| C |
| California
Relative Value Studies (CRVS) |
Top |
A
coded listing of physicians services with unit
values to indicate the relativity of charges to
the median. |
| Capitation |
Top |
(1)
The method of payment in which the provider is
paid a fixed amount for each person served no
matter what the actual number or nature of
services delivered.
(2) The cost of providing an individual with a
specific set of services over a set period of
time, usually a month or a year. |
| Carrier |
Top |
An
insurer, an underwriter of risk. |
| Carve-Outs |
Top |
A
payer strategy in which a payer separates
("carves-out") a portion of the
benefit and hires an MCO to provide these
benefits. This permits the payer to create a
health benefits package, get to market quicker
with such a package, and greater control of
their costs. Many HMOs and insurance companies
adopt this strategy because they do not have
in-house expertise related to the service
"carved out." |
| Case
Management |
Top |
The
process by which all health-related matters of a
case are managed by a physician or nurse or
designated health professional. Physician case
managers coordinate designated components of
health care, such as appropriate referral to
consultants, specialists, hospitals, ancillary
providers and services. Case management is
intended to ensure continuity of services and
accessibility to overcome rigidity, fragmented
services, and the mis-utilization of facilities
and resources. It also attempts to match the
appropriate intensity of services with the
patient's needs over time. |
| Case
mix |
Top |
The
types of inpatients a hospital or post acute
facility treats. The more complex the patients'
needs, the greater the amount spent for patient
care. |
| Case
mix index: |
Top |
A
measure of the relative costliness of treating
in an inpatient setting. An index of 1.05 means
that the facility's patients are 5 % more costly
than average. |
| Case
Rate |
Top |
Flat
fee paid for a client's treatment based on their
diagnosis and/or presenting problem. For this
fee, the provider covers all of the services the
client requires for a specific period of time.
Also bundled rate, or Flat Fee-Per-Case. Very
often used as an intervening step prior to
capitation. In this model, the provider is
accepting some significant risk, but does have
considerable flexibility in how it meets the
client's needs. Keys to success in this mode:
(1) properly pricing case rate, if provider has
control over it, and (2) securing a large volume
of eligible clients. |
| Catastrophic
Case |
Top |
A
catastrophic case is any medical condition where
total cost of treatment (regardless of payment
source) is expected to exceed an amount
designated by the HMO contract with the medical
group. |
| Certificate
of Need (CON) |
Top |
A
state agency must review and approve certain
proposed capital expenditures, changes in health
services provided, and purchases of expensive
medical equipment. Before the request goes to
the state, a local review panel (the health
systems agency or HSA) must evaluate the
proposal and make a recommendation. |
| Chronic
Care |
Top |
Long
term care of individuals with long standing,
persistent diseases or conditions. It includes
care specific to the problem as well as other
measures to encourage self-care, to promote
health, and to prevent loss of function. |
| Claims
Review |
Top |
The
method by which an enrollee's health care
service claims are reviewed prior to
reimbursement. The purpose is to validate the
medical necessity of the provided services and
to be sure, the cost of the service is not
excessive. |
| Clinical
Data Repository |
Top |
That
component of a computer-based patient record
(CPR) which accepts files, and stores clinical
data over time from a variety of supplemental
treatment and intervention systems for such
purposes as practice guidelines, outcomes
management, and clinical research. May also be
called a data warehouse. |
| Clinical
Decision Support |
Top |
The
capability of a data system to provide key data
to physicians and other clinicians in response
to "flags" or triggers which are
functions of embedded, provider-created rules. A
system that would alert case managers that a
client's eligibility for a certain service is
about to be exhausted would be one example of
this type of capacity. Also a key functional
requirement to support clinical or critical
pathways. |
| Clinical
or Critical Pathways |
Top |
A
"map" of preferred
treatment/intervention activities. Outlines the
types of information needed to make decisions,
the timelines for applying that information, and
what action needs to be taken by whom. Provides
a way to monitor care "in real time."
