Any Willing Provider Laws

Legislation that requires managed care plans to accept into their networks any provider willing to agree to the network's terms and conditions.

Board Certified

A physician who has passed examinations given by a medical specialty group and who has, as a result, been certified as a specialist in this area of practice.

Capitation; Capitated Plan

A method of paying participating providers a fixed amount per member per month (PMPM) for each member assigned to or enrolled with the provider. For these payments, the provider is obligated to provide or arrange for a defined range of health services to these members.

Case Management

A process that focuses on the coordination of services, with the development of an individualized service or care plan based on the needs of a specific client. The objective is to assure that the patient is given care in a setting that meets medical necessity and is the appropriate level of care to ensure the best outcome. A component of "Utilization Management" (see below).

Coinsurance

Percentage of benefit payments made by members of the health care plan (e.g. 20 percent of the charge for covered services). Coinsurance differentials may be included in a plan design to encourage use of network providers. Coinsurance also may be included to discourage inappropriate utilization, to help finance a health care plan, and to have members share the cost of their health care.

Concurrent Review

Monitoring of the medical treatment and progress toward recovery once a patient is admitted to a hospital to assure timely delivery of services and to confirm the necessity of continued inpatient care. This monitoring is under the direction of medical professionals. A component of "Utilization Management" (see below).

Coordinated Care

Links the treatments or services necessary to obtain an optimum level of medical care required by a patient from appropriate providers. It is also another term for "Managed Care" used by federal government officials.

Copayment

The flat dollar amount paid by members of a health care plan for designated benefits (such as $10 or $15 per office visit at the time of service). Copayments may be included in a plan design to discourage inappropriate utilization, to help finance a health care plan, and to have members share the cost of their health care.

Cost Sharing

Having the users of a health care plan share in the cost of medical care. Deductibles, coinsurance, and copayments are all examples of cost sharing.

Credentialing

The process used by managed care companies to examine and verify the medical qualifications of health care providers before admitting them to the health network.

Deductibles

A pre-defined flat dollar amount paid by members of a health care plan toward the cost of covered services before the plan begins to pay benefits.

Defensive Medicine

Use of unnecessary treatments, procedures or other medical services by doctors to minimize the threat of a malpractice lawsuit.

Discharge Planning

Medical personnel of a health plan working with the attending physician and hospital staff to assess alternatives to hospitalization, evaluate appropriate settings for care, and arrange for the discharge of a patient, including planning for subsequent care at home or in a skilled nursing facility. The goal is to determine when patients are ready to go home, and to provide a more comfortable, cost-efficient setting for continued treatment.

Fee-For-Service Insurance

(See Indemnity Insurance).

Gatekeeper

A primary care physician in a managed care environment who is responsible for managing the patient's overall care and who must authorize all specialist referrals. In most health maintenance organizations (HMOs), the secondary care is not covered by insurance if the primary care physician does not approve it.

HMO

One of the ways medical care is provided. The HMO contracts with physicians in a community to serve as Primary Care Physicians for patients covered by the HMO. Physicians in the HMO provide health care to the members for a fixed (capitated) fee or for a discounted rate. Delivery of health care is managed by each member's Primary Care Physician, who personally provides the care or refers the patient to a specialist.

There are several types of HMOs:

• Group Model HMO

  - The HMO contracts with a multi-specialty medical group to provide care for HMO members at a negotiated fee. HMO members are required to receive all medical care from the physicians in the group, unless referral is made to an outside physician.
  
  

• Independent Practice Association (IPA) Model HMO

  - An arrangement where the HMO contracts with an IPA to provide comprehensive health care for a negotiated fee. The IPA is a group of independent physicians that has organized to contract with managed care health plans. The physicians continue in their existing individual or single-specialty group practices. Physicians are compensated for their services by the IPA on a per capita, fee schedule, or fee-for-service basis.
  
  

• Network Model HMO

  - The least centralized form of HMO. The HMO health plan contracts with individual physicians or physician groups (who are not part of an IPA) to provide care for a negotiated fee. Physicians work out of their own offices and do not necessarily provide care exclusively for HMO members.
  
  

• Staff Model HMO

  - The most centralized form of an HMO. The physicians are contracted or salaried employees hired to provide care for members of the HMO exclusively. Premiums and revenues go to the HMO.
  
  

• Mixed Model HMO

  - Elements of two or more of the models above.

Indemnity Insurance

Traditional health insurance, sometimes call "Fee-For-Service" insurance. Patients may choose any physician or hospital, and the insurance company will reimburse a certain percentage of costs, usually after the patient pays an annual deductible. Copayments and deductibles today are growing as companies find it more difficult to afford this type of insurance coverage for their employees.

Managed Care

A coordinated approach to the design, financing, and delivery of health care, which balances price and utilization controls with access to high quality care.

National Committee for Quality Assurance (NCQA)

A national group responsible for devising and monitoring quality measurements and standards for health care entities.

Network

Groups of physicians, hospitals and other health care providers working with the health plan to offer care at negotiated rates.

Network Provider

Physicians, hospitals or other providers of medical services that have agreed to participate in a network, to offer their services at negotiated rates, and to meet other negotiated contractual provisions. Also called a "participating provider."

Open Enrollment

A period each year during which employees have an opportunity to change their employer-provided health care coverage. They usually can choose among various plans from different health insurance providers.

Outcomes Measurement

A process of systematically tracking a patient's clinical treatment and responses to that treatment, including measures of morbidity and functional status following treatment.

Per Member Per Month (PMPM)

A fixed amount paid to a provider on a periodic basis.

Point of Service (POS)

This health care product operates like a conventional HMO, with a primary care physician who acts as the patients' family doctor and refers them to specialist and ancillary services. With a POS plan, however, employees who want to see a specialist have the option of going directly to specialists and ancillary care providers. In that case, a form of indemnity insurance takes over the patient's health care coverage, usually at a less favorable benefit schedule.

PPO (Preferred Provider Organization)

A form of health insurance that provides high coverage with low copayments for patients who use physicians within the PPO network. Patients can choose to use other physicians, but their copayments are typically higher. Physicians are chosen to become part of the network as long as they meet certain standards set by the insurance provider and agree to hold their prices below a set ceiling.

Precertification

The process for reviewing non-emergency inpatient hospitalizations (as well as selected outpatient procedures) by comparison with established medical norms to determine appropriate setting and intensity of service.

Primary Care

Routine health care and well-visit screening tests (such as pap smears, blood pressure checks) and the first level of care for disease, illness, or injury.

Primary Care Physician

Typically a family physician, internist, or pediatrician who is the first doctor patients see before going to specialists. Primary care physicians usually perform routine physical examinations, well-baby care, and general diagnostic tests for illnesses.

Providers

A generic term used to characterize those who provide health care services, instead of those who receive it, pay for it, or regulate it. Physicians, hospitals, pharmacies, and laboratories are examples of "providers."

Utilization Review (UR)

Evaluation of the use of hospital services, including admission, length of stay, and ancillary services, using objective clinical criteria. It includes a review of outpatient costs as well.