Access to care
The ability and ease of patients to obtain healthcare when
they need it.
Accreditation
A standardized program for evaluating healthcare organizations to
ensure a specified level of quality, as defined by a set of national industry
standards. Organizations that meet accreditation criteria receive an official
authorization of approval of their services.
Actuarial study
Statistical analysis of a population based on the utilization and
demographic trends of the population. Results used to estimate healthcare plan
premiums or costs.
Acuity
Complexity and severity of the patient's health/medical condition.
Admission certification
A form of utilization review in which an assessment is made of the
medical necessity of a patient's admission to a hospital or other inpatient facility.
Admission certification ensures that patients requiring a hospital-based level
of care and length of stay appropriate for the admission diagnosis are usually
assigned and certified and payment for the services are approved.
Advance directives
Legally executed document that explains the patient's healthcare-related
wishes and decisions. It is drawn up while the patient is still competent and
is used if the patient becomes incapacitated or incompetent.
Adverse events
Any untoward occurrences, which under most conditions are not natural
consequences of the patient's disease process or treatment outcomes.
Advocacy
Acting on behalf of those who are not able to speak for or represent
themselves. It is also defending others and acting in their best interest.
Algorithm
The chronological delineation of the steps in, or activities of,
patient care to be applied in the care of patients as they relate to specific
conditions/situations.
Alternate level of
care A level of care that can safely be used in place
of the current level and determined based on the acuity and complexity of the
patient's condition and the type of needed resources.
Ambulatory payment
classification (APC) system An encounter-based classification
system for outpatient reim-bursement, including hospital-based clinics, emergency
departments, observation, and ambulatory surgery. Payment rates are based on categories
of services that are similar in cost and resource utilization.
Ancillary services
Other diagnostic and therapeutic hospital services that may be involved
in the care of patients other than nursing or medicine. Includes respiratory,
laboratory, radiology, nutrition, physical and occupational therapy, and pastoral
services.
Appeal
The formal process or request to reconsider a decision made not
to approve an admission or healthcare services, reimbursement for services rendered,
or a patient's request for postponing the discharge date and extending the length
of stay.
Appropriateness of
setting Used to determine if the care needed is being
delivered in the most appropriate and cost-effective setting possible.
Approved charge
The amount Medicare pays a physician based on the Medicare fee schedule.
Physicians may bill the beneficiaries for an additional amount, subject to the
limiting charge allowed.
Authorization
See certification.
Autonomy
A form of personal liberty of action in which the patient holds
the right and freedom to select and initiate his or her own treatment and course
of action, and taking control for his or her health; that is, fostering the patient's
independence and self-determination.
Benchmark
See benchmarking.
Benchmarking
An act of comparing a work process with that of the best competitor.
Through this process one is able to identify what performance measure levels must
be surpassed. Benchmarking assists an organization in assessing its strengths
and weaknesses and in finding and implementing best practices.
Beneficence
The obligation and duty to promote good, to further and support
a patient's legitimate interests and decisions, and to actively prevent or remove
harm; that is, to share with the patient risks associated with a particular treatment
option.
Beneficiary
An individual eligible for benefits under a particular plan. In
managed care organizations beneficiaries may also be known as members (HMO) or
enrollees (PPO).
Benefit package
The sum of services for which a health plan, government agency,
or employer contracts to provide. In addition to basic physician and hospital
services, some plans also cover prescriptions, dental, and vision care.
Benefits
The amount payable by an insurance company to a claimant or beneficiary
under the claimant's specific coverage.
Capitation
A fixed amount of money per-member-per-month (PMPM) paid to a provider
for covered services. The typical reimbursement method used by HMOs. Whether a
member uses the health service once or more than once, a provider who is capitated
receives the same payment.
Care management
A healthcare delivery process that helps achieve better health outcomes
by anticipating and linking patients with the services they need more quickly.
It also helps avoid unnecessary services by preventing medical problems from escalating.
Caregiver
The person responsible for caring for a patient in the home setting.
