Acronyms

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Access – The extent to which an individual who needs care and services is able to receive them.  Access is more than having insurance coverage or the ability to pay for services.  It is also determined by the availability of services, acceptability of services, cultural appropriations, locations, hours of operation, transportation needs, and cost.

Accreditation – An official decision made by a recognized organization that a health care plan, network, or other delivery system complies with applicable standards.

Administrative costs – Costs not linked directly to the provision of medical care.  Includes marketing, claims processing, billing, and medical record keeping, among others.

Adverse Selection – Occurs when plan enrollees include a higher percentage of high-risk individuals than are in the average population, resulting in the potential for greater health care utilization and therefore, increased costs.

AHP - Accountable Health Plan   - AHPs can be IDSs, MCOs, Health Networks, partnerships or joint ventures between practitioners, providers or payers that would assume responsibility for delivering medical care and managing the funds required to pay for the services rendered. Physicians and other providers would either work for, contract with or own these health plans. When an IDS or hospital group or IPA operates one or more health insurance benefit products, or a managed care organization acquires a large scale medical delivery component, it qualifies as an Accountable Health System or Accountable Health Plan.

ADL’s - Activities of daily living - An individual's daily habits such as bathing, dressing and eating. ADLs are often used as an assessment tool to determine an individual's ability to function at home, or in a less restricted environment of care.

ABC - Activity-based Costing - Activity-based costing defines healthcare costs in terms of a healthcare organization's processes or activities. The costs are then associated with significant activities or events. It relies on the following 3 step process: 1) Activity mapping, which involves mapping activities in an illustrated sequence; 2) Activity analysis, which involves defining and assigning a time value to activities; and , 3) bill of activities, which involves generating a cost for each main activity.

 

AAPCC - Adjusted Average Per Capita Cost - The basis for HMO or CMP reimbursement under Medicare-risk contracts. The average monthly amount received per enrollee is currently calculated as 95 percent of the average costs to deliver medical care in the fee-for-service sector. HCFA's best estimate of the amount of money care costs for Medicare recipients under fee-for-service Medicare in a given area. The AAPCC is made up of 122 different rate cells; 120 of them are factored for age, sex, Medicaid eligibility, institutional status, and whether a person has both part A and part B of Medicare. Actuarial projections of per capita Medicare spending for enrollees in fee-for-service Medicare. Separate AAPCCs are calculated - usually at the county level - for Part A services and Part B services for the aged, disabled, and people with ESRD. Medicare pays risk plans by applying adjustment factors to 95 percent of the Part A and Part B AAPCCs. The adjustment factors reflect differences in Medicare per capita fee-for-service spending related to age, sex, institutional status, Medicaid status, and employment status. A county-level estimate of the average cost incurred by Medicare for each beneficiary in the fee-for-service system. Adjustments are made so that the AAPCC represents the level of spending that would occur if each county contained the same mix of beneficiaries. Medicare pays health plans 95 percent of the AAPCC, adjusted for the characteristics of the enrollees in each plan.

ACR - Adjusted Community Rate - Health plans and insurance companies estimate their ACRs annually and adjust subsequent year supplemental benefits or premiums to return any excess Medicare revenue above the ACR to enrollees. This are the estimated payment rates that health plans with Medicare risk contracts would have received for their Medicare enrollees if paid their private market premiums, adjusted for differences in benefit packages and service use.

Appropriateness – The extent to which a particular procedure, treatment, test, or service is clearly indicated, not excessive, adequate in quantity, and provided in the setting best suited to a patient’s or member’s needs.

APR   - Adjusted Payment Rate - The Medicare capitated payment to risk-contract HMOs. For a given health plan, the APR is determined by adjusting county-level AAPCCs to reflect the relative risks of the plan's enrollees.

ASO - Administrative Services Organization - A contract between an insurance company and a self-funded plan where the insurance company performs administrative services only and the self-funded entity assumes all risk.

ASO - Administrative Services Only - A relationship between an insurance company or other management entity and a self-funded plan or group of providers in which the insurance company or management entity performs administrative services only, such as billing, practice management, marketing, etc., and does not assume any risk. The client bears the financial risk for the claims. Clients contracting for ASO can include health plans, hospitals, delivery networks, IPAs, etc. A provider system wishing to capitate may contract with a TPA for ASO for certain services for which the provider group does not want to bring in house. This is a form of outsourcing. See also TPA.

