OCR Text |
Show have a mechanism for assessing its effectiveness and may measure care against preestablished standards. R Risk The chance or possibility of loss. The sharing risk is often employed as a utilization control mechanism within the HMO setting. Risk is also defined in insurance terms as the possibility of loss associated with a given population. Risk Pool A pool of money that is to be used for defined expenses. Commonly, if the money that is put at risk is not expended by the end of the year, some or all of it is returned to those managing the risk. S Staff Model HMO An HMO that delivers health services through a physician group that is controlled by the HMO unit; most physicians are salaried employees who deal exclusively with HMO members. Self-Insurance The practice of an employer or organization assuming responsibility for health-care losses of its employees. This usually includes setting up a fund against which claim payments are drawn. Claims processing is often handled through an administrative services contract with an independent organization. Stop Loss That point at which a third party has reinsurance to protect against the overly large single claim or the excessively high aggregate claim during a given period of time. Large employers, who are self-insured, may also purchase "reinsurance" for stop-loss purposes. T Tertiary Care Subspecialty care usually requiring the facilities of a university-affiliated or teaching hospital that has extensive diagnostic and treatment capabilities. Third-Party Administrator Individual or company that contracts with employers who want to self-insure the health of their employees. They develop and coordinate self-insurance programs, process and pay the claim and may help locate stop-loss insurance for the employer. They also can analyze the effectiveness of the program and trace the patterns of those using the benefits. U Usual, Customary and Reasonable (UCR) A reimbursement method whereby a health insurance plan pays a physician's full charge if it is reasonable and does not exceed his or her usual charges and the amount customarily charged for the service by other physicians in the area. Utilization The patterns of use of a service or type of service within a specified time. Utilization is usually expressed in rate per unit of population-at-risk for a given period. Utilization Review Also known as utilization management or utilization control, utilization review is a systematic means for reviewing and controlling patients' use of medical care services as well as the appropriateness and quality of that care. Usually involves data collection, review, and/or authorization, especially for services such as specialist referrals, emergency room use, and hospitalization. W Withhold That portion of the monthly reimbursement to physicians withheld by an HMO to create an incentive for efficient care. A physician who exceeds utilization norms does not receive the withheld amount. This system serves as a financial incentive for lower utilization. The withhold can cover all services or be specific to hospital care, laboratory usage, or specialty referrals. 160 |