Can be a family member, friend, volunteer, or an assigned healthcare professional.
Carrier
An insurance company or administrator of benefits under an insurance
contract.
Carve out
Services excluded from a provider contract that may be covered through
arrangements with other providers. Providers are not financially responsible for
services carved out of their contract.
Case
management A patient care delivery system that focuses
on meeting outcomes within identified timeframes using appropriate resources.
Case management follows an entire episode of illness, from admission to discharge,
crossing all healthcare settings in which the patient receives care.
Case
management plan A timeline of patient care activities
and expected outcomes of care that address the plan of care of each discipline
involved in the care of a particular patient. It is usually developed prospectively
by an interdisciplinary healthcare team in relation to a patient's diagnosis or
surgical procedure.
Case manager
Responsible for coordinating the care delivered to an assigned group
of patients based on diagnosis or need. Other responsibilities include patient/family
education and outcomes monitoring and management.
Case mix complexity
An indication of the severity of illness, prognosis, treatment difficulty,
need for intervention, or resource intensity of a group of patients.
Case mix group (CMG)
Each CMG has a relative weight that determines the base payment
rate for inpatient rehabilitation facilities under the Medicare system.
Case mix index (CMI)
The sum of DRG-relative weights of all patients/cases seen during
a 1-year period in an organization, divided by the number of cases.
Case-based review
The process of evaluating the quality and appropriateness of care
based on the review of individual medical records to determine whether the care
delivered is acceptable. It is performed by healthcare professionals assigned
by the hospital or an outside agency (e.g., Peer Review Organization [PRO]).
Caseload
The total number of patients followed by a case manager at any point
in time.
Catastrophic case
Any medical condition in which total cost of treatment is expected
to exceed an amount designated by the HMO contract with the medical group.
Certification
The approval of patient care services, admission, or length of stay
by a health benefit plan (e.g., HMO, PPO) based on information provided by the
healthcare provider.
Claim
A form that is submitted to an insurance agency requesting payment
in return for healthcare services provided to an enrollee. The form contains information
such as member/enrollee identification number, provider identification, date of
service, type of service, quantity, procedure code, diagnosis code, and place
of service.
Clinical pathway
See case management plan.
Coding
A mechanism of identifying and defining patient care services/activities
as primary and secondary diagnoses and procedures. The process is guided by the
ICD-9-CM coding manual, which lists the various codes and their respective descriptions.
Coinsurance
A type of cost sharing in which the insured person pays or shares
part of the medical bill, usually according to a fixed percentage.
Comorbidity
A preexisting condition (usually chronic) that, because of its presence
with a specific condition, causes an increase in the length of stay by about 1
day in 75% of the patients.
Complication
An unexpected condition that arises during a hospital stay or healthcare
encounter that prolongs the length of stay at least by 1 day in 75% of the patients
and intensifies the use of healthcare resources.
Concurrent review
A method of reviewing patient care and services during a hospital
stay to validate the necessity of care and to explore alternatives to inpatient
care. It is also a form of utilization review that tracks the consumption of resources
and the progress of patients while being treated.
Consensus
Agreement in opinion of experts. Building consensus is a method
used when developing case management plans.
Continued stay
A type of review used to determine that each day of the hospital
stay is necessary and that care is being rendered at the appropriate level.
Continuous quality
improvement (CQI) A key component of total quality
management that uses rigorous, systematic, organization-wide processes to achieve
ongoing improvement in the quality of healthcare services and operations. It focuses
on both outcomes and processes of care.
Continuum of care
A range of medical, nursing, and social services and treatments
offered in a variety of settings that provide services most appropriate to the
level of care required.
Copayment
A supplemental cost-sharing arrangement between the member and the
insurer in which the member pays a specific charge for a specified service. Copayments
may be flat or variable amounts per unit of service and may be for such things
as physician office visits, prescriptions, or hospital services. The payment is
incurred at the time of service.
