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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 now also be purchased in printed book format if you would like to have a copy with you for easy reference.
IBNR - See Incurred But Not Reported, below.
ICD-9-CM or ICD-10-CM - See International Classification of Diseases, below.
IDS or ISN - see Integrated Delivery System, below.
Incentives - Profit sharing arrangements offered by HMOs and managed care plans that permit hospitals, providers, subcontractors and physicians to share in amounts earned from plan savings through reduced hospital and specialty referral usage. Normally, clinicians involved in profit-sharing will increase personal income or profit by reducing the quantity of care, supplies or services provided to patients. Consumers sometimes view these incentives as suspect, claiming profit sharing between health plans and providers results in reduction of quality of service. Federal fraud and abuse rules may affect the types of incentive plans that health centers and physicians may enter into. Managed care plans view incentives as necessary methods to align the physicians' (and sometimes hospitals') incentives with the incentives of the managed care plans.
Incidence - In epidemiology, the number of cases of disease, infection, or some other event having their onset during a prescribed period of time in relation to the unit of population in which they occur. Incidence measures morbidity or other events as they happen over a period of time. Examples include the number of accidents occurring in a manufacturing plant during a year in relation to the number of employees in the plant, or the number of cases of mumps occurring in a school during a month in relation to the number of pupils enrolled in the school. It usually refers only to the number of new cases, particularly of chronic diseases. Hospitals also track certain risk management or quality problems with a system called incidence reporting.
Incorporation by Reference - The method of making a document a part of a contract by referring to it in the body of the contract.
Incurred But Not Reported (IBNR) - Refers to a financial accounting of all services that have been performed but, as a result of a short period of time, have not been invoiced or recorded. Estimates of costs for medical services provided for which a claim has not yet been filed. Refers to claims that reflect services already delivered, but, for whatever reason, have not yet been reimbursed. These are bills "in the pipeline." This is a crucial concept for proactive providers who are beginning to explore arrangements that put them in the role of adjudicating claims--as the result, perhaps, of operating in a sub-capitated system. Failure to account for these potential claims could lead to some very bad decisions. Good administrative operations have fairly sophisticated mathematical models to estimate this amount at any given time.
Incurred Claims - All claims with dates of service within a specified period.
Incurred Claims Loss Ratio - Incurred claims divided by premiums.
Indemnify - To make good a loss through compensation or reimbursement.
Indemnity - Health insurance benefits provided in the form of cash payments rather than services. Insurance program in which covered person is reimbursed for covered expenses. An indemnity insurance contract usually defines the maximum amounts that will be paid for covered services. Indemnity insurance plans may have a PPO option, UR and case management features, or include a network or other preferred provider restrictions, but will not have an HMO plan. Indemnity is the traditional form of insurance. Normally when one thinks of indemnity health coverage, one is thinking of the type of plan that does not require “pre-certification” and does not restrict the physicians, drugs or hospitals that will be paid for. Indemnity coverage usually has higher premiums. Indemnity insurance plans are the classic plans - where few restrictions are in place. With these plans, members are normally able to use the providers of their choice and are able to make independent decisions about the type of care they wish to receive. Usually these plans include co-payments, deductibles and maximums but rarely require case management certification or approvals. Managed care, particularly HMO and capitation, has evolved away from the indemnity method. Yet, many people are still covered under indemnity plans.
Indemnity Carrier - Usually an insurance company or insurance group that provides marketing, management, claims payment and review, and agrees to assume risk for its subscribers at some pre-determined rate.
Indemnity Wraparound Policy - An out-of-plan product that an HMO offers through an agreement with an insurance company.
Indemnity Plan (Indemnity health insurance) - A plan that reimburses physicians for services performed, or beneficiaries for medical expenses incurred. Such plans are contrasted with group health plans, which provide service benefits through group medical practice.
Independent Agents - Agents that represent several health plans or insurers.
Independent External Review - An appeals review that is conducted by a third party that is not affiliated with the health plan or a providers' association and has no conflict of interest or stake in the outcome of the review. Also see Appeal.
Independent Practice Association (IPA) or Organization (IPO) - A delivery model in which the HMO contracts with a physician organization, which in turn contracts with individual physicians. The IPA physicians practice in their own offices and continue to also see their FFS patients. The HMO reimburses the IPA on a capitated basis; however, the IPA may reimburse the physicians on an FFS or capitated basis.
Indirectly Identifiable Health Information - Data that do not include personal identifiers, but link the identifying information to the data through use of a code. These data are still considered identifiable by the HIPAA Common Rule. See also HIPAA.
