Flashcards in Insurance Deck (121):
Access to Care
The ability and ease of patients to obtain healthcare when they need it.
A legal duty, imposed by statute or otherwise, owing by defendant to the one
Statistical analysis of a population based on its utilization of healthcare services
and demographic trends of the population. Results used to estimate healthcare plan premiums or
Complexity and severity of the patient's health/medical condition.
A trained insurance professional who specializes in determining policy rates, calculating
premiums, and conducting statistical studies.
Administrative Services Only (ASO)
An insurance company or third party administrator (TPA) that
delivers administrative services to an employer group. This usually requires the employer to be at
risk for the cost of health care services provided, which the this company/administrator processes and manages claims.
A person who handles claims (also referred to as Claims Service Representative)
A form of utilization review in which an assessment is made of the medical
necessity of a patient's admission to a hospital or other inpatient facility.
ensures that patients requiring a hospital-based level of care and length of stay appropriate for the
admission diagnosis are usually assigned and certified and payment for the services are approved.
Ambulatory Payment Classification (APC) System
An encounter-based classification system for
outpatient reimbursement, including hospital-based clinics, emergency departments, observation, and
ambulatory surgery. Payment rates are based on categories of services that are similar in cost and
The formal process or request to reconsider a decision made not to approve an admission
or healthcare services, reimbursement for services rendered, or a patient's request for postponing the
discharge date and extending the length of stay.
The amount Medicare pays a physician based on the Medicare fee schedule.
Physicians may bill the beneficiaries for an additional amount, subject to the limiting charge allowed.
Assignment of Benefits
Paying medical benefits directly to a provider of care rather than to a
member. This system generally requires either a contractual agreement between the health plan and
provider or written permission from the subscriber for the provider to bill the health plan.
Assumption of Risk
A doctrine based upon voluntary exposure to a known risk. It is distinguished
from contributory negligence, which is based on carelessness, in that it involves a comprehension
that a peril is to be encountered and a willingness to encounter it.
The term "assurance" is used more commonly in Canada and Great Britain.
The term "insurance" is the spreading of risk among many, among whom few are likely to suffer loss.
The terms are generally accepted as synonymous.
An individual eligible for benefits under a particular plan. In managed care
organizations they may also be known as members in HMO plans or enrollees in PPO plans.
The sum of services for which a health plan, government agency, or employer
contracts to provide. In addition to basic physician and hospital services, some plans also cover
prescriptions, dental, and vision care.
The amount payable by an insurance company to a claimant or beneficiary under the
claimant's specific coverage.
A fixed amount of money per-member-per-month (PMPM) paid to a care provider for
covered services rather than based on specific services provided. The typical reimbursement method
used by HMOs. Whether a member uses the health service once or more than once, a provider who
is capitated receives the same payment.
An insurance company formed by an employer to assume its workers' compensation and
other risks, and provide services.
The insurance company or the one who agrees to pay the losses. It may be
organized as a company, either stock, mutual, or reciprocal, or as an Association or Underwriters.
Services excluded from a provider contract that may be covered through arrangements
with other providers. Providers are not financially responsible for these services of their contract.
Rate of reimbursement that packages pricing for a certain category of services.
Typically combines facility and professional practitioner fees for care and services.
The dollar amount stated in a claim file which represents the estimate of the amount
A general class of insurance and workers' compensation insurance.
Certification or Authorization
The approval of patient care services, admission, or length of stay by a health benefit
plan (e.g., HMO, PPO) based on information provided by the healthcare provider.
A request for payment of reparation for a loss covered by an insurance contract.
One who seeks a claim or one who asserts a right or demand in a legal proceeding.
Claims Service Representative
A person who investigates losses and settles claims for an
insurance carrier or the insured. A term preferred to adjuster.
Clinical Review Criteria
The written screens, decision rules, medical protocols, or guidelines used
to evaluate medical necessity, appropriateness, and level of care.
A type of cost sharing in which the insured person pays or shares part of the medical
bill, usually according to a fixed percentage.
Continued Stay Review
A type of review used to determine that each day of the hospital stay is
necessary and that care is being rendered at the appropriate level. It takes place during a patient's
hospitalization for care.
A business entity that performs delegated functions on behalf of the organization.
Coordination of Benefits (COB)
An agreement that uses language developed by the National
Association of Insurance Commissioners and prevents double payment for services when a
subscriber has coverage from two or more sources.
A supplemental cost-sharing arrangement between the member and the insurer in
which the member pays a specific charge for a specified service. May be flat or variable
amounts per unit of service and may be for such things as physician office visits, prescriptions, or
hospital services. The payment is incurred at the time of service.