Credentialing
A review process to approve a provider who applies to participate
in a health plan. Specific criteria are applied to evaluate participation in the
plan. The review may include references, training, experience, demonstrated ability,
licensure verification, and adequate malpractice insurance.
Current procedural
terminology (CPT) A listing of descriptive terms and
identifying codes for reporting medical services and procedures performed by physicians.
Custodial care
Care provided primarily to assist a patient in meeting the activities
of daily living but not requiring skilled nursing care.
Database
An organized, comprehensive collection of patient care data. Sometimes
it is used for research or for quality improvement efforts.
Deductible
A specific amount of money the insured person must pay before the
insurer's payments for covered healthcare services begin under a medical insurance
plan.
Delay in service
Used to identify delays in the delivery of needed services and to
facilitate and expedite such services when necessary.
Demand management
Telephone triage and online health advice services to reduce members'
avoidable visits to health providers. This helps reduce unnecessary costs and
contributes to better outcomes by helping members become more involved in their
own care.
Denial
No authorization or certification is given for healthcare services
because of the inability to provide justification of medical necessity or appropriateness
of treatment or length of stay. This can occur before, during, or after care provision.
Diagnosis-related
group (DRG) A patient classification scheme that provides
a means of relating the type of patient a hospital treats to the costs incurred
by the hospital. DRGs demonstrate groups of patients using similar resource consumption
and length of stay.
Disability case management
A process of managing occupational and nonoccupational diseases
with the aim of returning the disabled employee to a productive work schedule
and employment.
Discharge criteria
See discharge outcomes.
Discharge
outcomes Clinical criteria to be met before or at
the time of the patient's discharge. They are the expected/ projected outcomes
of care that indicate a safe discharge.
Discharge planning
The process of assessing the patient's needs of care after discharge
from a healthcare facility and ensuring that the necessary services are in place
before discharge. This process ensures a patient's timely, appropriate, and safe
discharge and appropriate use of resources.
Discharge status
Disposition of the patient at discharge (e.g., left against medical
advice, expired, discharged home, transferred to a nursing home).
Disease management
The process of intensively managing a particular disease across
different care settings and levels of care using a population-based complex and
sophisticated program that places a heavy emphasis on health risk identification,
prevention, and maintenance.
Disenrollment
The process of terminating healthcare insurance coverage.
Distributive justice
Deals with the moral basis for the dissemination of goods and evils,
burdens and benefits, especially when making decisions regarding the allocation
of healthcare resources.
Durable medical equipment
Equipment needed by patients for self-care. Usually it must withstand
repeated use, is used for a medical purpose, and is appropriate for use in the
home setting.
Effectiveness of care
The extent to which care is provided correctly (i.e., to meet the
patient's needs, improve quality of care, and resolve the patient's problems).
Efficiency of care
The extent to which care is provided to meet the desired effects/outcomes
to improve quality of care and prevent the use of unnecessary resources.
Emotional intelligence
The ability to sense, understand, and effectively apply the power
and acumen of emotions as a source of energy, information, connection, and influence.
It also is the ability to motivate oneself and persist in the face of frustration;
control impulse; regulate one's mood; and keep distress from swamping the ability
to think, empathize, and hope.
Encounter
An outpatient or ambulatory visit by a health plan member to a provider.
It applies mainly to physician's office but may also apply to other types of encounters.
Enrollee
An individual who subscribes for a health benefit plan provided
by a public or private healthcare insurance organization.
Enrollment
The number of members in an HMO. The process by which a health plan
signs up individuals or groups of subscribers.
Exclusive provider
organization (EPO) A managed care plan that provides
benefits only if care is rendered by providers within a specific network.
Fee schedule
A listing of fee allowances for specific procedures or services
that a health plan will reimburse.
Fee-for-service (FFS)
Providers are paid for each service performed, as opposed to capitation.
Fee schedules are an example of fee-for-service.
First-level reviews
Conducted while the patient is in the hospital, care is reviewed
for its appropriateness.
