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Copyrightę 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 like to have it handy always.
Occupancy Rate - A measure of inpatient health facility use, determined by dividing available bed days by patient days. It measures the average percentage of a hospital's beds occupied and may be institution-wide or specific for one department or service.
Occupational Health - OSHA, county health departments and regulatory bodies oversee occupational health hazards in workplaces, including hospitals. Occupational health programs include the employer activities undertaken to protect and promote the health and safety of employees in the workplace, including minimizing exposure to hazardous substances, evaluating work practices and environments to reduce injury, and reducing or eliminating other health threats. Many health providers offer occupational health consultations as well as occupational health screenings, treatments and case-management. Employers and health providers often enter agreements whereby health providers will provide these services as well as managed the related workers compensation case management and rehabilitation programs. Employers seek to remain in compliance with regulations and reduce costs associated with employee injury and benefit utilization. Often, EAPs and drug prevention or drug testing programs are also combined under this category.
Office for Civil Rights - This office is part of HHS. Its HIPPA responsibilities include oversight of the privacy requirements.
Office of Inspector General (OIG) - The office responsible for auditing, evaluating and criminal and civil investigating for HHS, as well as imposing sanctions, when necessary, against health care providers. See also Fraud, FBI, and Dept. of Justice.
Ombudsperson or Ombudsman - A person within a managed care organization or a person outside of the health care system (such as an appointee of the state) who is designated to receive and investigate complaints from beneficiaries about quality of care, inability to access care, discrimination, and other problems that beneficiaries may experience with their managed care organization. This individual often functions as the beneficiary's advocate in pursuing grievances or complaints about denials of care or inappropriate care. Organizations are mostly able to designate a member of their own staff as ombudsman.
Open Access - A term describing a member's ability to self-refer for specialty care. Open access arrangements allow a member to see a participating provider without a referral from another doctor. Health plan members' abilities, rights or invitation to self refer for specialty care. Also called Open Panel.
Open Enrollment Period - A period during which subscribers in a health benefit program have an opportunity to select among health plans being offered to them, usually without evidence of insurability or waiting periods. A period of time which eligible subscribers may elect to enroll in, or transfer between, available programs providing health care coverage. Under an open enrollment requirement, a plan must accept all who apply during a specific period each year.
Open Formulary - The provision that drugs on the preferred list and those not on the preferred list will both be covered by a PBM or MCO. Also see Formulary.
Open Panel - An HMO in which any physician who meets the HMO's standards of care may contract with the HMO as a provider. These physicians typically operate out of their own offices and see other patients as well as HMO members.
Open PHO - A type of physician-hospital organization that is available to all of a hospital's eligible medical staff.
Organized Care System - Often used to discuss a more evolved form of IDSs and CCNs, this relatively new term describes the result of mergers and alliances between and among physicians, health systems, and managed care organizations. These systems often have the same performance imperatives as IDSs and CCNs: improve health status, integrate delivery, demonstrate value, improve efficiency of care delivery and prevention, and meet patient and community needs.
Original Medicare Plan - A fee-for-service health plan that lets enrollees go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. The enrollee must pay the deductible. Medicare pays its share of the Medicare-approved amount, and the enrollee pays a share (coinsurance). In some cases the enrollee may be charged more than the Medicare-approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
Outcome or Outcome Measures - Healthcare quality indicators that gauge the extent to which healthcare services succeed in improving or maintaining satisfaction and patient health. A clinical outcome is the result of medical or surgical intervention or nonintervention, or the results of a specific health care service or benefit package. The valued results of care as experienced primarily by the patient but also by physicians and all other participants in the processes contributing to the outcomes.
Outcomes Management - Providers and payers alike wish to find a method of managing care in a way that would produce the best outcomes. Managed care organizations are increasingly interested in learning to manage the outcome of care rather than just managing the cost of care. It is thought that through a database of outcomes experience, caregivers will know better which treatment modalities result in consistently better outcomes for patients. Outcomes management may lead to the development of clinical protocols. A clinical outcome is the result of medical or surgical intervention or nonintervention. Managed services organizations are now attempting to better manage clinical outcomes for their enrollees to increase the satisfaction of patients and payers while holding down costs.
Outcomes Measurement - System used to systematically track clinical treatment and responses to that treatment. The methods for measuring outcomes are quite varied among providers. Much disagreement exists regarding the best practice or tools to utilize to measure outcomes. In fact, much disagreement exists in the medical field about the definition of outcome itself. A tool to assess the impact of health services in terms of improved quality and/or longevity of life and functioning.
Outcomes Research - Research on measures of changes in patient outcomes, that is, patient health status and satisfaction, resulting from specific medical and health interventions. Attributing changes in outcomes to medical care requires distinguishing the effects of care from the effects of the many other factors that influence patients' health and satisfaction. With the elimination of the physician's fiduciary responsibility to the patient, outcomes data is gaining increasing importance for patient advocacy and consumer protection. Outcomes research will also be used in the future by payers to identify potential partners on the basis of good outcomes.
Outlier - A patient whose length of stay or treatment cost differs substantially from the stays or costs of most other patients in a diagnosis related group. Under DRG reimbursement, outliers are given exceptional treatment subject to peer review and organization review.
Outlier thresholds - The day and cost cutoff points that separate inlier patients from outlier patients.
Out of Area Benefits - Benefits supplied to a patient by a payer or managed care organization when the patient needs services while outside the geographic area of the network. MCOs often attempt to negotiate a case-by-case discount with providers when patients utilize their services while "out of area".
Out of Network Benefits - With most HMOs, a patient cannot have any services reimbursed if provided by a hospital or doctor who is not in the network. With PPOs and other managed care organizations, there may exist a provision for reimbursement of "out of network" providers. Usually this will involve higher copay or a lower reimbursement. See also point of service plans.
Out-of-Network Provider - A health care provider with whom a managed care organization does not have a contract to provide health care services. Because the beneficiary must pay either all of the costs of care from an out-of-network provider or their cost-sharing requirements are greatly increased, depending on the particular plan a beneficiary is in, out-of-network providers are generally not financially accessible to Medicaid beneficiaries.
Out of Pocket Expenses, Out of Pocket Costs - Dollar amounts set by MCOs that limit the amount a member has to pay out of his or her own pocket for particular healthcare services during a particular time period.Costs borne by the member that are not covered by health care plan. Portion of health services or health costs that must be paid for by the plan member, including deductibles, co-payments and co-insurance. In the age of managed care, out of pocket expenses can also refer to the payment of services not covered by or approved for reimbursement by the health plan.
Out of Pocket Limit - A cap placed on out of pocket costs, after which benefits increase to provide full coverage for the rest of the year. It is a stated dollar amount set by the insurance company, in addition to regular premiums.Outpatient Care - Care given a person who is not bedridden. Also called ambulatory care. Many surgeries and treatments are now provided on an outpatient basis, while previously they had been considered reason for inpatient hospitalization. Some say this is the fastest growing segment of healthcare.
Outpatient Hospital Care - Medical or surgical care furnished by a hospital to a patient if that patient has not been admitted as an inpatient but is registered on hospital records as an outpatient. If a doctor orders that a patient be placed under observation, it may be considered outpatient care, even if the patient stays under observation overnight.
This glossary can also be purchased in printed book format if you would like to have a copy for your briefcase or desk.
Copyrightę 1997 - Present Date, Pam Pohly, All Rights Reserved.