Current Procedural Terminology (CPT)
A listing of descriptive terms and identifying codes for
reporting medical services and procedures performed by health care providers and usually used for
Days per Thousand
A standard unit of measurement of utilization. Refers to an annualized use of
the hospital or other institutional care. It is the number of hospital days that are used in a year for
each thousand covered lives.
A specific amount of money the insured person must pay before the insurer's payments
for covered healthcare services begin under a medical insurance plan.
The process whereby an organization permits another entity to perform functions and
assume responsibilities on behalf of the organization, while the organization retains final authority to
provide oversight to the delegate.
Telephone triage and online health advice services to reduce members'
avoidable visits to health providers. This helps reduce unnecessary costs and contributes to better
outcomes by helping members become more involved in their own care.
No authorization or certification is given for healthcare services because of the inability to
provide justification of medical necessity or appropriateness of treatment or length of stay. This can
occur before, during, or after care provision.
Diagnosis-Related Group (DRG)
A patient classification scheme that provides a means of relating
the type of patient a hospital treats to the costs incurred by the hospital.
Demonstrate groups of patients using similar resource consumption and length of stay.
It also is known as a statistical
system of classifying any inpatient stay into groups for the purposes of payment.
May be primary or secondary; an outlier classification also exists. This is the form of reimbursement that the CMS uses to pay hospitals for Medicare and Medicaid recipients.
Also used by a few states for all
payers and by many private health plans (usually non-HMO) for contracting purposes.
The closing of a case is a process of gradual or sudden withdrawal of services, as
the situation indicates, on a planned basis.
The process of terminating healthcare insurance coverage for an enrollee/insured.
An insurance company organized and headquartered in a given state.
The determination that an individual has met requirements to obtain benefits under a
specific health plan contract.
An outpatient or ambulatory visit by a health plan member to a provider. It applies mainly
to physician's office but may also apply to other types of encounters.
An individual who subscribes for a health benefit plan provided by a public or private
healthcare insurance organization.
The number of members in an HMO. The process by which a health plan signs up
individuals or groups of subscribers.
Exclusive Provider Organization (EPO)
A managed care plan that provides benefits only if care is
rendered by providers within a specific network.
A term used to describe the relationship, usually in a percentage or ratio, of premium to
claims for a plan, coverage, or benefits for a stated period of time. Insurance companies in worker's
compensation report three types of experience to rating bureaus: 1) policy year experience; 2)
calendar year experience; and 3) accident year experience. *Policy year experience: Represents the
premiums and losses on all policies that go into effect within a given 12 month period. *Calendar
Year Experience: Represents losses incurred and premiums earned within a given 12-month period.
*Accident Year Experience: Represents accidents that occur within a given 12-month period and the
premiums earned during that time.
The process of determining the premium rate for a group risk, wholly or partially
on the basis of that group's experience.
A provision in most group policies for the return of premium to the policyholder
because of lower than anticipated claims.
A listing of fee allowances for specific procedures or services that a health plan will
Providers are paid for each service performed, as opposed to capitation.
A list of prescription drugs that provide choices for effective medications from which
providers may select, that are covered under a specific health plan.
primary care physician (usually a family practitioner, internist, pediatrician, or nurse
practitioner) to whom a plan member is assigned. Responsible for managing all referrals for specialty
care and other covered services used by the member.
A predetermined all-inclusive fee for a specific set of related services, treated as a
single unit for billing or reimbursement purposes.
Group Model HMO
The HMO contracts with a group of physicians for a set fee per patient to
provide many different health services in a central location. The group of physicians determines the
compensation of each individual physician, often sharing profits.
Health Benefit Plan
Any written health insurance plan that pays for specific healthcare services on
behalf of covered enrollees.
Protection which provides payment of benefits for coverage for covered sickness
or injury. Included under this heading are various types of insurance such as accident insurance,
disability income insurance, medical expense insurance, and accidental death and dismemberment
Health Maintenance Organization (HMO)
An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium.
There are four
basic models: group model, individual practice association (IPA), network model, and staff model.
An organization must possess the following to call itself one:
(1) an organized system for providing healthcare in a geographical area, (2) an agreed-on set of basic
and supplemental health maintenance and treatment services, and (3) a voluntarily enrolled group of people.
Home Health Resource Group (HHRG)
Groupings for prospective reimbursement under Medicare for home health agencies. Placement into one of these is based on the OASIS score. Reimbursement rates correspond to the level of home health provided.
Hospital-Issued Notice of Noncoverage (HINN)
A letter provided to patients informing them of
insurance noncoverage in case they refuse hospital discharge or insist on continued hospitalization
despite the review by the peer review organization (PRO) that indicates their readiness for discharge.