ASR - Age/Sex rates (ASR) - Also called table rates, they are given group products' set of rates where each grouping, by age and sex, has its own rates. Rates are used to calculate premiums for group billing and demographic changes are adjusted automatically in the group.

ASR   - Agency for Health Care Policy and Research - The agency of the Public Health Service responsible for enhancing the quality, appropriateness and effectiveness of health care services.

AFDC - Aid to Families with Dependent Children - The federal AFDC program provides cash welfare to: (1) needy children who have been deprived of parental support and (2) certain others in the household of such child. States administer the AFDC program with funding from both the federal government and state. The Personal Responsibility & Work Responsibility Act of 1996, enacted in August 1996, replaced AFDC with a new program called Temporary Assistance for Needy Families (TANF)

ALOS - Average Length of Stay - Refers to the average length of stay per inpatient hospital visit. Figure is typically calculated for both commercial and Medicare patient populations.

Any willing provider – A requirement that a health plan contract for the delivery of health care services with any provider in the area who would like to provide such services to the plan’s enrollees.

AWP - Average Wholesale Price - (Commonly used in pharmacy contracting, the AWP is generally determined through reference to a common source of information. Average cost of a non-discounted item to a pharmacy provider by wholesale providers.

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B

Behavioral Healthcare – Continuum of services for individuals at risk or, or suffering from, mental, additive, or other behavioral health disorders.

Beneficiary – A person certified as eligible for health care services.  A beneficiary may be a dependent or a subscriber.

Benefit Package – Services covered by a health insurance plan and the financial terms of such coverage.  These include cost, limitation on the amounts of services, and annual or lifetime spending limits.

BH – Behavioral Health - Commonly known as mental health and/or drug and alcohol services .

BH-MCO – Behavioral Health Managed Care Organization – An entity directly operated by the county government or licensed by the Commonwealth as a Health Maintenance Organization or risk-assuming Preferred Provider Organization which manages the purchase and provision of behavioral health services.

BHRS – Behavioral Health Rehabilitation Services

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C

CAO - County Assistance Office

Capitation – A fixed amount of money paid per person for covered services for a specific time; usually expressed in units of per member per month (pmpm).

Carve- in – A generic term that refers to any of a continuum of joint efforts between clinicians and service providers; also used specifically to refer to health care delivery and financing arrangements in which all covered benefits (e.g., behavioral and general health care) are administered and funded by an integrated system.

Carve- out – A health care delivery and financing arrangement in which certain specific health care services that are covered benefits (e.g., behavioral healthcare) are administered and funded separately from general healthcare services.  The carve-out is typically done through separate contracting or sub-contracting for services to the special population

Case Management – A system requiring that a single individual in the provider organization is responsible for arranging and approving all devices needed under the contract embraced by employers, mental health authorities, and insurance companies to ensure that individuals receive appropriate, reasonable health care services.

CASSP – Child and Adolescent Service System Program. CASSP helps children and adolescents with emotional disturbances to gain access to needed services. These services are planned collaboratively with the child's or adolescent's family, the mental health system, the school and other agencies.

CLIC - Community Leadership Involvement Campaign

COBRA (Consolidated Omnibus Budget Reconciliation Act) – An act that allows workers and their families to continue their employer-sponsored health insurance for a certain amount of time after terminating employment.  COBRA imposes different restrictions on individuals who leave their jobs voluntarily versus involuntarily. ( Department of Labor, 2002).

Coinsurance – The percentage of costs of medical care that a patient pays himself.  Coinsurance rates generally hover in the 10 percent to 20 percent range.  Coinsurance and deductibles are most commonly found in indemnity, fee-for-service insurance and the PPO market.  Their absence in the HMO arena is one of the strong marketing appeals of HMOs.

Concurrent Review – A method of reviewing patient care, during hospital confinement, to validate the necessity of current care and to explore alternatives to inpatient care.

Conversion Factor – A dollar amount for one base unit in the relative value scale (RVS).  The price to be paid to the provider for a given service equals the relative value of the service multiplied by the dollar amount of the conversion factor.  For example,  a blood sugar determination might have a relative value of 5.0, and the conversion factor might be $5.00.  The “price” of the blood sugar determination would therefore be $25.00.

Coordination of Benefits – A process wherein if an individual has two group health plans, the amount payable is divided between the plans so that the combined coverage amounts to, but does not exceed, 100 percent of the charges.

Co-payment – A supplemental cost-sharing arrangement in which the HMO enrollee pays, to the provider, a specified amount for a specific service.