Gag rules
A clause in a provider's contract that prevents physicians or other
providers from revealing a full range of treatment options to patients or, in
some instances, from revealing their own financial self-interest in keeping treatment
costs down. These rules have been banned by many states.
Gatekeeper
A primary care physician (usually a family practitioner, internist,
pediatrician, or nurse practitioner) to whom a plan member is assigned. Responsible
for managing all referrals for specialty care and other covered services used
by the member.
Global fee
A predetermined all-inclusive fee for a specific set of related
services, treated as a single unit for billing or reimbursement purposes.
Group model HMO
The HMO contracts with a group of physicians for a set fee per patient
to provide many different health services in a central location. The group of
physicians determines the compensation of each individual physician, often sharing
profits.
Guidelines
See practice guidelines.
Health benefit plan
Any written health insurance plan that pays for specific healthcare
services on behalf of covered enrollees.
Health maintenance
organization (HMO) An organization that provides or
arranges for coverage of designated health services needed by plan members for
a fixed prepaid premium. There are four basic models of HMOs: group model, individual
practice association (IPA), network model, and staff model. Under the Federal
HMO Act an organization must possess the following to call itself an HMO: (1)
an organized system for providing healthcare in a geographical area, (2) an agreed-on
set of basic and supplemental health maintenance and treatment services, and (3)
a voluntarily enrolled group of people.
Healthcare proxy
A legal document that directs the healthcare provider/agency in
whom to contact for approval/consent of treatment decisions or options whenever
the patient is no longer deemed competent to decide for self.
Home health resource
group (HHRG) Groupings for prospective reimbursement
under Medicare for home health agencies. Placement into an HHRG is based on the
OASIS score. Reimbursement rates correspond to the level of home health provided.
Hospital-issued notice
of noncoverage (HINN) A letter provided to patients
informing them of insurance noncoverage in case they refuse hospital discharge
or insist on continued hospitalization despite the review by the peer review organization
(PRO) that indicates their readiness for discharge.
ICD-9-CM
International Classification of Diseases, Ninth Revision, Clinical
Modification, formulated to standardize diagnoses. It is used for coding medical
records in preparation for reimbursement, particularly in the inpatient care setting.
Incentive
A sum of money paid at the end of the year to healthcare providers
by an insurance/managed care organization as a reward for the provision of quality
and cost-effective care.
Indemnity
Benefits paid in a predetermined amount in the event of a covered
loss. Fee-for-service health insurance plans are often referred to as indemnity
plans.
Indemnity benefits
Benefits in the form of payments rather than services. In most cases
after the provider has billed the patient, the insured person is reimbursed by
the company.
Independent case management
Also known as private case management
or external case management, it entails the provision
of case management services by case managers who are either self-employed or are
salaried employees in a privately owned case management firm.
Indicator
A measure or metric that can be used to monitor and assess quality
and outcomes of important aspects of care or services.
Individual practice association (IPA) model
HMO An HMO model that contracts
with a private practice physician or healthcare association to provide healthcare
services in return for a negotiated fee. The IPA then contracts with physicians
who continue in their existing individual or group practice.
Informed consent
Consent given by a patient, next of kin, legal guardian, or designated
person for a kind of intervention, treatment, or service after the provision of
sufficient information by the provider.
Inpatient rehabilitation
facilities patient assessment instrument (IRF-PAI)
The Inpatient Rehabilitation Facilities Patient Assessment Instrument, used to
classify patients into distinct groups based on clinical characteristics and expected
resource needs. The PAI determines the CMG classification.
Integrated delivery
system (IDS) A single organization or group of affiliated
organizations that provides a wide spectrum of ambulatory and tertiary care and
services. Care may also be provided across various settings of the healthcare
continuum.
Intensity of service
An acuity of illness criteria based on the evaluation/treatment
plan, interventions, and anticipated outcomes.
Intermediate outcome
A desired outcome that is met during a patient's hospital stay.
It is a milestone in the care of a patient or a trigger point for advancement
in the plan of care.
