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Show membership and utilization, finance, and descriptive information on health plan management. Hold Harmless Clause A clause frequently found in managed care contracts whereby the HMO and the physician hold each other not liable for malpractice or corporate malfeasance if either of the parties is found to be liable. Many insurance carriers exclude this type of liability from coverage. It may also refer to language that prohibits the provider from billing patients if their managed care company becomes insolvent. State and federal regulations may require this language. I Indemnify To make a good loss. Independent Practice Association (IPA) A health maintenance organization delivery model in which the HMO contracts with a physician organization, which, in turn, contracts with individual physicians. The IPA physicians practice in their own offices and continue to see fee-for-service patients. The HMO reimburses the IPA on a capitated basis; however, the IPA usually reimburses the physicians on a fee-for-service basis. This type of system combines prepayment with the traditional means of delivering health care. Inpatient Services Inpatient hospital services are items and services furnished to a hospital inpatient by the hospital, including bed and board, nursing and related services, diagnostic and therapeutic services, and medical or surgical services. M Managed Care A general term for organizing doctors, hospitals, and other providers into groups in order to enhance the quality and cost-effectiveness of health care. Managed Care Organizations include HMOs, PPOs, POSs, EPOs, etc. Managed Service Organization (MSO) An entity that contracts for the provision of management and administrative support services to health-care providers, including physicians and physician networks. Usually organized by a hospital, services offered through an MSO may include claims processing, billing and collection services, personnel recruitment, group purchasing, information management systems, contract negotiations and administration, utilization review, quality assurance, and credentialing. Market Share The proportion of eligible enrollees in a defined market that a managed care or insurance company has enrolled as members in its plan; usually market share is expressed as a percentage of the market potential. Medical Group Practice The American Group Practice Association, the American Medical Association, and the Medical Group Management Association define medical group practice as: "provision of health-care services by a group of at least three licensed physicians engaged in a formally organized and legally recognized entity sharing equipment, facilities, common records, and personnel involved in both patient care and business management." Medically Necessary Those covered services required to preserve and maintain the health status of a member or eligible person in accordance with the area standards of medical practice. Multispecialty Group A group of doctors who represent various medical specialties and who work together in a group practice. N National Committee for Quality Assurance (NCQA) A non-profit organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers, and the public sector. Network Model HMO An HMO that contracts with two or more independent group practices to provide health services. This type may include a few solo practices, but is primarily organized around groups. O Open Enrollment A period of time in which eligible subscribers may elect to enroll, or transfer between, available programs providing health-care coverage. 158 |