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You are here > Home > Managed Care Terminology > D Words Glossary of Terms in Managed Health Care The following are definitions of commonly used terms in the medical provider, hospital and managed care industries. This dictionary is comprised of 26 individual pages, one for each letter of the alphabet. To find a certain word that starts with this letter of the alphabet, may we suggest that you please try the "find" or "search" function in your browser. Or you may simply scroll down the list. If your word starts with another letter, please use the alphabet index below. This glossary can also be
purchased in printed book format if you would like to have it handy or
accessible in your desk or briefcase.
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | D Data
Aggregation – Combining of sets of protected health
information by a business associate to permit data analysis. Database Management System (DBMS) - The separation of data from the computer application that allows entry or editing of data. Data Condition - A description of the circumstances in which certain data is required. Data Content - Under HIPAA, this is all the data elements and code sets inherent to a transaction, and not related to the format of the transaction. Data Mapping - The process of matching one set of data elements or individual code values to their closest equivalents in another set of them. This is sometimes called a cross-walk. Data
Use Agreement (DUA) - HIPAA
Regulation states that a health care entity may use or disclose a "limited data
set" if that entity obtains a data use agreement from the potential recipient
and can only be used for research, public health or healthcare operations.
Relates to privacy rules of HIPAA. A satisfactory assurance between the
covered entity and a researcher using a limited data set that the data will only
be used for specific uses and disclosures. The data use agreement is required to
include the following information: to establish that the data will be used for
research, public health or health care operations (further uses or disclosure
are not permitted); to establish who is permitted to use or receive the limited
data set; and to provide that the limited data set recipient will: (1) not use
or further disclose the information other than as permitted by the data use
agreement or as required by law; (2) use appropriate safeguards to prevent use
or disclosure of the information other than as provided in the agreement; (3)
report to the covered entity any identified use or disclosure not provided for
in the agreement; (4) ensure that any agents, including a subcontractor, to whom
the limited data sets are provided agree to the same restrictions and conditions
that apply to the recipient; and (5) not identify the information or contact the
individuals. Data Warehouse - A specific database (or set of databases) containing data from many sources that are linked by a common subject (e.g., a plan member). Days
(Or Visits) 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. The formula used to calculate
days per thousand is as follows: (# of days/member months) x (1000 members) x (#
of months). An indicator calculated by taking the total number of days (for
inpatient, residential, or partial hospitalization) or visits (for outpatient)
received by a specific group for a specific period of time (usually one year). A
measure used to evaluate utilization management performance. Day Outlier - A patient with an atypically long length of stay compared with other patients in a particular diagnosis related group. DBMS - See Database Management System DCI - See Duplicate Coverage Inquiry
Decedents - Deceased individuals. Afforded
privacy rights under the HIPAA Privacy Rule, even though not considered "human
subjects" protected under the Common Rule. As is the current practice, all
research protocols involving the review of medical records of deceased subjects
or of living and deceased subjects require review and approval by the HRC/IRB
and can be conducted without informed consent and authorization only if the
protocol satisfies the criteria for a waiver. If the research includes access to
the records of decedents, the investigator will be asked to document that the
decedents will only be used for research and that the information is necessary
for the research. The covered entity may require the investigator to provide
proof of death.
Decision Support Systems -
Computer technologies used in healthcare that allow providers to collect and
analyze data in more sophisticated and complex ways. Activities supported
include case mix, budgeting, cost accounting, clinical protocols and pathways,
outcomes, and actuarial analysis.
Deductibles - Amounts required to be paid by the insured
under a health insurance contract, before benefits become payable. Different
components of a health plan may have separate deductibles. Usually
expressed in terms of an "annual" amount.
Deductible Carry Over Credit
- Charge incurred during the last three months of a year that may be applied to
the deductible and which may be carried over into the next year.
Defensive Medicine - Doctors
in recent years have admitted to and have been accused of prescribing additional
tests or procedures to justify their care, strengthen support for their
decisions or simply to corroborate their diagnosis. This defensiveness is a
result of lawsuits, malpractice claims and the onslaught of external UR entities
questioning care decisions. Defensive medicine is said to be one of the primary
causes of the increasing cost of health care. Many physicians and the AMA fight
for tort reform to reduce the need for defensive medicine. However, patient
groups and patient advocates, not in favor of tort reform, explain that the
right to sue for malpractice is a valid method of holding physicians accountable
for mistakes made. Defined Care - An umbrella term used for Defined Contribution, Consumer-Driven and Self-Directed health plan arrangements and other consumer-centered initiatives.