Internet
A public, cooperative creation that operates using national and
international telecommunication technologies and networks, including high-speed
data lines, phone lines, satellite communications, and radio networks.
Justice
Maintaining what is right and fair and making decisions that are
good for the patient.
Length of stay
The number of days that a health plan member stays in an inpatient
facility.
Levels of service
Based on the patient's condition and the needed level of service,
used to identify and verify that the patient is receiving care at the appropriate
level.
Liability
Legal responsibility for failure to act appropriately or for actions
that do not meet the standards of care, inflicting harm on another person.
Licensure
A mandatory and official form of validation provided by a governmental
agency in any state affirming that a practitioner has acquired the basic knowledge
and skill and minimum degree of competence required for safe practice in his or
her profession.
Litigation
A contest in a court for the purpose of enforcing a right, particularly
when inflicting harm on another person.
Living will
A legal document that directs the healthcare team/provider in holding
or withdrawing life support measures. It is usually prepared by the patient while
he or she is competent, indicating the patient's wishes.
Malpractice
Improper care or treatment by a healthcare professional. A wrongful
conduct.
Managed care
A system of healthcare delivery that aims to provide a generalized
structure and focus when managing the use, access, cost, quality, and effectiveness
of healthcare services. Links the patient to provider services.
Managed competition
A state of healthcare delivery in which a large number of consumers
choose among health plans that offer similar benefits. In theory, competition
would be based on cost and quality and ideally would limit high prices and improve
quality of care.
Management service
organization A management entity owned by a hospital,
physician organization, or third party. It contracts with payers and hospitals/physicians
to provide certain healthcare management services such as negotiating fee schedules
and handling administrative functions, including utilization management, billing,
and collections.
Medicaid
A federal program administered and operated individually by state
governments that provides medical benefits to eligible low-income persons needing
healthcare. The costs of the program are shared by the federal and state governments.
Medical durable power
of attorney A legal document that names a surrogate
decision maker in the event that the patient becomes unable to make his or her
own healthcare decisions.
Medical loss ratio
(MLR) The ratio of healthcare costs to revenue received.
Calculated as total medical expense/total revenue.
Medical necessity
on admission A type of review used to determine that
the hospital admission is appropriate, clinically necessary, justified, and reimbursable.
Medically necessary
A term used to describe the supplies and services provided to diagnose
and treat a medical condition in accordance with nationally recognized standards.
Medicare
A nationwide, federally administered health insurance program that
covers the cost of hospitalization, medical care, and some related services for
eligible persons. Medicare has two parts. Part A covers inpatient hospital costs
(currently reimbursed prospectively using the DRG system). Medicare pays for pharmaceuticals
provided in hospitals but not for those provided in outpatient settings. Also
called Supplementary Medical Insurance Program. Part
B covers outpatient costs for Medicare patients (currently reimbursed retrospectively).
Minimum data set (MDS)
The assessment tool used in skilled nursing facility settings to
place patients into RUGs, which determines the facilities reimbursement rate.
Multidisciplinary
action plan (MAP) See case
management plan (CMP).
Negligence
Failure to act as a reasonable person. Behavior is contrary to that
of any ordinary person facing similar circumstances.
Network model HMO
This is the fastest growing form of managed care. The plan contracts
with a variety of groups of physicians and other providers in a network of care
with organized referral patterns. Networks allow providers to practice outside
the HMO.
Nonmaleficence
Refraining from doing harm to others; that is, emphasizing quality
care outcomes.
Nursing case management
See also case management.
A process model using the components of case management in the delivery aspects
of nursing care. In nursing case management delivery systems, the role of the
case manager is assumed by a registered professional nurse.
Outcome
The result and consequence of a healthcare process. A good outcome
is a result that achieves the expected goal. An outcome may be the result of care
received or not received.
Outcome and assessment
information set (OASIS) A prospective nursing assessment
instrument completed by home health agencies at the time the patient is entered
for home health services. Scoring determines the HHRG.