International Classification of Diseases, Ninth Revision, Clinical Modification, formulated
to standardize diagnoses. It is used for coding medical records in preparation for reimbursement,
particularly in the inpatient care setting. ICD-10 is expected to be published soon.
A sum of money paid at the end of the year to healthcare providers by an
insurance/managed care organization as a reward for the provision of quality and cost-effective care.
Security against possible loss or damages. Reimbursement for loss that is paid in a
predetermined amount in the event of covered loss.
Benefits in the form of payments rather than services. In most cases after the
provider has billed the patient, the insured person is reimbursed by the company.
Individual Practice Association (IPA) Model HMO
An HMO model that contracts with a private
practice physician or healthcare association to provide healthcare services in return for a negotiated
fee. They then contracts with physicians who continue in their existing individual or group practice.
A system/plan for a large number of people who are subject to the same loss and agree
to have an insurer assess a premium, so when one suffers a loss, there is economic relief from the
pooled resources. It also is known as protection by written contract against the financial hazards, in
whole or part of the happenings of specified fortuitous events
The person, organization, or other entity who purchases insurance.
The insurance company or any other organization which assumes the risk and provides the
policy to the insured.
The minimum reserve which a company must keep to meet future claims and
obligations as they are calculated under the state insurance code.
Length of Stay
The number of days that a health plan member/patient stays in an inpatient facility,
home health, or hospice.
Long-Term Disability Income Insurance
Insurance issued to an employee, group, or individual to provide a reasonable replacement of a portion of an employee's earned income lost through a serious
prolonged illness during the normal work career.
Efforts by the insurer and the insured to prevent accidents and reduce loss through
the maintenance and updating of health and safety procedures.
Loss Expense Allocated
That part of expense paid by an insurance company in settling a particular claim, such as legal fees, by excluding the payments to the claimant.
The percent relationship which losses bear to premiums for a given period.
The dollar amount designated as the estimated cost of an accident at the time the
first notice is received.
A system of healthcare delivery that aims to provide a generalized structure and
focus when managing the use, access, cost, quality, and effectiveness of healthcare services. Links the patient to provider services.
A joint federal/state program which provides basic health insurance for persons with
disabilities, or who are poor, or receive certain governmental income support benefits (i.e. Social
Security Income or SSI) and who meet income and resource limitations. Benefits may vary by state. May be referred to as "Title XIX" of the Social Security Act of 1966.
Authorized under Section 1915(C) of the Social Security Act, provide states with greater flexibility to serve individuals with substantial long-term care needs at home or in the community rather than in an institution. The federal government "waives" certain Medicaid rules. This allows a state to select a portion of the population on Medicaid to receive
specialized services not available to Medicaid recipients.
A nationwide, federally administered health insurance program that covers the cost of
hospitalization, medical care, and some related services for eligible persons.
Has two parts:
Part A covers inpatient hospital costs (currently reimbursed prospectively using the DRG system).
Pays for pharmaceuticals provided in hospitals but not for those provided in outpatient settings.
Also called Supplementary Medical Insurance Program.
Part B covers outpatient costs for
patients (currently reimbursed retrospectively).
Network Model HMO
This is the fastest growing form of managed care. The plan contracts with a
variety of groups of physicians and other providers in a network of care with organized referral
patterns. Networks allow providers to practice outside the HMO.
Panel of Providers
Usually refers to the healthcare providers, including physicians, who are
responsible for providing care and services to the enrollee in a managed care organization. These
providers deliver care to the enrollee based on a contractual agreement with the managed care organization.
The party responsible for reimbursement of healthcare providers and agencies for services
rendered such as the Centers for Medicare and Medicaid Services and managed care organizations.
Review by healthcare practitioners of services ordered or furnished by other
practitioners in the same professional field.
Peer Review Organization (PRO)
A federal program established by the Tax Equity and Fiscal
Responsibility Act of 1982 that monitors the medical necessity and quality of services provided to Medicare and Medicaid beneficiaries under the prospective payment system.
A daily reimbursement rate for all inpatient hospital services provided in one day to one
patient, regardless of the actual costs to the healthcare provider. The rate can vary by service (medical, surgical, mental health, etc.) or can be uniform regardless of intensity of services.
Organization of physicians and hospitals that is responsible for negotiating contractual agreements for healthcare provision with third-party payers such as managed
Point-of-Service (POS) Plan
A type of health plan allowing the covered person to choose to
receive a service from a participating or a nonparticipating provider, with different benefit levels
associated with the use of participating providers. Members usually pay substantially higher costs in terms of increased premiums, deductibles, and coinsurance.
An element of utilization review that examines the need for proposed
services before admission to an institution to determine the appropriateness of the setting,
procedures, treatments, and length of stay.