Defined Contribution Coverage -
A payment process for procurement of health benefit plans whereby employers
contribute a specific dollar amount toward the costs of insurance coverage for
their employees. Sometimes this includes an undefined expectation of guarantee
of the specific benefits to be covered.
Defined Contribution Health Plan
- Health Plans that involve employer funding of a fixed (as opposed to variable)
dollar amount for health benefits, which employees may then use to purchase
benefits from an employer arranged funding mechanism. The benefits could either
be group benefits packaged and arranged by the employer, or purchased
individually by the employees. See also Variable Contribution Health Plan.
Deidentified - Under the HIPAA Privacy Rule, data
are deidentified if either (1) an experienced expert determines that the risk
that certain information could be used to identify an individual is "very small"
and documents and justifies the determination, or (2) the data do not include
any of the following eighteen identifiers (of the individual or his/her
relatives, household members, or employers) which could be used alone or in
combination with other information to identify the subject: names, geographic
subdivisions smaller than a state (including zip code), all elements of dates
except year (unless the subject is greater than 89 years old), telephone
numbers, FAX numbers, email address, Social Security numbers, medical record
numbers, health plan beneficiary numbers, account numbers, certificate/license
numbers, vehicle identifiers including license plates, device identifiers and
serial numbers, URLs, internet protocol addresses, biometric identifiers, full
face photos and comparable images, and any unique identifying number,
characteristic or code; note that even if these identifiers are removed, the
Privacy Rule states that information will be considered identifiable if the
covered entity knows that the identity of the person may still be determined. Dental Health Maintenance Organization (DHMO) - An organization that provides dental services through a network of providers to its members in exchange for some form of prepayment. Dental POS - A dental service plan that allows a member to use either a DHMO network dentist or to seek care from a dentist not in the HMO network. Members choose in-network care or out-of-network care at the time they make their dental appointment and usually incur higher out-of-pocket costs for out-of-network care. See also Point of Service. Dental PPO - An organization that provides dental care to its members through a network of dentists who offer discounted fees to the plan members. See also Preferred Provider Organization. Department of Health and Human Services (DHHS) - The federal agency that oversees Medicare, Medicaid and other federal health care programs.Also see DOJ, Fraud and FBI. Department of Justice (U.S. DOJ) - The federal agency that enforces the law and handles criminal investigations. As the nation's largest law firm, the DOJ protects citizens through effective law enforcement, crime prevention and crime detection. It is the agency that prosecutes those in the health care system guilty of proven "fraudulent" activity. Also see Fraud and FBI.
Dependent - Person covered by someone else's health plan.
In a payer's policy of insurance, a person other than the subscriber eligible to
receive care because of a subscriber's contract.
Designated Mental Health Provider
- Person or place authorized by a health plan to provide or suggest appropriate
mental health and substance abuse care.
Designated Record Set -
A health care provider's medical and billing records about individuals and any
records used by the provider to make decisions about individuals. Individuals,
including research subjects, have the right under the HIPAA Privacy Rule to
access and amend protected health information in a Designated Record Set. DHMO - See Dental Health Maintenance Organization. Diagnosis Related Groups (DRGs) - An inpatient or hospital classification system used to pay a hospital or other provider for their services and to categorize illness by diagnosis and treatment. A classification scheme used by Medicare that clusters patients into 468 categories on the basis of patients' illnesses, diseases and medical problems. Groupings of diagnostic categories drawn from the International Classification of Diseases and modified by the presence of a surgical procedure, patient age, presence or absence of significant comorbidities or complications, and other relevant criteria. System involving classification of medical cases and payment to hospitals on the basis of diagnosis. Used under Medicare's prospective payment system to reimburse inpatient hospitals, regardless of the cost to the hospital to provide services. Diagnostic and Treatment Codes - Special codes that consist of a brief, specific description of each diagnosis or treatment and a number used to identify each diagnosis and treatment. Also see Coding.
Direct Contracting -
Providing health services to members of a health plan by a group of providers
contracting directly with an employer, thereby butting out the middleman or
third party insurance carrier. This can be provider heaven, since
middleman-MCO-is cut out and provider gets some portion of the money usually
made by it. Key is to price services correctly, since provider is usually at
full risk in this situation. Takes a strong IDS, MSO or AHP to do this
successfully.