Outcome indicators
Measures of quality and cost of care. Metrics used to examine and
evaluate the results of the care delivered.
Outcomes management
The use of information and knowledge gained from outcomes monitoring
to achieve optimal patient outcomes through improved clinical decision making
and service delivery.
Outcomes measurement
The systematic, quantitative observation, at a point in time, of
outcome indicators.
Outcomes monitoring
The repeated measurement over time of outcome indicators in a manner
that permits causal inferences about what patient characteristics, care processes,
and resources produced the observed patient outcomes.
Outlier
Something that is significantly well above or below an expected
range or level.
Outlier threshold
The upper range (threshold) in length of stay before a patient's
stay becomes an outlier. It is the maximum number of days a patient may stay in
the hospital for the same fixed reimbursement rate. The outlier threshold is determined
by the Centers for Medicare and Medicaid Services (CMS), formerly known as the
Health Care Financing Administration (HCFA).
Overutilization
Using established criteria as a guide, determination is made as
to whether the patient is receiving services that are redundant, unnecessary,
or in excess.
Panel of providers
Usually refers to the healthcare providers, including physicians,
who are responsible for providing care and services to the enrollee in a managed
care organization. These providers deliver care to the enrollee based on a contractual
agreement with the managed care organization.
Payer
The party responsible for reimbursement of healthcare providers
and agencies for services rendered such as the Centers for Medicare and Medicaid
Services and managed care organizations.
Peer review organization (PRO)
A federal program established by the Tax Equity and Fiscal Responsibility
Act of 1982 that monitors the medical necessity and quality of services provided
to Medicare and Medicaid beneficiaries under the prospective payment system.
Per diem
A daily reimbursement rate for all inpatient hospital services provided
in one day to one patient, regardless of the actual costs to the healthcare provider.
Performance improvement
The continuous study and adaptation of the functions and processes
of a healthcare organization to increase the probability of achieving desired
outcomes and to better meet the needs of patients.
Physician-hospital
organization Organization of physicians and hospitals
that is responsible for negotiating contractual agreements for healthcare provision
with third-party payers such as managed care organizations.
Plaintiff
A person who seeks a lawsuit in court because of a belief that his
or her rights have been violated or a legal injury has occurred.
Point-of-service (POS)
plan A type of health plan allowing the covered person
to choose to receive a service from a participating or a nonparticipating provider,
with different benefit levels associated with the use of participating providers.
Members usually pay substantially higher costs in terms of increased premiums,
deductibles, and coinsurance.
Practice
guidelines Systematically developed statements on
medical practices that assist a practitioner in making decisions about appropriate
diagnostic and therapeutic healthcare services for specific medical conditions.
Practice guidelines are usually developed by authoritative professional societies
and organizations.
Preadmission certification
An element of utilization review that examines the need for proposed
services before admission to an institution to determine the appropriateness of
the setting, procedures, treatments, and length of stay.
Preauthorization
See precertification.
Precertification
(prior approval) The process
of obtaining and documenting advanced approval from the health plan by the provider
before delivering the medical services needed. This is required when services
are of a nonemergent nature.
Preexisting condition
A condition or illness for which a member has received treatment
during a specified period before becoming a member/enrollee of a health insurance
policy.
Preferred provider organization (PPO)
A program in which contracts are established with providers of medical
care. Providers under a PPO contract are referred to as preferred
providers. Usually the benefit contract provides significantly better benefits
for services received from preferred providers, thus encouraging members to use
these providers. Covered persons are generally allowed benefits for nonparticipating
provider services, usually on an indemnity basis with significant copayments.
Premature discharge
The release of a patient from care before he or she is deemed medically
stable and ready for terminating treatment/care (e.g., discharging a patient from
a hospital when he or she is still needing further care and/or observation).
Premium
The rate that a plan subscriber pays for coverage of specific health
services.
Prepaid health plan
Health benefit plan in which a provider network delivers a specific
complement of health services to an enrolled population for a predetermined payment
amount (see capitation).
