients

group practice
a formal organization of three or more physicians who provide medical services as a legal entity

group practice without walls
a network of physicians who have formed a single legal entity but maintain their individual practices; the assets of individual practices may be acquired by the larger entity, but some autonomy is retained at each site


health alliances
affiliations of payers that negotiate contracts with providers to ensure that care is delivered economically and equitably to their member employers and/or employees

health maintenance organization (HMO)
an organization that provides, offers or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium

Health Care Financing Administration (HCFA)
the federal agency responsible for administering Medicare and overseeing states' administration of Medicaid

Health Plan Employer Data and Information Set (HEDIS)
a core set of performance measures to assist employers and other health purchasers in understanding the value of health care purchases and evaluating health plan performance

home health agency (HHA)
a facility or program that is authorized to provide health care services in the home

home health care
health care services that are provided in a patient's home

a type of care for the terminally ill and their families in which treatment is geared to enable the patient to live as fully as possible, to relieve/control pain, involve the family within the unit of care, and center the caring process in the home whenever possible

hospital without walls
a term used to describe the range of high-tech services that can be provided outside the hospital setting


International Classification of Diseases, 9th Edition (Clinical Modification)(ICD-9-CM)
a listing of diagnoses and identifying codes used by physicians for reporting diagnoses of health plan enrollees; this process provides a uniform language to ensure reliable and consistent labeling on claim forms

indemnity insurer
an insurance company that provides coverage to participating consumers

independent practice association (IPA)
a legal entity, usually owned by participating physicians or other health care providers, which contracts on behalf of its participating providers with a health plan company, typically an HMO

a patient who receives treatment and lodging within a hospital

inpatient care
care provided to admitted patients

integrated delivery system
the affiliation or formal merger of a variety of organizations, typically including hospitals, physicians and physician groups, outpatient service organizations, managed care organizations, and others, for the purpose of delivering patient care in a coordinated fashion to a defined population

an MD or DO who specializes in the diagnosis and medical treatment of diseases in adults

individual practice association (IPA)
any legal entity that enters into an arrangement for the provision of services with persons who are licensed to practice medicine, osteopathic medicine and/or dentistry with other care personnel


Joint Commission on Accreditation of Health care Organizations (JCAHO)
a private, national regulatory body that conducts regular organizational audits substantiating accreditation

just-in-time purchasing/stockless purchasing
a supply system organized so that the right amount of medical supplies is made available at the correct time, in order to avoid the cost and administrative burdens of maintaining large supply inventories


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laparoscopic surgery
see videoscopic surgery

long-term care
nursing homes and other services providing care to the elderly and chronically ill for significant amounts of time


managed care
a system of health care delivery that influences utilization and cost of services and measures performance

managed competition
in health care, the concept of an overall financing and delivery system that promotes lower prices and higher quality of care delivery through incentives for cooperation among providers and between providers and payers, without extensive regulatory pressure on pricing and structuring in the system

management service organization (MSO)
a legal entity that provides practice management, administrative and support services to individual physicians or group practices

mandated benefits
those benefits that health plans are required by state or federal law to provide to policy-holders and eligible dependents

Maximum Allowable Costs (MAC)
a list of prescription medications, established by the health plan and distributed to pharmacies, that will be covered at a generic product level

federal government health care assistance provided to states; the program covers individuals who are indigent and lack the financial means to pay their health care and hospitalization bills; the individuals who qualify for this program can vary from state to state

Medicaid waiver
a formal process in which states petition the federal government to approve the design of alternatives to traditional and federally mandated Medicaid benefits packages

medical necessity
the evaluation of health care services to determine if they are: medically appropriate and necessary to meet basic health needs, consistent with the diagnosis or condition, and rendered in a cost-effective manner consistent with national medical practice guidelines regarding type, frequency and duration of treatment

medical record/patient record
a written or electronic record of a person's illnesses and treatments

federal government support usually administered by the state to elderly individuals to pay for their health care

