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Glossary of Managed Care Terms
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| G |
| Gatekeeper |
Top |
A
primary care physician responsible for
overseeing and coordinating all aspects of a
patient's medical care. In order for a patient
to receive a specialty care referral or hospital
admission, the gatekeeper must pre-authorize the
visit, unless there is an emergency. |
| Grievance
Procedures |
Top |
The
process by which an insured can air complaints
and seek remedies. |
| Gross
Charges Per 1,000 |
Top |
An
indicator calculated by taking the gross charges
incurred by a specific group for a specific
period of time, dividing it by the average
number of covered members or lives in that group
during the same period, and multiplying the
result by 1,000. This is calculated in the
aggregate and by modality of treatment, e.g.,
inpatient, residential, partial hospitalization,
and outpatient. A measure used to evaluate
utilization management performance. |
| Gross
Costs Per 1,000 |
Top |
An
indicator calculated by taking the gross costs
incurred for services received by a specific
group for a specific period of time, dividing it
by the average number of covered members or
lives in that group during the same period, and
multiplying the result by 1,000. This is
calculated in the aggregate and by modality of
treatment, e.g. inpatient, residential, partial
hospitalization, and outpatient. A measure used
to evaluate utilization management performance.
This is the key concept for the provider. What
matters is our cost and, in managed care, we
must control this indicator and make sure it is
below our Collections per 1,000. |
| Group
Insurance |
Top |
Any
insurance policy or health services contract by
which groups of employees (and often their
dependents) are covered under a single policy or
contract, issued by their employer or other
group entity. |
| Group
Model HMO |
Top |
(a)
An HMO model in which the HMO contracts with one
or more medical groups to provide services to
members. As with the staff model, all services
except hospital care are generally provided
under one roof. Both group and staff models are
known collectively as prepaid group practice
plans.
(b) (Also direct service plan, group practice
prepayment plan; prepaid health care): A plan
which provides health services to persons
covered by a prepayment program through a group
of physicians usually working in a group clinic
or center. |
| Group
Practice |
Top |
A
group of persons licensed to practice medicine
in the State, who, as their principal
professional activity, and as a group
responsibility, engage or undertake to engage in
the coordinated practice of their profession
primarily in one or more group practice
facilities, and who (in their connection) share
common overhead expenses (if and to the extent
such expenses are paid by members of the group),
medical and other records, and substantial
portions of the equipment and the professional,
technical, and administrative staffs. |
| Group
Practice without Walls |
Top |
Similar
to an independent practice association, this
type of physician group represents a legal and
formal entity where certain services are
provided to each physician by the entity, and
the physician continues to practice in his/her
own facility. It can include marketing, billing
and collection, staffing, management, and the
like. |
| Guidelines |
Top |
You
may hear these referred to as practice
parameters. Clinical practice guidelines or
protocols. These are statements by authoritative
bodies as to the procedures appropriate for the
physician to employ in making a diagnosis and
treating it. The goal of guidelines is to change
practice styles, reduce inappropriate and
unnecessary care and cut costs. |
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