Primary care
The point when the patient first seeks assistance from the medical
care system. It also is the care of the simpler and more common illnesses.
Primary care provider
Assumes ongoing responsibility for the patient in both health maintenance
and treatment. Usually responsible for orchestrating the medical care process
either by caring for the patient or by referring a patient on for specialized
diagnosis and treatment. Primary care providers include general or family practitioners,
internists, pediatricians, and sometimes OB/GYN doctors.
Principal diagnosis
The condition that chiefly required the patient's admission to the
hospital for care.
Principal procedure
A procedure performed for definitive rather than diagnostic treatment,
or one that is necessary for treating a certain condition. It is usually related
to the principal diagnosis.
Prior authorization
See precertification.
Prospective payment system
A healthcare payment system used by the federal government since
1983 for reimbursing healthcare providers/agencies for medical care provided to
Medicare and Medicaid participants. The payment is fixed and based on the operating
costs of the patient's diagnosis.
Prospective review
A method of reviewing possible hospitalization before admission
to determine necessity and estimated length of stay.
Protocol
A systematically written document about a specific patient's problem.
It is mainly used as an integral component of a clinical trial or research. It
also delineates the steps to be followed for a particular procedure or intervention
to meet desired outcomes.
Quality assurance
The use of activities and programs to ensure the quality of patient
care. These activities and programs are designed to monitor, prevent, and correct
quality deficiencies and noncompliance with the standards of care and practice.
Quality improvement
An array of techniques and methods used for the collection and analysis
of data gathered in the course of current healthcare practices in a defined care
setting to identify and resolve problems in the system and improve outcomes of
care.
Quality indicator
A predetermined measure for assessing quality; a metric.
Quality management
A formal process by which an organization measures the extent to
which the providers conform to defined standards and, based on the data, improve
the process, structure, and outcomes of care.
Quality monitoring
A process used to ensure that care is being delivered at or above
acceptable quality standards and as identified by the organization or national
guidelines.
Rehabilitation impairment
categories (RIC) Represent the primary cause of the
rehabilitation stay. They are clinically homogeneous groupings that are then subdivided
into CMGs.
Reimbursement
Payment regarding healthcare and services provided by a physician,
medical professional, or agency.
Relative weight
An assigned weight that is intended to reflect the relative resource
consumption associated with each DRG. The higher the relative weight, the greater
the payment/reimbursement to the hospital.
Report card
An emerging tool that is used by healthcare providers, purchasers,
policymakers, governmental agencies, and consumers to compare and understand the
actual performance of health plans and other service delivery programs. It usually
includes data in major areas of accountability such as quality, utilization of
resources, consumer satisfaction, and cost.
Resource utilization
group (RUG) Classifies skilled nursing facility patients
into 7 major hierarchies and 44 groups. Based on the MDS, the patient is classified
into the most appropriate group, and with the highest reimbursement.
Retrospective review
A form of medical records review that is conducted after the patient's
discharge to track appropriateness of care and consumption of resources.
Risk
Probability that revenues of the insurer will not be sufficient
to cover expenditures incurred in the delivery of contracted services.
Risk management
A comprehensive program of activities to identify, evaluate, and
take corrective action against risks that may lead to patient or staff injury
with resulting financial loss or legal liability. This program aims at minimizing
losses.
Risk sharing
The process whereby an HMO and contracted provider each accept partial
responsibility for the financial risk and rewards involved in cost-effectively
caring for the members enrolled in the plan and assigned to a specific provider.
Root cause analysis
A process used by healthcare providers and administrators to identify
the basic or causal factors that contribute to variation in performance and outcomes
or underlie the occurrence of a sentinel event.
Sentinel event
An unexpected occurrence, not related to the natural course of illness,
that results in death, serious physical or psychological injury, or permanent
loss of function.
Severity of illness
An acuity of illness criteria that identifies the presence of significant/debilitating
symptoms, deviations from the patient's normal values, or unstable/abnormal vital
signs or laboratory findings.