These pathways are developed by clinicians for
specific diseases or events. Proactive providers
are working now to develop these pathways for
the majority of their interventions and
developing the software capacity to distribute
and store this information. |
| Closed
Panel |
Top |
Physicians
who belong to a specially formed, but legally
separate, medical group that only serves the HMO
deliver medical services in the HMO-owned health
center or satellite clinic. This term usually
refers to a group or staff HMO models. |
| COBRA |
Top |
A
federal law, which permits many, people who lose
eligibility under a group health plan to
continue that coverage without lapse. |
| Coinsurance |
Top |
The
percentage of costs of medical care that a
patient pays himself. Coinsurance rates
generally hover in the 10 percent to 20 percent
range. Coinsurance and deductibles are most
commonly found in indemnity, fee-for-service
insurance and the PPO market. Their absence in
the HMO arena is one of the strong marketing
appeals of HMOs. |
| Commercial
Plan |
Top |
Refers
to the benefit package an insurance company/HMO/PPO
offers to employers. This is distinguished from
a senior plan, which is offered to Medicare
beneficiaries. |
|
Community Care Network (CCN) |
Top |
This
vehicle provides coordinated, organized, and
comprehensive care to a community's population.
Hospitals, primary care physicians, and
specialists link preventive and treatment
services through contractual and financial
arrangements, producing a network, which
provides coordinated care with continuous
monitoring of quality and accountability to the
public. While the term, Community Care Network (CCN),
often is used interchangeably with Integrated
Delivery System (IDS), the CCN tends to be
community based and non-profit. |
| Community
Health Information Network (CHIN) |
Top |
An
integrated collection of computer and
telecommunication capabilities that permit
multiple providers, payers, employers, and
related healthcare entities within a geographic
area to share and communicate client, clinical,
and payment information. Also known as Community
Health Management Information System. |
| Community
Rating |
Top |
Under
the HMO Act, community rating is defined as a
system of fixing rates of payment for health
services which may be determined on a per person
or per family basis and may vary with the number
of persons in a family, but must be equivalent
for all individuals and for all families of
similar composition. With community rating,
premiums do not vary for different groups of
subscribers or with such variables as the
group's claims experience, age, and sex or
health status. Although there are certain
exceptions, in general, federally qualified HMOs
must community rate. The intent of community
rating is to spread the cost of illness evenly
over all subscribers rather than charging the
sick more than the healthy for coverage. |
| Comorbid
condition |
Top |
A
medical condition that, along with the principal
diagnosis, exists at admission and is expected
to increase hospital length of stay by at least
one day for most patients. |
| Complication |
Top |
A
medical condition that arises during a course of
treatment and is expected to increase the length
of stay by at least one day for most patients. |
| Comprehensive
Major Medical Insurance |
Top |
A
policy designed to provide the protection
offered by both a basic and major medical health
insurance policy. A low deductible, a
co-insurance feature, and high maximum benefits
generally characterize it. |
| Computer-based
Patient Record (CPR) |
Top |
A
term for the process of replacing the
traditional paper-based chart through automated
electronic means; generally includes the
collection of patient-specific information from
various supplemental treatment systems, i.e., a
day program and a personal care provider; its
display in graphical format; and its storage for
individual and aggregate purposes. Also called
Electronic Medical Record, On-Line Medical
Record, and Paperless Patient Chart. |
| Concurrent
Review |
Top |
A
method of reviewing patient care, during
hospital confinement, to validate the necessity
of current care and to explore alternatives to
inpatient care. |
| Consumer
Health Alliance |
Top |
Regional
cooperatives between government and the public
that will oversee the new payment system. Once
all health insurance purchasing cooperatives (HIPPC's),
the alliance would make sure health plans within
a region conformed to federal coverage and
quality standards, and oversee costs within any
mandated budget. |
| Continued
Stay Review |
Top |
A
review conducted by an internal or external
auditor to determine if the current place of
service is still the most appropriate to provide
the level of care required by the client. |
| Continuity
of Care |
Top |
The
degree to which the care of a patient from the
onset of illness until its completion is
continuous, that is without interruption. |
| Continuum
of Care |
Top |
A
