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.
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access
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
accreditation
an official authorization or approval to an organization determined by industry-derived standards
acquisition
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
aftercare
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 surgerysurgery that doesn't require an overnight hospital stay;
also called outpatient surgery
or same-day surgery—click 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
bedsize
total number of beds in a hospital
behavioral health care
treatment of mental and psychoactive substance abuse disorders
benefit
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
capacity
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
CareMap®
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
certification
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
coinsurance/copayment
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
consolidation
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
copayment
a nominal fee charged to HMO members to offset costs of paperwork and administration for each office visit or pharmacy prescription
cost-effectiveness
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
deductible
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
disease
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
emergency
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
geriatrician
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
hospice
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
inpatient
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
internist
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
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
Medicaid
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
Medicare
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
merger
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
morbidity
the rate of disease, illness or accidents among a patient population
mortality
the death rate among a patient population
multidisciplinary
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
outlier
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 surgerysurgery that doesn't require an overnight hospital stay; also called
ambulatory surgery
or same-day surgery—click here for information about outpatient surgery at Stony Brook
overcapacity
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
payer/purchaser
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
pharmaceutical
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
premium
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
provider
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
recidivism
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
reengineering
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
reinsurance
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
reserves
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 surgerysurgery that doesn't require an overnight hospital stay;
also called ambulatory surgery
or outpatient surgery—click here for information about same-day surgery at Stony Brook
screening
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
subscriber
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
trending
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
triage
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
unbundling
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
underwriting
a review of prospecting and renewing cases for appropriate pricing, risk assessment and administrative feasibility
utilization
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
work-up
the total patient evaluation, which may include laboratory assessments, radiologic series, medical history, and diagnostic procedures