Cost-sharing – A health insurance policy provision that requires the insured party to pay a portion of the costs of covered services.  Deductibles, coinsurance, and co-payment are types of cost-sharing.

Credentialing – The process of determining eligibility for a hospital, PHO, of other medical staff membership, and privileges to be granted to physicians.  Credentials and performance are periodically reviewed, which could result in a doctor’s privileges being denied, modified, or withdrawn.

Customary and Reasonable – Refers to a fee, which falls within a common range of community fees.

 

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D

Days per Thousand – A measurement of the number of days of hospital care used in a year per 1,000 HMO members.

Deductible – The amount an individual must pay for health care expenses before insurance (or a self-insured company) begins to pay to pay its contract share.  Often insurance plans are based on yearly deductible amounts.

Durable Medical Equipment – Equipment which meets the following criteria: can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally, is not useful to a person in the absence of illness/injury, and is appropriate for home use.

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E

EAP (Employee Assistance Plan) – Resources provided by employers either as part of, or separate from, employer-sponsored health plans.  EAPs typically provide preventative care measure, various health care screenings, and/or wellness activities (Center for Mental Health Services, 2000).

Economic Credentialing – This means taking a physician’s economic behavior into account (i.e. tests ordered, hospital bed days, outcomes) in deciding upon medical staff appointment or re-appointment.

Effective Date – The date on which the Health Plan Agreement goes into effect.

Encounter – A member visit to the medical group with the intent of seeing a health care provider.  There may be a variety of services performed at an encounter: a brief office visit, EKG, lab test, and an immunization.

Enrollee – A person eligible for services from a managed care plan.

Enrollment – The total number of covered persons in a health plan.  Also refers to the process by which a health plan enrolls group and individuals for membership or the number of enrollees who sign up in any one group.

EPO - Exclusive Provider Organization - A health plan in which patients must go to a participating provider or receive no benefit. This is a cross between an HMO and a PPO. Like a PPO doctors typically are paid on a fee-for-service basis and aren't at risk. However, patients have less freedom to go out of network than with a PPO.

This means taking a physician’s economic behavior into account (i.e. tests ordered, hospital bed days, outcomes) in deciding upon medical staff appointment or re-appointment.

EQRO - External Quality Review Organization

ERISA (Employment Retirement Income Security Act) – Health plans that are self- insured are exempt from state regulation under this 1974 act.

 

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F

FDS - Food and Drug Administration – This is the federal agency that evaluates and approves prescription drugs.

Fee Schedule – A listing of charges or established benefits for specified medical or dental procedures.

FFS - Fee-For-Service - A system of payment for health care whereby a fee is rendered for each service delivered. This traditional method contrasts with that used in the prepaid sector where services are covered by a fixed payment made in advance that is independent of the number of services rendered.

FFR – HealthChoices Behavioral Health Financial Reporting Requirements

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G

Gatekeeper – Primary care physician or local agency responsible for coordinating and managing the health care needs of members.  Generally, in order for specialty services such as mental health and hospital care to be covered, the gatekeeper must first approve the referral.

Group Model – In a group model HMO, the HMO contracts with a group of physicians, which is paid a set amount per patient to provide a specified range of services.  The group of physicians determines the compensation of each individual physician, often sharing profits.  The practice may be located in a hospital or clinic setting.

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H

HC – HealthChoices – The name of PA’s 1915 (B) waiver program to provide mandatory managed healthcare to medical assistance recipients.

HCFA - Health Care Financing Administration - The agency within the Department of Health and Human Services which administers federal health financing and related regulatory programs, principally the Medicare, Medicaid, and Peer Review Organization.

HC-L/C - HealthChoices Lehigh/Capital – The mandatory Medical Assistance managed care program for the counties of Adams, Berks, Cumberland, Dauphin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and York.

HC-SE - HealthChoices Southeast – The mandatory Medical Assistance managed care program in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.

HC-SW - HealthChoices Southwest – The mandatory Medical Assistance managed care program for Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, and Westmoreland counties.

HEDIS - Health Plan Employer Data Set – A set of health care quality measure developed by the National Committee for Quality Assurance consisting of statistics on health are delivered by plans, including preventive care and rates for certain surgical procedures.

HIPAA – Health Insurance Portability and Accountability Act

HIPP – Health Insurance Premium Payment

HIV – Human Immunodeficiency Virus

HMO - A health maintenance organization or HMO was originally defined as a prepaid organization that provided health care to voluntarily enrolled members in a return for a preset amount of money on a per member/per month basis. Today, the definition can include two additional possibilities, specifically a licensed health plan that: 1) places at least some of its providers at risk for medical expenses; and 2) utilizes designated (usually primary care) physicians as gatekeepers.