Medicare update
an annual federal adjustment to modify the Medicare reimbursement structure

medigap policy
a privately purchased insurance policy that pays for the cost of services not covered by Medicare

medical/surgical supplies
both durable and disposable items used for medical and surgical treatments

mental heath
the condition of being sound mentally and emotionally

when two or more health care organizations are combined into a single legal entity

minimal access surgery
see "minimally invasive surgery" below

minimally invasive surgery
this newly developed approach to surgery can mean use of a smaller incision compared with conventional techniques; it can also mean treating a surgical disease effectively with minimal disruption to a patient's physiology, or vital processes, as in "off pump" open heart surgery that doesn't use the heart-lung machine (see MIDCAB); also called minimal access surgery—see Stony Brook's Center for Minimally Invasive Surgery

modified fee-for-service reimbursement
a system in which providers are paid on a fee-for-service basis, with certain fee maximums for each procedure

the rate of disease, illness or accidents among a patient population

the death rate among a patient population

the determination of treatment plans and delivery of care by groups of clinical and affiliated care professionals representing a wide range of specialties and expertise—for examples of this approach to patient care, see Stony Brook's Carol M. Baldwin Breast Care Center and Leg and Foot Ulcer Treatment Group

multihospital system
a central association that owns, leases or controls, by contract, two or more hospitals; some benefits of this arrangement are: improved availability of capital markets; mutual purchasing for greater economies of scale; and mutual use of technical and management personnel

multiple option plan
a health plan design that offers employees the option of electing to enroll under one of several types of coverage, usually an HMO, a PPO, and a major medical indemnity plan


network-model HMO
an HMO that contracts with more than one physician group and may contract with single-and multi-specialty groups; the physician works out of his/her own office and may share in utilization savings, but does not necessarily provide care exclusively for HMO members

not-for-profit hospital
a hospital with a tax exemption status due to its classification as a charitable organization; the exemption, which is regulated by the IRS, allows the hospital to forego tax payment in a number of areas, the most visible of which are tax on net income, payroll and property; in return, the hospital must meet various requirements outlined by the IRS

nurse practitioner (NP)
a registered nurse with training beyond basic nursing education, who performs physical exams and diagnostic tests, counsels patients, and develops treatment programs; he/she receives intensive education for areas of specialization


occupational therapy
therapy designed to increase and restore independence to perform day-to-day functions for victims of accident, illness or disability

operating margin
a portion of net income attributable to the excess of operating revenue over expenses; this measure is used by many analysts as the primary indicator of hospital profitability

outcome measure
an evaluation of the results of treatment for a particular disease or condition, generally measured in terms of a patient's ability to function, quality of life and length of life

outcomes measurement and management
the ongoing process of gathering data on clinical outcomes in any of a number of areas, and measuring, comparing, analyzing and using the data in order to improve patient care and the care delivery process

an individual, organization or case that falls far outside a statistical mean; an example may be a hospital stay that is unusually long or expensive considering the nature of the treatment

outpatient care
care that is provided to patients who are not admitted to a health care facility

outpatient surgery
surgery that doesn't require an overnight hospital stay; also called ambulatory surgery or same-day surgeryclick here for information about outpatient surgery at Stony Brook

a situation in which a hospital or hospital-based system has more inpatient beds than needed by its patient population; also applies to the concept of entire markets, regions or the overall health care system having more beds than needed, particularly in an operating environment becoming more and more dominated by managed care and capitation


program of all-inclusive care for the elderly (PACE/OnLok)
a nationwide replication of a care/financial model created by OnLok Inc. to provide total care and psychosocial services for the frail elderly who are eligible for nursing home admission but who could remain in their own homes with proper support; provides preventive and supportive services designed to keep people in their homes and reduce the use of hospital and nursing home care

patent-centered care/patient-focused care
the process of organizing care delivery according to patient, rather than provider-operational, needs; often involves the restructuring of staffing and activity patterns in a provider organization

patient representative
a person who investigates and mediates patients' problems and complaints in relation to a hospital's services

a person or organization that pays or underwrites coverage for health care expenses

pediatric hospital
a hospital geared toward treating diseases and illnesses found in children

peer review
a review of a health professional's performance of clinical professional activities by peer(s) through formally adopted written procedures that provide for adequate notice and an opportunity for a hearing of the professional under review

peer review organization
an organization established to review the quality of care and appropriateness of admissions, readmissions and discharges for Medicare and Medicaid patients

pharmacy and therapeutics (P&T) committee
a panel composed of physicians, pharmacists and other clinicians who evaluate pharmaceuticals and therapeutic agents in order to optimize pharmaceutical utilization; this group usually approves and maintains the organization's drug formulary

pertains to drugs, pharmacy or pharmacists

pharmaceutical care
a strategy that attempts to utilize drug therapy more efficiently to achieve definite outcomes that improve a patient's quality of life; a set of relationships and decisions through which pharmacists, physicians, nurses, and patients work together to design, implement, and monitor a therapeutic plan that will produce specific therapeutic outcomes

physical therapy
this therapy helps people whose strength, ability to move, or sensation is impaired; treatments are designed to control pain, strengthen muscles and improve coordination

physician's assistant (PA)
a staff member who takes over some of the more routine tasks traditionally performed by an MD, such as taking medical histories and doing physical examinations

physician-hospital organization (PHO)
an organization formed by hospital(s) and physician groups to obtain payer contracts and further mutual interests; physicians see patients in their private practices as stated by the terms in the agreement