Directly Identifiable Health Information - Any information that includes
personal identifiers. To determine what data may be considered identifiable,
please see items that must be removed under the definition of Deidentified.
Direct Payment Subscriber -
A person enrolled in a prepayment plan who makes individual premium payments
directly to the plan rather than through a group. Rates of payment are generally
higher, and benefits may not be as extensive as for the subscriber enrolled and
paying as a member of the group. Disallowance - When a payer declines to pay for all or part of a claim submitted for payment.
Discharge Planning - Required by Medicare and JCAHO for all
hospital patients. A procedure where aftercare services are determined for after
discharge from the inpatient facility. See also Case Management.
Disclosure – Refers to the release of identifiable
health information, regarding a patient or patient(s). Disclosure involves the
release of information to anyone or any entity outside of the covered entity.
See also HIPAA Privacy Rule.
Discounted Fee-For-Service -
A financial reimbursement system whereby a provider agrees to supply services on
an FFS basis, but with the fees discounted by a certain percentage from the
physician's usual and customary charges. An agreed upon rate for service between
the provider and payer that is usually less than the provider's full fee. This
may be a fixed amount per service, or a percentage discount. Providers generally
accept such contracts because they represent a means to increase their volume or
reduce their chances of losing volume. Disease Management - A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition. Also known as disease state management. Disenrollment - The process or end result of a termination of coverage. Voluntary termination would include a member quitting because he or she simply wants out. Involuntary termination would include leaving the plan because of changing jobs. A rare and serious form of involuntary disenrollment is when the plan terminates a member's coverage against the member's will. This is usually only allowed (under state and federal laws) for gross offenses such as fraud, abuse, nonpayment of premium or copayments, or a demonstrated inability to comply with recommended treatment plans. Disproportionate Share (DSH) Adjustment - A payment adjustment under Medicare's PPS for Medicaid utilization at hospitals that serve a relatively large volume of low-income patients, pregnant patients or other patients under the Medicaid program. Disproportionate share has been a continuing topic in Congress. Some wish to eradicate to reduce costs. Rural facilities, teaching hospitals and hospitals in poverty areas claim that the reduction or elimination of disproportionate share payments would cause hospitals to close, move or reduce care to the poor. DSH is a method whereby the government recognizes that hospitals treating high percentages of Medicaid payments would not be able to cover their costs and remain in service without additional government subsidy. DME - See Durable Medical Equipment DMERC - See Durable Medical Equipment Regional Carrier. DOJ - See Department of Justice. DRG - See Diagnosis Related Groups. Drug Card - See Prescription Drug Plan. Drug Categories - Groupings that reflect therapeutic uses of drugs based on the International Classification of Diseases (ICD-9) diagnostic codes. For example, drugs may belong to the analgesic category or the antiparkinson category. Categories may also be based on an organ system, such as the cardiovascular category. In 2004, the United States Pharmacopeia (USP), a non-profit non-governmental organization, received directive from the Medicare Modernization Act to publish guidelines on drug categories and classes. These guidelines are to be used by prescription drug plans (PDPs) in developing their formularies for the Medicare population. The USP defined 41 therapeutic categories, 32 of which are further divided into pharmacologic classes. Overall, the draft model includes 137 classes and 9 categories that have no classes, for a total of 146 unique therapeutic categories and pharmacologic classes. PDPs that adopt the guidelines are required to include at least two drugs from each class in a category. If a category is not broken into classes, the PDP must include at least two drugs from the category. For classes that have additional subdivisions, PDPs are required to cover 1 drug from each such subdivision. See also Medicare Part D or Prescription Drug Plan. Drug Classes - Classes are subcomponents of drug categories and are based either on the chemical structure of the drug or on its "mechanism of action," i.e., how it works to achieve its results. For example, the analgesic category, or drugs which treat pain, is broken down into two classes - opioids (such as codeine or morphine) and non-opioids (such as ibuprofen or aspirin). Certain classes are subdivided into an additional level of specificity. For example, the beta-adrenergic blocking agent class of the cardiovascular category, or drugs used to treat hypertension, is subdivided into alpha-beta-adrenergic blocking agents (such as Normodyne), cardioselective beta-adrenergic blocking agents (such as Brevibloc), and nonselective beta-adrenergic blocking agents (such as Inderal). In 