range of medical, nursing treatments and social
services in a variety of settings that provides
services most appropriate to the level of care
required. For example, a hospital may offer
services ranging from nursery to a hospice. |
| Contract |
Top |
A
legal agreement between a payer and a
subscribing group or individual which specifies
rates, performance covenants, the relationship
among the parties, schedule of benefits and
other pertinent conditions. The contract usually
is limited to a 12-month period and is subject
to renewal thereafter. Statute or regulation
does not require contracts, and less formal
agreements may be made. |
| Contract
Provider |
Top |
Any
hospital, skilled nursing facility, extended
care facility, individual, organization, or
agency licensed that has a contractual
arrangement with an insurer for the provision of
services under an insurance contract. |
| Contract
Year |
Top |
A
period of twelve (12) consecutive months,
commencing with each Anniversary Date. May or
may not coincide with a calendar year. |
| Conversion |
Top |
In
group health insurance, the opportunity given
the insured and any covered dependents to change
his or her group insurance to some form of
individual insurance, without medical evaluation
upon termination of his group insurance. |
| Conversion
Factor (CF) |
Top |
A
dollar amount for one base unit in the relative
value scale (RVS). The price to be paid to the
provider for a given service equals the relative
value of the service multiplied by the dollar
amount of the conversion factor. For example, a
blood sugar determination might have a relative
value of 5.0, and the conversion factor might be
$5.00. The "price" of the blood sugar
determination would therefore be $25.00. |
| Conversion
Plan |
Top |
A
member's group plan is canceled; the member opts
to continue coverage under an individual plan. |
| Conversion
Privilege |
Top |
The
right of an individual insured under a group
policy to certain kinds of individual coverage,
without a medical examination, upon termination
of his association with the group. |
| Coordination
of Benefits (COB) |
Top |
A
process wherein if an individual has two group
health plans, the amount payable is divided
between the plans so that the combined coverage
amounts to, but does not exceed, 100 percent of
the charges. |
| Co-Payment |
Top |
A
cost-sharing arrangement in which the HMO
enrollee pays a specified flat amount for a
specific service (such as $2.00 for an office
visit or $1.00 for each prescription drug). The
amount paid must be nominal to avoid becoming a
barrier to care. It does not vary with the cost
of the service, unlike co-insurance that is
based on some percentage of cost. |
| Corporate
Practice of Medicine |
Top |
State
laws prohibiting lay people, organizations and
corporations from directly or indirectly
practicing medicine. They are designed to ensure
that those making decisions about the provision
of medical services will not be subject to
commercial exploitation. |
| Cost
Outlier |
Top |
In
Medicare, a patient who is more costly to treat
compared with other patients in a particular
diagnosis related group. |
| Cost
Sharing |
Top |
The
general set of financing arrangements whereby
the consumer must pay out-of-pocket to receive
care, either at the time of initiating care, or
during the provision of health care services, or
both. Cost sharing can also occur when an
insured pays a portion of the monthly premium
for health care insurance. |
| Cost
Shifting |
Top |
Charging
one group of patients more in order to make up
for underpayment by others. Most commonly,
charging some privately insured patients more in
order to make up for underpayment by Medicaid or
Medicare. |
| Coverage |
Top |
Health
care services provided or authorized by the
payer's Medical Staff or payment for health care
services. |
| Covered
Benefit |
Top |
A
medically necessary service that is specifically
provided for under the provisions of an Evidence
of Coverage. A covered benefit must always be
medically necessary, but not every medically
necessary service is a covered benefit. For
example, some elements of custodial or
maintenance care, which are excluded from
coverage, may be medically necessary, but are
not covered. |
| Credentialing |
Top |
The
process of determining eligibility for hospital,
PHO, of other medical staff membership, and
privileges to be granted to physicians.
Credentials and performance are periodically
reviewed, which could result in a doctor's
privileges being denied, modified, or withdrawn. |
| Current
Procedural Terminology (CPT) |
Top |
A
standardized mechanism of reporting services
using numeric codes as established and updated
annually by the AMA. |
| Custodial
Care |
Top |
Care
provided primarily to assist a patient in
meeting the activities of daily living, but not
care requiring skilled nursing services. |
| Customary
and Reasonable |
Top |
Refers
to a fee that falls within a common range of
community fees. |