Horizontal consolidation – When local health plans, or local hospitals, merge.  This practice was popular in the late 1990s and was used to expand regional business presence (Academy for Health Services Research and Policy, 2001).

Hospice Services – Services to provide care to the terminally ill and their families.

Hospital Day – A term to describe any twenty-four hour period commencing at 12:00 am, or 12:00 p.m., whichever is used by a hospital to determine a hospital day, during which a patient receives hospital services at the hospital.

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I

IBNR – Incurred but not reported claims

IEAP – Independent Enrollment Assistance Program

Indemnity plan – Indemnity insurance plans are an alternative to managed care plans.  These plans charge consumers a set amount for coverage and reimburse (fully or partially) consumers for most medical services (Insurance Finder, 2001).

IPS - Independent Practice Association – An organization of doctors and other medical practices that is formed to negotiate with an HMO to provide medical services.

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J

JCAHO - Joint Commission for the Accreditation of Healthcare Organizations

JDC - Juvenile Detention Center

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K
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L

LTCCAP - Long Term Care Capitation

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M

MA – Medical Assistance

MAAC – Medical Assistance Advisory Committee

MAID – Medical Assistance Identification Number

Managed Care – An organized system for delivering comprehensive mental health services that allows the managed care entity to determine was services will be provided to an individual in return for a prearranged financial payment.  Generally, managed care controls health care costs and discourages unnecessary hospitalization and overuse of specialists, and the health plan operates under contract to payer.

MCO - Managed Care Organization - A system of health care delivery which manages the cost and quality of and access to health care services. Managed care plans typically include a panel of contracted providers, limitation on benefits to subscribers who use noncontracted providers (unless authorized to do so), and some type of authorization system. Forms of managed care include, but are not limited to, HMOs, PPOs, POS plans or PSOs.

Medical Loss Ratio (MLR) – Cost ratio of total benefits used compared to revenues received.  Usually referred to by a ratio, such as .96 -- which means that 96% of premiums were spent on purchasing medical services.  The goal is to keep this ratio below 1.00 -- preferably in the .80 range, since the MCO's or insurance company's profits comes from premiums.  Currently, successful HMOs do have MLRs in the .70-.80 range; the ratio between the cost to deliver medical care and the amount of money that was taken in by a plan.  Insurance companies often have a MLR of 96% or more: tightly managed HMOs may have MLRs of 75%-85%, although the overhead (or administrative cost ratio) is concomitantly higher.

Medically Necessary – Health insurers often specify that, in order to be covered, a treatment of drug must be medically necessary for the consumer.  Anything that falls outside of the realm of medical necessary is not usually covered.  The plan will use prior authorization and utilization management procedures to determine whether the term “medically necessary” is applicable.  (Bazelon Center for Mental Health Law, 1997).

Medicaid – Medicaid is a health insurance assistance program funded by the Federal, State, and local monies.   It is run by State guidelines and assists low-income persons by paying for most medical expenses (Centers for Medicare and Medicaid Services, 2002)

Medical Group Practice – A number of physicians working in a systematic association with the joint use of equipment and technical personnel and with centralized administration and financing organization.

Medicare – Medicare is a Federal insurance program serving the disable and persons over the age of 65.  Most costs are paid via trust funds the beneficiaries have paid into throughout the courses of their lives; small deductibles and some co-payments are required.  (Centers for Medicare and Medicaid Services, 2002)

MediGap – MediGap plans are supplements to Medicare insurance.  MediGap plans vary from State to State; standardized MediGap plans also may be known as Medicare Select plans. (Centers for Medicare and Medicaid Services, 2002)

MIS – Management Information System

MM - Member month – one member covered by the HealthChoices behavioral health program for one month

MSO - Management Services Organization - A management entity owned by a hospital, physician organization, or third party. The MSO contracts with payers and hospitals/physicians to provide services such as negotiating fee schedules, handling administrative functions, and billing and collections.

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N

NAMI – National Alliance for the Mentally Ill

  Network – The system of participating providers and institutions in a managed care plan.

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O

OCYF – Office of Children, Youth and Families

OIP – Other Insurance Paid

OMAP – Office of Medical Assistance Programs

OMH – Office of Mental Health & Substance Abuse (OMH) area offices are responsible for the supervision and direction of the state mental hospitals and for monitoring and providing program consultation and technical assistance to county mental health programs and providers within an assigned geographical area. Each area office is responsible for annual planning and budget review and approval for both state mental hospitals and county mental health programs, as well as monitoring state and federal allocations to all programs and hospitals. Area offices also are responsible for the licensure of community mental health service providers.