2004, the United States Pharmacopeia (USP), a non-profit non-governmental organization, received directive from the Medicare Modernization Act to publish guidelines on drug categories and classes. These guidelines are to be used by prescription drug plans (PDPs) in developing their formularies for the Medicare population. The USP defined 41 therapeutic categories, 32 of which are further divided into pharmacologic classes. Overall, the draft model includes 137 classes and 9 categories that have no classes, for a total of 146 unique therapeutic categories and pharmacologic classes. PDPs that adopt the guidelines are required to include at least two drugs from each class in a category. If a category is not broken into classes, the PDP must include at least two drugs from the category. For classes that have additional subdivisions, PDPs are required to cover 1 drug from each such subdivision. See also Medicare Part D. Drug Formulary - Varying lists of prescription drugs approved by a given health plan for distribution to a covered person through specific pharmacies. Health plans often restrict or limit the type and number of medicines allowed for reimbursement by limiting the drug formulary list. The list of prescription drugs for which a particular employer or State Medicaid program will pay. Formularies are either "closed," including only certain drugs or "open," including all drugs. Both types of formularies typically impose a cost scale requiring consumers to pay more for certain brands or types of drugs. See also Formulary. Drug List - A list of drugs covered by a plan. This list is also called a formulary. Drug Plan - When people join a Prescription Drug Plan, they use the plan member cards that are received from the plans when they go to the pharmacies to purchase prescriptions. When they use their cards, they will normally get discounts on their prescriptions. See also Prescription Drug Plan. Drug
Risk Sharing Arrangements - Provider organizations may be at
partial, full or no risk for drug costs. Providers at partial risk share in the
proportion of savings and / or cost overruns. Groups at full risk realize all
the savings or absorb all of the losses. Groups at no risk absorb none of the
profits or losses. These arrangements are normally made between HMOs and
providers (doctors/hospitals) in the HMO’s attempt to discourage the overuse of
drugs that will cause a loss of profit for the HMO. In a shared risk
arrangement, the HMO and provider share the losses and profits, thus aligning
their incentives with one another. Drug Utilization Review (DUR) - Review of an insured population's drug utilization with the goal of determining how to reduce the cost of utilization. Reviews often result in recommendations to practitioners, including generic substitutions, use of formularies, use of copayments for prescriptions and education. In some cases, practitioners are now penalized or rewarded depending on their drug prescription related costs and utilization. Some speculate that these incentives can adversely effect doctor decisions. DSH - See Disproportionate Share Adjustment DUA - Data Use Agreement Dual
Choice (Multiple Choice, Dual Option, DC) - Provisions in the HMO Act of 1973 that
required employers that offered healthcare coverage to more than 25 employees to
offer a choice of traditional indemnity coverage or managed healthcare coverage
under either a closed-panel HMO or an open-panel HMO. Section 1310 of the HMO Act provides for dual
choice. A choice given to employees to select between two or more health plans
offered by an employer. The opportunity for an individual within an employed
group to choose from two or more types of health care coverage such as an HMO
and a traditional insurance plan. Many states also have legislated mandates
regarding choices offered within employer packages. Dual
Eligible - A Medicare beneficiary who also receives the
full range of Medicaid benefits offered in his or her state. Medicare usually
pays the charges for inpatient while Medicaid will pay the co-pay for inpatient
care in hospitals. Medicare will be considered the primary insurer for inpatient
care for the Care/Caid patient.
Duplicate Coverage Inquiry (DCI)
- Method used by an insurance company or group medical plan to inquire about the
existing coverage of another insurance company or group medical plan. Duplication of Benefits - When a person is covered under two or more health plans with the same or similar coverage. DUR - See Drug Utilization Review. Durable Medical Equipment (DME) - Items of medical equipment owned or rented which are placed in the home of an insured to facilitate treatment and/or rehabilitation. Certain medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs, or hospital beds. DME generally consist of items that can withstand repeated use. DME is primarily and customarily used to serve a medical purpose and is usually not useful to a person in the absence of illness or injury. DME is paid for under both Medicare Part B and Part A for home health services. Durable Medical Equipment Regional Carrier (DMERC) - A private company that contracts with Medicare (and other health plans) to pay bills for durable medical equipment. A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | Home Copyright© 1997 - 2007, Pam Pohly, All Rights Reserved. |
