OCR Text |
Show serves the HMO. This term generally applies only to staff and group model HMOs. This term may also be used to designate a physician practice that is closed to new patients. Coinsurance A cost-sharing requirement under a health insurance policy which provides that the insured will assume a portion or percentage of the costs of covered services. After the deductible is paid, this provision forces the subscriber to pay for a certain percentage of any remaining medical bills, usually 20 percent. Community Rating Setting insurance rates based on the average cost of providing health services to all people in a geographic area, without adjusting for each individual's medical history or likelihood of using medical services. Concurrent Review Review of a procedure or hospital admission done by a health-care professional while the service is being performed. Concurrent review may be done off-site through the use of a telephone or fax, or at the site of care. Coordination of Benefits (COB) Provisions and procedures used by third-party payers to determine the amount payable to each payer when a claimant is covered under two or more group health plans. Co-payment A type of cost-sharing which requires the insured or subscriber to pay a specified flat dollar amount, usually on a per unit of service basis, with the third-party payer reimbursing some portion of remaining charges. Cost Sharing The general set of financing arrangements whereby the consumer must pay out-of-pocket to receive care, either at the time of initiating care, or during the provision of health-care services, or both. Cost sharing can also occur when an insured pays a portion of the monthly premium for health-care insurance. Cost Shifting Charging one group of patients more in order to make up for underpayment by others. Most commonly, charging some privately insured patients more in order to make up for underpayment by Medicaid or Medicare. Credentialing The process of reviewing a practitioners credentials, i.e., training, experience, or demonstrated ability, for the purpose of determining if criteria for clinical privileges are met. D Days/100/Year A common utilization measurement used in the health-care industry that refers to a ratio of the number of days a patient population has for a particular service, per 1,000 members enrolled for a given year. Deducible The out-of-pocket expenses that must be borne by an insurance subscriber before the insurer will begin reimbursing the subscriber for additional expenses. Diagnosis-related groups (DRG) A system used by Medicare and other insurers to classify illnesses according to diagnosis and treatment. All Medicare inpatient hospital operating costs are determined in advance and paid on a per-case basis, according to fixed amount or weight established for each DRG. E Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) EPSDT program covers screening and diagnostic services to determine physical or mental defects in Medicaid recipients under age 21, as well as health-care and other measures to correct or ameliorate any defects and chronic conditions discovered. Employee Retirement Income Security Act (ERISA) A 1974 federal law that governs self-funded employer health benefit programs. ERISA exempts self-insured health plans from state laws governing health insurance, including contribution to risk pools, prohibitions against disease discrimination and other state health reforms. Exclusions Clauses in a health insurance contract that deny coverage for select individuals, groups, locations, properties, or risks; clauses in a 156 |