| Access |
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The patient's ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care. |
| Accountable Health Plan (AHP) |
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A joint venture between practitioners and institutions (insurance companies, HMO's, or hospitals) that would assume responsibility for delivering medical care. Physicians and other providers would either work for or contract with these health plans. As IDSs form and demonstrate their ability to managed capitated care, they begin to struggle with issues of ownership or alliance partnerships with health maintenance organizations (HMOs), insurance companies, or other financing entities. An Accountable Healthcare System describes an IDS with a financing component. When an IDS operates one or more health insurance benefit products, or a managed care organization acquires a large-scale medical delivery component, it qualifies as an Accountable Health System or Accountable Health Plan. In the 1994 debate on healthcare reform, the proposed system of managed competition provided for an Accountable Health Plan that would have combined delivery and financing, and assumed accountability for patient care. |
| Actuarial |
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Refers to the statistical calculations used to determine the managed care company's rates and premiums charged their customers based on projections of utilization and cost for a defined population. |
| Actuary |
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A person who determines insurance policy rates, reserves and dividends, as well as conducts various other statistical studies. You don't develop capitated rates, or agree to a capitated contract without one of these working for you in some capacity. |
| Acute Care |
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A pattern of health care in which a patient is treated for an acute (immediate and severe) episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Specialized personnel using complex and sophisticated technical equipment and materials usually give acute care in a hospital. Unlike chronic care, acute care is often necessary for only a short time. |
| Adjudication |
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Processing claims according to contract. |
| Adjusted Average Per Capita Cost (AAPCC) |
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HCFA's best estimate of the amount of money care costs for Medicare recipients under fee-for-service Medicare in a given area. The AAPCC is made up of 122 different rate cells; 120 of them are factored for age, sex, Medicaid eligibility, institutional status, and whether a person has both part A and part B of Medicare. |
| Administrative Costs |
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Costs related to utilization review, insurance marketing, medical underwriting, agents' commissions, premium collection, claims processing, insurer profit, quality assurance programs, and risk management. |
| Administrative Services Organization (ASO) |
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A contract between an insurance company and a self-funded plan where the insurance company performs administrative services only and the self-funded entity assumes all risk. |
| Admission Certification |
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A method of assuring that only those patients who need hospital care is admitted. Certification can be granted before admission (preadmission) or shortly after (concurrent). Length-of-stay for the patient's diagnosed problem is usually assigned upon admission under a certification program. |
| Admissions Per 1,000 |
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An indicator calculated by taking the total number of inpatient and/or outpatient admissions from a specific group, e.g., employer group, HMO population at risk, for a specific period of time (usually one year), dividing it by the average number of covered members in that group during the same period, and multiplying the result by 1,000. This indicator can be calculated for behavioral health or any disease in the aggregate and by modality of treatment, e.g., inpatient, residential, and partial hospitalization, etc. |
| Adverse Selection |
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(a) Occurs when premium doesn't cover cost. Some populations, perhaps due to age or health status, have a great potential for high utilization.
(b) Some population parameter such as age (e.g., a much greater number of 65-year-olds or older to young population) that increases the potential for higher utilization and often increases costs above those covered by a payers capitation rate. |
| Allowed Amount |
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Maximum dollar amount assigned for a procedure based on various pricing mechanisms. Also known as a maximum allowable. |
| Ambulatory Care |
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Health services provided without the patient being admitted. The services of ambulatory care centers, hospital outpatient departments, physicians' offices and home health care services fall under this heading. |
| Ambulatory Surgery |
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Surgery performed on a non-hospitalized patient; patient goes home the same day as the surgery. |
| Ambulatory Visit Group (AVG) |
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Similar to DRGs (Diagnosis-Related Group), except outpatient rather than inpatient hospital care. |
| Ancillary Services |
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Professional charges for x-ray, laboratory tests, and other similar patient services. |
| Anniversary Date |
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The beginning of an employer group's benefit year. The first day of effective coverage as contained in the policy Group Application and subsequent annual anniversaries of that date. An insured has the option to transfer from an indemnity plan (which may have maximum benefit levels) to an HMO. |
| Audit of Provider Treatment or Charges |
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A qualitative or quantitative review of services rendered or proposed by a health provider. The review can be carried out in a number of ways: a comparison of patient records and claim form information, a patient questionnaire, a review of hospital and practitioner records, or a pre- or post-treatment clinical examination of a patient. Some audits may involve fee verification. Something we had better get used to being subjected to since this is usually first type or "first generation" managed care approach. |
| Average Wholesale Price (AWP) |
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Commonly used in pharmacy contracting, the AWP is generally determined through reference to a common source of information. |