Skilled care
Patient care services that require delivery by a licensed professional
such as a registered nurse or physical therapist, occupational therapist, speech
pathologist, or social worker.
Staff model HMO
The most rigid HMO model. Physicians are on staff with some sort
of salaried arrangement and provide care exclusively for the health plan enrollees.
Subacute care facility
A healthcare facility that is a step down from an acute care hospital
and a step up from a conventional skilled nursing facility intensity of services.
Supplementary medical
insurance (SMI) A secondary medical insurance plan
used by a subscriber to supplement healthcare benefits and coverage provided by
the primary insurance plan. The primary and secondary/supplementary plans are
unrelated and provided by two different agencies.
Target utilization
rates Specific goals regarding the use of medical
services, usually included in risk-sharing arrangements between managed care organizations
and healthcare providers.
Telephone triage
Triaging patients to appropriate levels of care based on a telephonic
assessment of a patient. Case managers use the findings of their telephone-based
assessment to categorize the patient to be of an emergent, urgent, or nonurgent
condition.
Telephonic case management
The delivery of healthcare services to patients and/or families
or caregivers over the telephone or through correspondence, fax, e-mail, or other
forms of electronic transfer. An example is telephone triage.
Third-party payer
An insurance company or other organization responsible for the cost
of care so that individual patients do not directly pay for services.
Total quality management
See quality management.
Transitional planning
The process case managers apply to ensure that appropriate resources
and services are provided to patients and that these services are provided in
the appropriate setting or level of care as delineated in the standards and guidelines
of regulatory and accreditation agencies.
Underutilization
Using established criteria as a guide, determination is made as
to whether the patient is receiving all of the appropriate services.
Utilization
The frequency with which a benefit is used during a 1-year period,
usually expressed in occurrences per 1000 covered lives.
Utilization management
Review of services to ensure that they are medically necessary,
provided in the most appropriate setting, and at or above quality standards.
Utilization review
A mechanism used by some insurers and employers to evaluate healthcare
on the basis of appropriateness, necessity, and quality.
Utilization review
accreditation commission (URAC) A not-for-profit organization
that provides reviews and accreditation for utilization review services/programs
provided by freestanding agencies. It is also known as the American Accreditation
Health Care Commission.
Variance
Any expected outcome that has not been achieved within designated
timeframes. Categories include system, patient, and practitioner.
Veracity
The act of telling the truth.
Withhold
A portion of payments to a provider held by the managed care organization
until year end that will not be returned to the provider unless specific target
utilization rates are achieved. Typically used by HMOs to control utilization
of referral services by gatekeeper physicians.
Workers' compensation
A program that provides medical benefits and replacement of lost
wages for persons suffering from injury or illness that is caused by or occurred
in the workplace.
REFERENCES
There are many excellent sources for case management-related
terminology. The glossary of terms was developed based on the authors' own views
and understanding of case management practice and adaptations from other sources,
including the following:
American Medical Association Specialty
Organization, Inc: AMSO
dot com, managed care terms, 2001. Available online at http://www.amso.com/terms.html
(accessed 2/11/02).
American Nurses Association:
Healthcare in chaos: will we ever see real managed care?
1997. Available online at http://www.nursingworld.org/mods/mod3/cemcfull.htm
(accessed 2/12/02).
Huntington J: Glossary
for managed care, Online J Iss Nurs 1997. Available
online at
http://nursingworld.org/ojin/tpc2/tpc2_gls.htm (accessed 2/12/02).
Integrated Healthcare Association: Managed
healthcare: a brief glossary, 1997. Available online at http://www.iha.org/gloss.htm
(accessed 3/20/02).
Kongstvedt P: Essentials of managed
care, ed 4, Gaithersburg, Md, 2001, Aspen.
Powell S: Advanced case management:
outcomes and beyond, Philadelphia, 2000, Lippincott Williams & Wilkins.
Powell S: Case management: a practical
guide to success in managed care, ed 2, Philadelphia, 2000, Lippincott
Williams & Wilkins.
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