| R |
| Referral
Authorization |
Top |
A
verbal or written approval of a request for a
member to receive medical services or supplies
outside of the participating medical group. |
| Referral
Physician |
Top |
A
physician who has a patient referred to him by
another Source for examination, surgery, or to
have specific procedures performed on the
patient, usually because the referring source is
not prepared or qualified to provide the needed
service. |
| Referral
Pool |
Top |
An
amount set aside to pay for non-capitated
services provided by a PCP, services provided by
a referral specialist and/or emergency services. |
| Referral
Services |
Top |
Medical
Services arranged for by the physician and
provided outside the physician's office other
than Hospital Services. |
| Referring
Physician |
Top |
A
physician who sends a patient to another source
for examination, surgery, or to have specific
procedures performed on the patient, usually
because the referring physician is not prepared
or qualified to provide the needed service. |
| Registered
Nurses (RNs) |
Top |
Registered
nurses are responsible for carrying out the
physician's instructions. They supervise
practical nurses and other auxiliary personnel
who perform routine care and treatment of
patients. Registered nurses provide nursing care
to patients or perform specialized duties in a
variety of settings from hospital and clinics to
schools and public health departments. A license
to practice nursing is required in all states.
For licensure as a registered nurse (R.N.), an
applicant must have graduated from a school of
nursing approved by the state board for nursing
and have passed a state board examination. |
| Reinsurance |
Top |
The
practice of an HMO or insurance company of
purchasing insurance from another company to
protect itself against part or all the losses
incurred in the process of honoring the claims
of policyholders. Also referred to as "stop
loss" or "risk control
insurance". |
| Relative
Value Scale (RVS) |
Top |
RVS
is the compiled table of relative value units (RVUs),
which is a value given to each procedure or unit
of service. As payment systems, RVS is used to
determine a formula that multiplies the RVU by a
dollar amount, called a converter (see
conversion factor). |
| Reserves |
Top |
(a)
A fiscal method of withholding a certain
percentage of premium to provide a fund for
committed but undelivered health care and such
uncertainties as: longer hospital utilization
levels than expected, over utilization of
referrals, accidental catastrophes and the like.
(b) The fiscal method of providing a fund for
committed but undelivered health services or
other financial liabilities. A percentage of the
premiums support this fund. |
| Resource-Based
Relative Value Scale (RBRVS) |
Top |
A
Medicare weighting system to assign units of
value to each CPT code (procedure) performed by
physicians and other providers. The number of
units or value for each procedure includes a
portion for physician skill, expenses associated
with the procedure, and geographic area. |
| Retrospective
Review Process |
Top |
A
review that is conducted after services are
provided to a patient. The review focuses on
determining the appropriateness, necessity,
quality, and reasonableness of health care
services provided. Becoming seen as least
desirable method; supplanted by concurrent
reviews. |
| Risk |
Top |
The
chance or possibility of loss. For example,
physicians may be held at risk if
hospitalization rates exceed agreed upon
thresholds. The sharing of risk is often
employed as a utilization control mechanism
within the HMO setting. Risk is also defined in
insurance terms as the possibility of loss
associated with a given population. |
| Risk
Load |
Top |
In
underwriting, a factor that is multiplied into
the rate to offset some adverse parameter of the
group. |
| Risk
Sharing |
Top |
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. |