Physician Payment Review Commission (PPRC)
a bipartisan congressional advisory group established in 1986 to advise Congress on setting Medicare and Medicaid reimbursement

point-of-service (POS) plan
a health benefit plan that allows the patient to receive health care from any provider of choice, with differing levels of coverage based on whether a provider participates in the plan

practice guidelines/parameters
a series of treatment intervention recommendations that guide clinicians in their patient care decisions

preadmission certification
the practice of reviewing claims for hospital admission before the patient actually enters the hospital

preexisting condition
a medical condition that has been diagnosed prior to a person's obtaining medical coverage

preferred provider organization (PPO)
a managed care plan involving discounted fee-for-service pricing, that maintains the organizational independence of the individual physicians, hospitals and other providers participating in the plan

a fixed amount paid in advance by an insured to an insurer to provide a defined set of benefits for a specific period of time

preventive care
an ongoing process of preventive maintenance that can include: screenings, counseling, immunizations, routine physicals, healthy eating habits and regular exercise

primary care
health care services provided by generalists, including family practitioners, internists and pediatricians

primary care physician
the first line of defense in health care; a primary care physician is usually a family practitioner, pediatrician, obstetrician/gynecologist or internist

process improvement
the concept of using specific methods (such as TQM/CQI, patient-centered care, reengineering) to restructure the work processes of an organization in order to improve processes

professional review organization
an organization that reviews the activities and records of a health care provider, institution, or group

Prospective Payment Assessment Commission (ProPAC)
a federal commission established under the Social Security Act amendments to advise and assist Congress and the Department of Health and Human Services in maintaining and updating the Medicare prospective payment system

prospective payment
payment for services in which the payment is set before the services are actually provided; this payment is issued regardless of the cost incurred in providing the services

a person or organization who provides health care services

provider sponsored organization (PSO)
a form of provider-sponsored network

provider sponsored network (PSN)
formal affiliations of providers, organized and operated as integrated networks, that contract with HMOs, employers, and government entities

psychiatric hospital
a hospital that treats patients with mental or emotional disorders


quality assurance
a traditional function in hospitals and other health care organizations that involves the monitoring and evaluation by individuals or a department of the levels of quality being provided in the organization and delivery of services; historically allied with the risk management function

quality improvement
a continuous process of evaluating processes and procedures in health care delivery and support functions and seeking improvements in efficiency, cost-effective care and patient satisfaction

quality-of-life measures
an assessment of patients' perceptions of how they deal with their disease or with their everyday life when suffering from a particular condition


real-time information system
a system that processes transactions fast enough to keep an operation going at the speed required; also means simultaneous performance of a electronic counterpart to a real-world operation

reasonable and customary
a range of fees for specific health services in specific geographic areas that recognizes prevailing reimbursement patterns; this term is most often used to describe standards of fee-for-service physician reimbursement under Medicare and other programs

the phenomenon of patients returning to a hospital or other provider for a recurrence of a medical problem or condition

recreational therapy
"play" therapy consisting of games and exercises designed to enhance movement, strengthen muscles and improve coordination of patients who have been injured

the realignment and restructuring of an organization's work flow and processes, personnel hierarchy, and strategic development in order to create a more efficient, better-positioned and more dynamic organization

referring physician
a physician (usually a primary care physician) who provides a referral to a specialist

rehabilitation hospital
a hospital that provides health-related, social, and/or vocational services to disabled people to help them attain their maximum functional capacity

this type of insurance is purchased by HMOs, insurance companies or self-insured employers and is designed to protect against large losses incurred in the process of honoring claims

report cards
the formal release of data used for comparing the performance of health care organizations and plans, for the purpose of evaluating the quality of their care delivery and/or outcomes

request for proposal (RFP)
a solicitation from a health care organization, foundation or government agency notifying interested parties that funds are available for selected or specified projects, research, or other undertakings

funds for incurred but not reported health services or other financial liabilities

resource-based relative value scale (RBRVS)
a fee schedule introduced by HCFA to reimburse physicians' Medicare fees based on the amount of time and resources expended in treating patients, with adjustments for overhead costs and geographic differences

return on investment
a measurement of the amount of positive results generated by the investment of effort and allocation of resources toward a specific project or goal

retrospective review
determination of medical necessity and/or appropriate billing practice for services already rendered

