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Show Managed Care Glossary (Reprinted by permission from The Texas Medical Association) A Administrative Costs Costs incurred by health-care insurers relating, but not limited, to utilization review, insurance marketing, medical underwriting, agents' commissions, premium collection, claims processing, insurer profit, quality assurance programs, and risk management. Adverse Selection Among applicants for a given group or individual program, the tendency for those with an impaired health status, or who are prone to higher than average utilization of benefits, to be enrolled in disproportionate numbers and lower deductible plans. Agency for Health Care Policy and Research (AHCPR) The agency of the Public Health Service responsible for enhancing the quality, appropriateness, and effectiveness of healthcare services. The agency was created by Congress in 1989 to engage quality improvement related activities, including development of peer-reviewed outcomes studies and practice parameters. Ambulatory Care Health-care services provided on an outpatient basis. No overnight stay in a hospital is required. The services of ambulatory care centers, hospital outpatient departments, physicians' offices and home health-care services fall under this heading. Average Length of Stay (ALOS) Refers to the average length of stay per inpatient hospital visit. Figure is typically calculated for both commercial and Medicare patient populations. B Beneficiary Individual who is either using or eligible to use insurance benefits, including health insurance benefits, under an insurance contract. Benefit Payment Schedule List of amounts an insurance plan will pay for covered health-care services. C Capitation A payment system whereby managed care plans pay health-care providers a fixed amount to care for a patient over a given period. Providers are not reimbursed for services that exceed the allotted amount. The rate may be fixed for all members or it can be adjusted for the age and gender of the member, based on actuarial projections of medical utilization. Carve-Out Arrangement The process of minimizing financial risk in a capitated contract by "carving out" or removing services over which a physician or other provider group has no control. Commonly carved-out services include behavioral health, laboratory, and x-ray services. Case Management The process by which all health-related matters of a case are managed by a physician or nurse or designated health professional. Physician case managers coordinate designated components of health care, such as appropriate referral to consultants, specialists, hospitals, ancillary providers and services. Case management is intended to ensure continuity of services and accessibility to overcome rigidity, fragmented services, and the inappropriate utilization of facilities and resources. It also attempts to match the appropriate intensity of services with the patient's needs over time. CHAMPUS Civilian Health and Medical Program of the Uniformed Services. Claims Review The method by which an enrollee's healthcare service claims are reviewed prior to reimbursement. The purpose is to validate the medical necessity of the provided services and to be sure the cost of the service is not excessive. Closed Panel Medical services are delivered in the HMO-owned health center or satellite clinic by physicians who belong to a specially formed, but legally separate, medical group that only 155 |