| Accreditation |
Acceptance
by a nongovernmental state of national peer
body as meeting prescribed or desirable standards
set by the body. |
| Actuary |
A
person trained in the insurance field, who determines
policy rates, reserves and dividends as well
as conducts various other statistical studies. |
| Administrative
Services Only (ASO) |
An
arrangement under which an insurance carrier
or an independent organization will, for a fee,
handle the administration of claims, benefits
and other administrative functions for a self-insured
group. |
| Admissions
per 1,000 |
A
measure used to evaluate utilization management
performance that is calculated by taking the
total number of admissions from a specific group
for a specific period of time (usually one year),
dividing it by the average number of covered
members or lives in that group during the same
time period, and multiplying the result by 1,000.
|
| Allowable
Charges |
Generic
term referring to the maximum fee that a third
party will use in reimbursing a provider for
a given service. |
| Allowable
Costs |
Items
or elements of a provider's costs that are reimbursable
under a payment formula. |
| ALOS |
Average
length of stay. |
| At
Risk |
The
state of being subject to some uncertain event
occurring which connotes loss or difficulty.
In the financial sense, this refers to an individual,
organization or insurance company assuming the
chance of loss through running the risk of having
to provide or pay for more services than paid
for through premiums or per capita payments. |
| Broker |
The
go-between for individuals, companies and health
insurers. A broker helps locate, negotiate,
and negotiate health insurance contracts.
A broker may also be an agent for the insurance
company, delivering policies and collecting
premiums. |
| Capitation |
A
method for payment of providers. Usually
this is a prepaid amount per month to the provider
per covered member. In risk arrangements,
the provider is then responsible for providing
all behavioral health services required by members
of that group during that month for the fixed
fee, regardless of the amount of charges incurred. |
| Capitated
Measurement Programs |
The
provider is required to provide all management
services (precertification, utilization review,
case management, discharge planning, etc.) required
for the fixed fee, while the costs of treatment
services are paid separately. |
| Carve
Outs |
The
process of withdrawing benefits or services
from the medical plan and insuring separately.
The financial risks for the coverage of the
benefits are transferred from the group insurer
or purchaser of health care to the organization
that has contracted for provision of the services. |
| Case
Management |
The
monitoring, planning and coordination of treatment
rendered to patients with conditions requiring
high cost or extensive services. Case
management is intended to ensure an appropriate
and cost-effective course of treatment in an
appropriate setting. |
| Cost
Shifting |
The
practice by some providers of redistribution
of the difference between normal charges and
amounts received from certain payers by increasing
charges made to other payers. |
| Customary
Charges |
Term
used interchangeably with usual charge and referring
to that amount the provider normally charges
the majority of patients for a particular medical
service. |
| Days
per 1,000 |
A
measure used to evaluate utilization management
performance. It is calculated by taking
the total number of day (for inpatient, residential,
or partial hospitalization) or visits (for outpatient)
received by a specific group for a specific time
period (usually one year). This number
is then divided by the average number of covered
members or lives in that group during the same
period and multiplied by 1,000. |
| Discounted
Fee-for-Service |
An
agreed upon rate for service between the provider
and payer that is usually less than the provider's
full fee. This may be a fixed amount per
service, or a percentage discount. |
| Doctoral
Psychologist |
Doctoral
psychologists generally provide individual psychotherapy
and psychological testing. In a managed
care environment, psychologists who have a group
psychotherapy orientation are a valuable asset
as a group is seen as being a cost-effective
type of service delivery for some types of treatment.
|
| EAP |
Traditional
Employee Assistance Programs are a type of service
offered to employees and their family members,
by the employer, to help them locate assistance
needed for behavioral health, legal, and/or
financial difficulties. The employee or
family member speaks to a counselor confidentially.
The counselor then either provides short-term
treatments (usually between 2 and 10 visits)
or refers them to an appropriate service provider. |
| ERISA |
Employee
Retirement Income Security Act of 1974 regulates
the majority or private pension and welfare
group benefit plans in the U.S. |
| Gatekeeper |
An
individual, usually a clinician, who controls
the access to behavioral health services for
members of a specific group. |
| HMO |
A
payer organization that limits beneficiaries'
choice of providers to a finite provider network
and requires the referral of a primary care
physician (PCP) to obtain specialty care.
The PCP is usually at financial risk for the
care of the beneficiary. Seeking care from a
non-network provider without a referral from
the PCP usually results in no payment for services
by the payer organization. |
| Managed
Health Care |
A
system created with the intent to control the
cost of health care that uses financial incentives
and management controls to direct patients to
providers who are responsible for giving appropriate
care in cost-effective treatment settings. |
| Negotiated
Rates |
The
reduction in physician or other health service
fee schedule components which results from the
contractual agreement between a provider and
a preferred provider organization (PPO). |
| Per
Capita |
Payments
for health care based on number of beneficiaries
enrolled in the insurer's program, regardless
of the number who actually receive services. |
| Per
Diem |
An
agreed upon rate per inpatient, residential,
or partial hospitalization day that is all inclusive.
All ancillary services, in addition to therapies
and room and board are included in this rate. |
| Per
Member Per Month (pmpm) |
A
unit of measurement related to each enrollee
for each month. |
| Per
Service |
Payment
for healthcare base on number and types of health
and medical services provided. |
| Pharmacoeconomics |
The
field involving the assessment of the cost effectiveness
of drug therapy in terms of long-term benefits
to the patient. |
| PPO |
A
preferred provider organization. A PPO is a
network of providers that have agreed to discount
services that, in turn, are retailed either
to insurance groups or other direct purchasers
of care, such as self-insured companies. |
| Problem
Focused Therapy |
A
type of outpatient psychotherapy, generally
short term (average of six to eight sessions)
with the emphasis focused on the problem the
client brings to the therapy session.
When this problem has been resolved, therapy
is terminated. |
| Risk
Sharing |
An
arrangement in which the health care system
assumes total responsibility for all health
care services related to a specific diagnosis-related
group or disease process for a fixed dollar
amount or in which the system receives capitation
for a specific number of members and in turn
provides health care services. |
| Sliding
Fee Scale |
A
schedule of discounts in charges, or a deductible
not set at a fixed amount, for services based
on the consumer's ability to pay, according
to income and family size. |
| TPA |
A
third party administrator is the party which
pays claims and/or provides administrative services
for an employee benefit plan. |
| Utilization
Review |
The
activity of determining the medical necessity
and appropriateness of treatment being provided. |
