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Show Outcomes Management A technology of patient experience designed to help patients, payers, and providers make more rational medical care-related choices based on better insight into the effect of these choices on the patient's life. Through longitudinal, observational studies, outcomes management seeks to measure and evaluate a patient's functional health status and quality of life over time and to document changes in the patient's clinical condition as a result of therapeutic interventions. Outcomes management differs from clinical trials in that data are collected as part of routine medical care, and it attempts to determine what is appropriate resource consumption. Outlier One who does not fall within the norm; term typically used in utilization review. A provider who uses either too many or too few services. Out-of-Area Benefits The coverage allowed to HMO members for emergency situations outside of the prescribed geographic area of the HMO. Outpatient Services Outpatient services are medical and other services provided by a hospital or other qualified facility, such as a mental health clinic, rural health clinic, mobile X-ray unit, or free-standing dialysis unit. Such services include outpatient physical therapy services, diagnostic X-ray and laboratory tests. Participating Provider A health-care provider who participates through a contractual arrangement with a health-care service contractor, HMO, PPO, IPA or other managed care organization. Peer Review A review by members of the same profession regarding the quality of care provided a patient, including documentation of care, diagnostic steps used, conclusions reached, therapy given, appropriateness of utilization, and reasonableness of charges claims. Performance Standards Standards an individual provider is expected to meet, especially with respect to quality of care. The standards may define volume of care delivered per time period. PMPM (Per Member Per Month) The average cost of providing services to any member per month. Point-of-Service Plan (POS) Also known as an open-ended HMO, POS plans encourage, but do not require, members to choose a primary care physician. As in traditional HMOs the primary care physician acts as a "gatekeeper" when making referrals; plan members may, however, opt to visit non-network providers at their discretion. Subscribers choosing not to use the primary care physician must pay higher deductibles and copays than those using network physicians. Practice Parameters The American Medical Association defines "practice parameters" as strategies for patient management, developed to assist physicians in clinical decision making. They may also be referred to as practice options, practice guidelines, practice policies, or practice standards. Preadmission Review The practice of reviewing claims for inpatient admission prior to the patient entering the hospital in order to assure that the admission is medically necessary. Preauthorization A method of monitoring and controlling utilization by evaluating the need for medical service prior to it being performed. Preferred Provider Organization (PPO) A health-care arrangement between purchasers of care and providers that offers benefits at a reasonable cost by providing members incentives to use providers within the network. Members who prefer to use nonpreferred physicians may do so, but only at a higher cost. Preferred providers must agree to specified fee schedules in exchange for a preferred status and are required to comply with certain utilization review guidelines. Q Quality Assurance (QA) Activities and programs intended to assure the quality of care in a defined medical setting. Such programs include peer or utilization review components to identify and remedy deficiencies in quality. The program must 159 |