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Copyright© 1997 - 2011, Pam Pohly, All Rights Reserved.
This glossary can now also be purchased in printed book format!
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 prefer to have it handy in your desk or briefcase.
Gag Clause - A provision of a contract between a managed care organization and a health care provider that restricts the amount of information a provider may share with a beneficiary or that limits the circumstances under which a provider may recommend a specific treatment option.
Gatekeeper - A primary care physician, utilization review, case management, local agency or managed care entity responsible for determining when and what services a patient can access and receive reimbursement for. In HMOs, it is commonly an arrangement in which a primary care provider serves as the patient's agent, arranges for and coordinates appropriate medical care and other necessary and appropriate referrals. In that case, the gatekeeper PCP is involved in 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 PCP must preauthorize the visit, unless there is an emergency. The term gatekeeper is also used in health care business to describe anyone (EAP, employer based case manager, UR entity, case manager, etc.) that makes the decision of where a patient will receive services.
Gatekeeping - The process by which a gatekeeper makes the decision where a patient will receive services. In managed care, gatekeeping can also refer to the UR processes of referrals and procedures that must first be preauthorized by an agent of the MCO except in cases of emergency care. See also Gatekeeper.
Generic Drug or Generic Equivalent - A drug which is exactly the same as a brand name drug and which may be manufactured and marketed after the brand name drug’s patent expires (approximately 9-10 years after the brand-name drug entered the market). Generic drugs cost significantly less than brand name drugs, and are identical in terms of efficacy, safety, side effect profile, and dosing. Important exceptions to this may include drugs such as immunosuppressants or drugs with a “narrow therapeutic index” such as anti-arrhythmics. “Narrow therapeutic index” refers to drugs that have a high rate of side effects at commonly administered dosages. Also see Formulation Substitution.
Generic Substitution - Substituting a generic drug for an identical brand-name drug that has lost its patent protection. Generic substitution lowers drug costs for both consumers and prescription benefit managers while providing equal efficacy, safety, side effect profile and dosing (with a few important exceptions. For more information on exceptions to generic substitution see Formulation Substitution.
Genetics - The study of how particular traits are passed from parents to children. Identifiable genetic information receives the same level of protection as other health care information under the HIPAA Privacy Rule. Of note for genetic researchers, the rule defines "identifiable" information to include information from the individual as well as relatives. Thus researchers considering whether to de-identify data should review the definition of de-identified information closely.
Geographic Availability - The number of primary care providers within a given radius of a particular target.
GLB Act - See Financial Services Modernization Act.
Global Budgeting - Limits placed on categories of health spending. A method of hospital cost containment in which participating hospitals must share a prospectively set budget. Method for allocating funds among hospitals may vary but the key is that the participating hospitals agree to an aggregate cap on revenues that they will receive each year. Global budgeting may also be mandated under a universal health insurance system.
Global Fee - A total charge for a specific set of services, such as obstetrical services that encompass prenatal, delivery and post-natal care. Managed care organizations will often seek contracts with hospitals that contain set global fees for certain sets of services. Outliers and carve-outs will be those services not included in the global negotiated rates.
GPWW - See Group Practice without Walls.
Guaranteed Issue - Requirement that health plans offer coverage to all businesses during some period each year.
Grace Period - Period past the due date of a premium during which coverage may not be cancelled.
Gramm-Leach-Bliley Act - See Financial Services Modernization Act.
Grievance - A complaint by an enrollee regarding the way Medicare or a health plan provides its service. Normally, if an enrollee has a complaint about a treatment decision or a service that is not covered, the enrollee will file an appeal, rather than a grievance. Also see Appeal.
Grievance Procedures - The process by which an insured can air complaints and seek remedies.
Gross Charges Per 1,000 - 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 - 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 Health Plan - A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer, employee organization or other organized group.
Group Health Plan Number - A number that is assigned to all group health plans in the future by the CMS division administering the transactions, code sets, security and administrative simplification portions of the Health Insurance Portability and Accountability Act (HIPAA) GSA - General Services Administration. See also HIPAA and CMS.
Group Insurance - 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 Market - A market segment that includes groups of two or more people that enter into a group contract with an MCO under which the MCO provides healthcare coverage to the members of the group.
Group Model HMO, Group Network HMO, Group Practice Model HMO - An HMO that contracts with one or more independent group practice to provide services to its members in one or more locations. Health care plan involving contracts with physicians organized as a partnership, professional corporation, or other legal association. It can also refer to an HMO model in which the HMO contracts with one or more medical groups to provide services to members. In either case, the payer or health plan pays the medical group, which is, in turn, is responsible for compensating physicians. The medical group may also be responsible for paying or contracting with hospitals and other providers.
Group Practice - 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 practices use the acronyms PA, IPA, MSO and others. Group practices are far more common now than a decade ago because physicians seek to lower costs, increase contracting power and share payer contracts.
Group Practice without Walls (GPWW) - 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. Also called clinic without walls.Guaranteed Eligibility - A defined period of time (3-6 months) that all patients enrolled in prepaid health programs are considered eligible for Medicaid, regardless of their actual eligibility for Medicaid. A State may apply to CMS for a waiver to incorporate this into their contracts.
Guaranteed Issue Rights - Rights that senior citizens have in certain situations when insurance companies are required by law to sell or offer them Medigap policies. In these situations, an insurance company can’t deny someone a policy, or place conditions on a policy, such as exclusions for pre-existing conditions, and can’t charge the citizen more for a policy because of past or present health problems. Also called Medigap Protections.
Guaranteed Renewable - A right that a senior citizen has that requires an insurance company to automatically renew or continue the citizen's Medigap policy, unless the citizen makes untrue statements to the insurance company, commits fraud or doesn't pay your premiums.
This glossary can also be purchased in printed book format if you would like to have a copy for your briefcase or desk.
Copyright© 1997 - Present Date, Pam Pohly, All Rights Reserved.