OMHSAS – Office of Mental Health and Substance Abuse Services

OMR – Office of Mental Retardation

ORC – Other Related Conditions

Open Enrollment – The annual period during which people in a “dual choice” health benefits program can choose among the two, or more, plans being offered.  Also the period during which a federally qualified HMO must make its plan available with restrictions to individuals who are not part of a group.

OSP – Office of Social Programs

Outcome   – The result of a specific health care service or benefit package.

Outcomes measure – A tool to assess the impact of health services in terms or improved quality and/or longevity of life and functioning.

Outcomes research – Studies that measure the effects of care or services.

Out of Area – Refers to the treatment given an HMO member outside of the geographical limits of his own HMO.  The coverage generally is restricted to emergency services.

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P

PARP – Prior Authorization Review Panel

PCP – Primary Care Physician

PDA – Pennsylvania Department of Aging

Per Diem Cost –  Cist per day; hospital or other institutional cost for a day of care.

Performance Measure – A measure that describes the health care being provided.  Current performance measures indicate whether a health plan or provider has appropriately provided certain services expected to lead desirable outcomes.

PERT – Program Evaluation and Review Technique

PH – Physical Health

PH-MCO – Physical Healthcare Managed Care Organization – Provides services to all physical healthcare members.

PMPM - Per Member Per Month - Generally used by HMOs and their medical providers as an indicator of revenue, expenses, or utilization of services per member per one-month period; e.g., "we receive a capitation payment of $30 per member per month."

PMPY - Per Member Per Year - Generally used by HMOs and their medical providers as an indicator of revenue, expenses or utilization of services per member per year; .e.g., Our patients come in to see the doctor on an average of 3.7 times per member per year.

PHO - Physician-Hospital Organization - It is owned jointly by a hospital and a physician group. The PHO, in turn, contract with hospitals and physicians for the delivery of services to payers under contract to the PHO. It can also provide management services and perform other services typically associated with an MSO.

PIC - Public Information Campaign

PO - Physician Organization - A group of physicians banding together, usually for the purpose of contracting with managed care entities or to represent the physician component in a PHO.

PPO - A preferred provider organization or PPO is a health plan that contracts with independent providers at a discount for services. The panel is limited in size and usually has some type of utilization review system associated with it. A PPO may be risk-bearing, like an insurance company, or non-risk bearing, like a physician-sponsored PPO that markets itself to insurance companies or self-insured companies via an access fee.

POS - A point-of-service or POS plan is an open-ended product in that enrolled members do not have to choose how to receive services until they need them. Plan participants typically receive a higher level of reimbursement for benefits (for example, 100 percent) if they choose to use the plan's network of providers and comply with the plan's authorization system. However, plan members also have the option to go outside the network for services for which they may receive a lower reimbursement from the health plan, typically 70 or 80 percent.

POSNet - Pennsylvania Open Systems Network

Practice Guidelines – Systematically developed statements to standardize care and to assist in practitioner and patient decisions about the appropriate health care for specific circumstances.  Practice guidelines are usually developed through a process that combines scientific evidence of effectiveness with expert opinion.  Practice guidelines are also referred to as clinical criteria, protocols, algorithms, review criteria, and guidelines.

Medicaid – Medicaid is a health insurance assistance program funded by the Federal, State, and local monies.  It is run by State guidelines and assists low-income persons by paying for most medical expenses (Centers for Medicare and Medicaid Services, 2002)

Pre-exiting condition – A medical condition that is excluded from coverage by an insurance company because the condition was believe to exist prior to the individual obtaining a policy from the insurance company.  Many insurance companies now impose waiting periods for coverage of pre-existing conditions.  Insurers will cover the condition after the waiting period, of no more than twelve months, has expired.

Prior Authorization – The approval a provider must obtain from an insurer or other entity before furnishing certain health services, particularly inpatient hospital care, in order for the service to be covered under the plan.

PSO - A provider-sponsored organization or PSO may also be known as a PSN (provider-sponsored network) and is a network developed by providers (physicians or hospitals, for example), which is formed for the purpose of direct contracting with employers, government agencies or other purchasers. A PSO which includes both physicians and hospitals is commonly known as an integrated delivery system or IDS.

