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Gatekeeper
an HMO physician who coordinates a patient's care and
who effectively controls costs by minimizing unnecessary
services. |
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Health maintenance organization
(HMO)
an organization that provides comprehensive health care
services for a prepaid fee to a voluntarily enrolled membership.
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ICD-9-CM (International Classification
of Diseases-9th Revision-Clinical Modification)
the classification of the diseases by diagnoses codified
into four-digit numbers. Frequently used for billing purposes
by hospitals. |
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Incurred by not reported (IBNR)
expenses
an accounting term for all services that have been performed
but have not yet been billed, or the invoice has not yet
been received, by the provider. |
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Member
any individual or dependent who is enrolled in and covered
by a managed health care plan. |
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Open enrollment
a period during which the employees of an insured employer
are allowed to enroll in the plan. |
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Medicare
Part A
the Medicare portion that covers expenses incurred in
hospitals, extended care facilities, hospices, etc. |
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Medicare Part
B
the Medicare portion that covers physicians' services
and other types of care not covered under Part A. |
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Preferred provider organization
(PPO)
a health care provider arrangement in which a third-party
payer contracts with a group of medical care providers
who agree to furnish services at negotiated fees in return
for prompt payment and a guaranteed patient volume. PPOs
control costs by keeping fees down and curbing excessive
services through utilization control. |
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Resource-based relative value
system (RBRVS)
a coding system introduced by Medicare for outpatient
physician fees. The system assigns pricing units to various
procedures based on the medical training, resources and
time involved, and replaces DRGs, with the phase-in to
be completed by 1996. |
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Respite care
temporary care provided in a patient's home to give the
primary caregiver, usually a family member, time off from
a demanding job. |
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Skilled
nursing facility (SNF)
a facility, either part of a hospital or a separate nursing
home, that provides inpatient services for persons requiring
skilled nursing care. |
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Stop-loss insurance
insurance that reimburses a plan, plan sponsor, or medical
group/IPA for losses that exceed a certain limit. The
limit is usually expressed as a percentage of expected
claims or specified dollar amount. |
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Tertiary care
the aspect of inpatient care dealing with illnesses or
conditions that require the costly services of a highly
specialized medical center. |
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Third-party administrator
a person or organization that provides certain administrative
services to group benefits plans, including premium accounting,
claims review and payment, claims utilization review,
maintenance of employee eligibility records and negotiation
with insurers that provide stop-loss protection for large
claims. |
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Triage
a term that originated on the battlefield, triage is the
evaluation of the urgency and seriousness of a patient's
condition and the establishment of a priority list for
multiple patients. |
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Usual, customary and reasonable
(UCR)
the maximum reimbursement, which is based upon historical
fee patterns and is sometimes referred to as U& C. |
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Utilization
review
a cost-control method used by some insurers and employers
in recent years to evaluate health care on the basis of
appropriateness, necessity and quality. For hospital review,
it can include pre-admission certification, concurrent
review with discharge, planning and retrospective review.
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