Individually Identifiable Health Information – A term used in healthcare to describe a subset of health information that identifies the individual or can reasonably be used to identify the individual. State and Federal confidentiality laws as well as HIPAA have standards and rules regarding the protection of individually identifiable health information of patients. See also HIPAA.
Individual Market - A market segment composed of customers not eligible for Medicare or Medicaid who are covered under an individual contract for health coverage.
Individual Plans - A type of insurance plan for individuals and their dependents who are not eligible for coverage through employer group coverage.
Individual Stop-Loss Coverage - A type of stop-loss insurance that provides benefits for claims on an individual that exceed a stated amount in a given period. Also known as specific stop-loss coverage.
Individual (Independent) Practice Association (IPA) - An organized form of prepaid medical practice in which participating physicians remain in their independent office settings, seeing both enrollees of the IPA and private-pay patients. Participating physicians may be reimbursed by the IPA on a fee-for-service basis or a capitation basis. Sometimes thought of as an HMO model in which the HMO contracts with a physician organization that in turn contracts with individual physicians. The IPA physicians provide care to HMO members from their private offices and continue to see their fee-for-service patients.
Informed Consent – Refers to requirements (by HIPAA, Medicare, State and Federal Laws) that healthcare providers and researchers explain the purposes, risks, benefits, confidentiality protections, and other relevant aspects of the provision of medical care, a specific procedure or participation in medical research. Informed consent is also required for the authorization of release or disclosure of individually identifiable health care information, under HIPAA.
Inpatient Care - Health care given to a registered bed patient in a hospital, nursing home, skilled nursing, or other medical or post acute institution.
In-Plan Services - Services that are covered under the state Medicaid plan and included in the patient's managed care contract and/or are furnished by a participating provider.
Insolvency - A legal determination occurring when a managed care plan no longer has the financial reserves or other arrangements to meet its contractual obligations to patients and subcontractors.
Institutional Review Board (IRB) – A group of medical professionals formed together for the purpose of providing peer review to protect the rights of human subjects in medical research and clinical trials. HIPAA privacy regulations require an IRB also to protect the privacy rights of research subjects in specific ways.
Integrated Delivery System (IDS) or Integrated Services Network (ISN) - Many different, but similar, definitions exist for IDS. IDS, as an entity, does not have to abide by strict regulations, as does an HMO. When an IDS offers a health plan, however, it must then abide by the requirements of the state and federal government for health plans, insurance companies or HMOs. Without owning a health plan product, an IDS will usually abide by the regulations that govern its separate businesses, that is, regulations governing hospitals, clinics and physicians. An IDS can be a financial or contractual arrangement between health providers (usually hospitals and doctors) to offer a comprehensive range of health care services through a separate legal entity operating, at least for these purposes, as a single health care delivery system. IDS can be a network of organizations usually including hospitals and physician groups, that provides or arranges to provide a coordinated continuum of services to a defined population and is held both clinically and fiscally accountable for the outcomes of the populations served. IDS can also be a healthcare provider organization which vertically integrates physician, hospital, and, usually, also health plan businesses in some manner in order to establish a full continuum of care, seamless of delivery of services and the ability to manage care under new reimbursement arrangements. Also called delivery system, vertically integrated system, horizontally integrated system, health delivery network, accountable health plan, and other names.
Intensive Care Management - Intensive community services for individuals with severe and persistent mental illness that are designed to improve planning for their service needs. Services include outreach, evaluation, and support.
Interface - A means of communication between two computer systems, two software applications or two modules. Real time interface is a key element in healthcare information systems due to the need to access patient care information and financial information instantaneously and comprehensively. Such real time communication is the key to managing health care in a cost effective manner because it provides the necessary decision-making information for clinicians, providers and payers.
Internal Medicine - Generally, that branch of medicine that is concerned with diseases that do not require surgery, specifically, the study and treatment of internal organs and body systems; it encompasses many subspecialties; internists, the doctors who practice internal medicine, often serve as family physicians to supervise general medical care.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM, ICD-10-CM) - This is the universal coding method used to document the incidence of disease, injury, mortality and illness. A diagnosis and procedure classification system designed to facilitate collection of uniform and comparable health information. The ICD-9-CM was issued in 1979. This system is used to group patients into DRGs, prepare hospital and physician billings and prepare cost reports. Classification of disease by diagnosis codified into six-digit numbers. See also coding.Intervention Strategy - A generic term used in public health to describe a program or policy designed to have an impact on an illness or disease. Hence a mandatory seat belt law is an intervention designed to reduce automobile-related fatalities.
IPA or IPO - See Independent Practice Association.
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.