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Q

QA (Quality Assurance) – An approach to improving the quality and appropriateness of medical care and other services.  Includes a formal set of activities to review, assess, and monitor care to ensure that identified problems are addressed.

QARI – Quality Assurance Reform Initiative

QM – Quality Management

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R

RBRVS (Relative Based Relative Value Scale) – A method of determining physicians’ fees based on the time, training, skill, and other factors required to deliver various services.

RBUC – Received But Unpaid Claim

Reinsurance – The practice of an HMO or insurance company of purchasing insurance from another company to protect itself against part of all the losses incurred in the process of honoring the claims of policyholders.  Also referred to as “stop loss” or “risk control insurance.”

Retrospective Review – A method of reviewing patient care, after hospital discharge, to determine quality, necessity, and appropriateness of care.

RFP – Request For Proposal

Risk – Possibility that revenues of the insurer will not be sufficient to cover expenditures incurred in the delivery of contractual services.  A managed care provider is at risk if actual expenses exceed the payment amount.

Risk adjustment – the adjustment of premiums to compensate health plans for the risks associated with individuals who are most likely to require costly treatment.  Risk adjustment takes into account the health status and risk profile of patients.

Risk sharing – Situation in which the managed care entity assumes responsibility for services of a specific group but is protected against expected high costs by a pre-arranged agreement for higher payments for those individuals who need significantly more costly ser vices.  Risk is usually shared by the managed care entity and the State.

RTF – Residential Treatment Facility

RVS – Relative Value Scale.  RVS is the compiled table of relative value units (RVUs), which is a value given to each procedure or unit of service.  As payment systems, RVS is used to determine a formula which multiplies the RVU by a dollar amount, called a converter. (See also conversion factor)

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S

Section 1115 Waiver – A statutory provision that allows a State to operate its system of care for Medicaid enrollees in a manner different from that proscribed by the Center for Medicare and Medicaid Services (CMS), in an attempt to demonstrate the efficacy and cost-effectiveness of an alternative delivery system through research and evaluation.

Section 1915(b) Waiver – A statutory provision that allows a State to partially limit the choice of providers for Medicaid enrollees; for example, under the waiver, a State can limit the number of times per year that enrollees can choose to drop out of an HMO.

Single Stream funding – The consolidation of multiple sources of funding into a single stream. This is a key approach used in progressive mental health systems to ensure that “funds follow consumers.”

SNU – Special Needs Unit

SSA – Social Security Act

Stop-loss – The practice of an HMO or insurance company of protecting itself or its contracted medical group against part or all losses above a specified dollar amount incurred in the process of caring for its policyholders.  Usually involves the HMO or insurance company purchasing insurance from another company to protect itself.  Also referred to as reinsurance.

Sub-capitation – An arrangement whereby a capitated health plan pays is contracted providers on a capitated basis.

Subscriber – Employment group or individual that contracts with an insurer for medical services.

Supplemental benefits – Benefits contracted for by an employer group, which is outside of, or in addition to, the basic health plan.

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T

TANF – Temporary Assistance to Needy Families. TANF provides cash assistance from state and federal funds to families with dependent children who are deprived of the care or support of one or both parents due to absence, incapacity or unemployment.

Tertiary care – Medical care requiring a setting outside of the routine, community standard; care to be provided within a regional medical center having comprehensive training, specialists, and research training.

Third party payment – A term used to describe the monetary reimbursement for medical services from someone other than the member of the member’s insurance plan.

Third party payer – A public or private organization that is responsible for the health care expenses of another entity.

TPA - Third Party Administrator - An organization that administers health care benefits, mostly for self-insured employers. Services may include claims review and claims processing.

TPL – Third Party Liability

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U

Underwriting – The review of prospective or renewing cases to determine their risk and their potential cost.

 Utilization – The level of use of a particular service over time.

 UM – Utilization Management

UR – Utilization Review.  Retrospective analysis of the patterns of service usage in order to determine means for optimizing the value of service provided, minimizing the cost and maximizing the effectiveness and appropriateness.

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V

Vertical disintegration – A practice of selling off health plan subsidiaries or provider activities.  Vertical disintegration was a tend in the late 1990s (Academy for Health Services Research and Health Policy, 2001).

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W

WIC – Women’s Infants’ and Children Program

Withhold – The portion of the monthly capitation payments to physicians withheld by the HMO until the end of the year or other time period to create an incentive for efficient care.  The withhold is at risk.  For example, if the physician exceeds utilization norms, he does not receive it.  It serves as a financial incentive for lower utilization.

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