Precertification or Preauthorization
The process of obtaining and documenting advanced approval from the health plan
by the provider before delivering the medical services needed. This is required when services are of a
A physical and/or mental condition of an insured which first manifested
itself prior to the issuance of the individual policy or which existed prior to issuance and for which
treatment was received.
Preferred Provider Organization (PPO)
A program in which contracts are established with providers of medical care. Providers under this contract are referred to as preferred providers.Usually the benefit contract provides significantly better benefits for services received from preferred
providers, thus encouraging members to use these providers. Covered persons are generally allowed benefits for nonparticipating provider services, usually on an indemnity basis with significant copayments.
The periodic payment required to keep a policy in force
Prepaid Health Plan
Health benefit plan in which a provider network delivers a specific complement
of health services to an enrolled population for a predetermined payment amount (see capitation).
Primary Care Provider
Assumes ongoing responsibility for the patient in both health maintenance
and treatment. Usually responsible for orchestrating the medical care process either by caring for the patient or by referring a patient on for specialized diagnosis and treatment.
Include general or family practitioners, internists, pediatricians, and sometimes OB/GYN doctors.
Prospective Payment System
A healthcare payment system used by the federal government since
1983 for reimbursing healthcare providers/agencies for medical care provided to Medicare and Medicaid participants. The payment is fixed and based on the operating costs of the patient's diagnosis.
The charge per unit of payroll which is used to determine workers' compensation or other
insurance premiums. The rate varies according to the risk classification within which the policyholder may fall.
The application of the proper classification rate and possibly other factors to set the amount of premium for a policyholder. The three principle forms of rating are: 1) manual rating; 2) experience rating; and 3) retrospective rating.
Payment regarding healthcare and services provided by a physician, medical
professional, or agency.
An assigned weight that is intended to reflect the relative resource consumption
associated with each DRG. The higher the weight, the greater the payment/reimbursement to
The uncertainty of loss with respect to person, liability, or the property of the insured OR
Probability that revenues of the insurer will not be sufficient to cover expenditures incurred in the delivery of contracted services.
A comprehensive program of activities to identify, evaluate, and take corrective
action against risks that may lead to patient or staff injury with resulting financial loss or legal liability.
This program aims at minimizing losses.
The process whereby an HMO and contracted provider each accept partial responsibility for the financial risk and rewards involved in cost-effectively caring for the members
enrolled in the plan and assigned to a specific provider.
An employer who can meet the state legal and financial requirements to assume by
him or herself all of its risk and pay for the losses, although the employer may contract with an insurance carrier or others to provide certain essential services.
Short-Term Disability Income Insurance
The provision to pay benefits to a covered disabled person/employee as long as he/she remains disable up to a specific period not exceeding two years.
(Supplemental Security Income)
Federal financial benefit program sponsored by the Social Security Administration.
Staff Model HMO
The most rigid HMO model. Physicians are on the staff of the HMO with some
sort of salaried arrangement and provide care exclusively for the health plan enrollees.
Supplementary Medical Insurance (SMI)
A secondary medical insurance plan used by a subscriber to supplement healthcare benefits and coverage provided by the primary insurance plan.
The primary and secondary/supplementary plans are unrelated and provided by two different agencies.
Target Utilization Rates
Specific goals regarding the use of medical services, usually included in
risk-sharing arrangements between managed care organizations and healthcare providers.
Third Party Administration
Administration of a group insurance plan by some person or firm other than the insurer of the policyholder.
Third Party Administrator (TPA)
An organization that is outside of the insuring organization that handles only administrative functions such as utilization review and processing claims. They are used by organizations that actually fund the health benefits but do not find it costeffective
to administer the plan themselves.
Third Party Payer
An insurance company or other organization responsible for the cost of care so
that individual patients do not directly pay for services.
Using established criteria as a guide, determination is made as to whether the
patient is receiving all of the appropriate services.
The frequency with which a benefit is used during a 1-year period, usually expressed in
occurrences per 1000 covered lives.
Review of services to ensure that they are medically necessary, provided
in the most appropriate care setting, and at or above quality standards.
A mechanism used by some insurers and employers to evaluate healthcare on
the basis of appropriateness, necessity, and quality.
A portion of payments to a provider held by the managed care organization until year end
that will not be returned to the provider unless specific target utilization rates are achieved. Typically
used by HMOs to control utilization of referral services by gatekeeper physicians.
An insurance program that provides medical benefits and replacement of
lost wages for persons suffering from injury or illness that is caused by or occurred in the workplace.
It is an insurance system for industrial and work injury, regulated primarily among the separate states,
but regulated in certain specified occupations by the federal government.