risk contract
an agreement between HCFA and an HMO or other provider to furnish at a minimum all Medicare-covered services to Medicare-eligible enrollees for an annually determined, fixed monthly payment rate from the government and a monthly premium paid by the enrollee; the HMO or provider is then liable for services regardless of their extent, expense or degree

risk manager
a person who is responsible for risk management which involves: claim management, establishment of management information systems to encourage personnel to report occurrences of actual or potential loss, education of staffs because personnel and medical staffs generally need to improve their understanding of what situations may constitute loss potential, review of policies and procedures, and evaluation of insurance coverage and contracts

risk pool
a defined account to which revenue and expenses are posted; it attempts to define expected claim liabilities of a given defined account as well as required funding to support the claim liability


same-day surgery
surgery that doesn't require an overnight hospital stay; also called ambulatory surgery or outpatient surgeryclick here for information about same-day surgery at Stony Brook

the method by which managed care organizations limit access to health care for unnecessary reasons

seamless care
the experience by patients of smooth and easy movement from one aspect of comprehensive health care to another, notable for the absence of red tape

secondary care
health care services provided by specialists, such as cardiologists, dermatologists, and others, to whom patients are referred by their primary care providers

self-funded insurance
when an employer funds benefit plans from its own resources

service area
a geographic area serviced by a provider organization or health plan

single-payer system
when a single entity (usually the government) is responsible for the financing and administration of an entire health system

short form 36 (SF36)
an assessment and evaluation tool used to determine the quality of life and functional status following a patient's hospitalization or use of health care services

skilled nursing facility
a facility that accepts patients in need of rehabilitation and medical care that is of a lesser intensity than that received in a hospital

social HMO
an HMO that incorporates social services with medical services for a membership composed solely of senior citizens; Medicare funding is used with the aim of prolonging wellness among the elderly and thus reducing the need for alternate health care

staff-model HMO
a health care model that directly employs physicians to provide health care to its members

standard benefits package
a minimum set of identical health care benefits provided universally and uniformly across an entire population; the term has usually been used to describe a minimum benefits package set mandated by law under a federal or state health care reform plan

stop-loss insurance
insurance coverage designed to protect health plans or self-insured companies from losses resulting from claims greater than a specific dollar amount per covered person per year

strategic planning
the process of evaluating an organization's strategic options and alternatives in an ongoing future-oriented manner

a member of a health plan

subacute care
medical and skilled nursing services provided to patients who are not in an acute phase of illness but who require a level of care higher than that provided in a long-term care setting

swing-bed hospital
a rural hospital with fewer than 100 beds that provides either acute care or skilled post-acute care services in acute care beds, depending on demand

systems integration
the realignment of the health care provider field from an overall pattern of fragmentation and individuation of provider organizations to a pattern in which organizations come together in larger, integrated networks, both affiliated and owned, in order to deliver more efficient and better patient care and optimize their operations


technology assessment
the evaluation process of new or existing diagnostic and therapeutic devices and procedures, including clinical outcomes such as the effect on a patient's quality of life and the effect on society

tertiary care
health care services that require treatment from highly specialized providers and often involve highly sophisticated technology

tertiary care physician
a highly specialized physician, such as a cardiothoracic surgeon, neurosurgeon, radiologist, and others

therapeutic substitution
the substitution of one drug for another

third-party administrator
an outside party that administers group benefits and processes claims for a self-insured company or a health plan

third-party payer
an organization that pays or underwrites coverage for health care expenses of another entity, usually an employer

a calculation used to anticipate future utilization of a group based on past utilization by applying a trend factor, a rate at which direct and indirect medical costs are changing

the classification of sick or injured persons according to severity in order to direct care and ensure the efficient use of medical and nursing staff and facilities

transitional care
care that is provided to patients to help them move from one stage of illness to the next


the accounting practice of coding separately the individual units of a medical or surgical procedure, rather than as an overall group, in order to achieve the maximum reimbursability under a particular payment system, such as Medicare

a review of prospecting and renewing cases for appropriate pricing, risk assessment and administrative feasibility

measures of patient volume and service of time usage tracked over specific periods

utilization management
a process of integrating review and case management of services in a cooperative effort with other parties, including patients, employers, providers, and payers

utilization review
reviews medical appropriateness and analyzes the hospital's efficiency in providing necessary services in the most cost-effective way


videoscopic surgery
newly developed approach to surgery which avoids conventional incisions; also called endoscopic surgery, laparoscopic surgery, or minimally invasive surgery
click here for information about videoscopic minimally-invasive surgery at Stony Brook

voluntary hospital
a private, not-for-profit hospital that is autonomous, self-established, and self-supported


the total patient evaluation, which may include laboratory assessments, radiologic series, medical history, and diagnostic procedures


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