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Show D Diagnosis Related Groups (DRGs) Groupings of diagnostic categories drawn from the International Classification of Disease and modified by the presence of a surgical procedure, patient age, presence or absence of significant co-morbidity's or complications, and other relevant criteria. DRGs are the case-mix measure used in Medicare's prospective payment system. E Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) A program mandated by law as part of the Medicaid program. The law requires that all States have in effect a program for eligible children under age 21 to ascertain their physical or mental defects and to provide such health care treatments and other measures to correct or ameliorate defects and chronic conditions discovered. The State programs also have active outreach components to inform eligible persons of the benefits available to them, to provide screening and, if necessary, to assist in obtaining appropriate treatment. Exclusive Provider Arrangement (EPA) An indemnity or service plan that provides benefits only if care is rendered by the institutional and professional providers with which it contracts. Experience Rating A method of adjusting health plan premiums based on the historical utilization data and distinguishing characteristics of a specific subscriber group. F Fee-For-Service Method of billing for health services under which a physician or other practitioner charges separately for each patient encounter or service rendered; it is the method of billing used by the majority of U.S. physicians. Fee Schedule An exhaustive list of physician services in which each entry is associated with a specific monetary amount that represents the approved payment level for a given insurance plan. G Gatekeeper The primary care practitioner in managed care organizations who determines whether the presenting patient needs to see a specialist or requires other non-routine services. The goal is to guide the patient to appropriate services while avoiding unnecessary and costly referrals to specialists. H Health Care Financing Administration The government agency within the Department of Health and Human Services which directs the Medicare and Medicaid programs and conducts research to support those programs. Health Insurance Purchasing Cooperatives (HIPCs) Public or private organizations that secure health insurance coverage for the workers of all member employers. The goal of these organizations is to consolidate purchasing responsibilities to obtain greater bargaining clout with health insurers, plans and providers, to reduce the administrative costs of buying, selling and managing insurance policies. Health Manpower Shortage Area (HMSA) An area or group that the U.S. Department of Health and Human Services designates as having an inadequate supply of health care providers. Health Plan Employer Data and Information Set (HEDIS) A core set of performance measures designed by the National Committee for Quality Assurance to enable plans and employers to accurately trend health plan performance in a comparative manner. Health Systems Agency (HSA) A health planning agency created under the National Health Planning and Resources Development Act of 1974. HSAs were usually nonprofit private organizations and served defined health service areas as designated by the States. Utah's Health: An Annual Review 1996 123 |
