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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 like to have it handy at all times.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) - The Federal law that created the current risk and cost contract provisions under which health plans contract with CMS (formerly HCFA). Legislation that created the target rate of increase cost based limits on reimbursements for inpatient operating costs. These limits are considered per Medicare discharges total amounts. A facility's target amount is derived from costs in its base year (1st full fiscal year of operation with application to CMS as same) updated to the current fiscal year by the annual allowable rate of increase. Medicare payments for operating costs generally may not exceed the facility's target amount and still be paid by CMS. These provisions apply to hospitals and units excluded from PPS and DRG. When cost reports fall short of the TEFRA limit, certain paybacks are provided. If costs exceed TEFRA, facilities can submit an exception report and may or may not be provided additional payment. Many facilities that established TEFRA limits in the early 1980s are finding they consistently exceed their TEFRA limits. Units normally under the TEFRA rules are psychiatric units, rehab units, free standing specialty hospitals, oncology outpatient clinics and others.
Telehealth, Telemedicine, Telehealth, E-Health - The use of telecommunications (i.e., wire, internet, radio, optical or electromagnetic channels transmitting text, x-ray, images, records, voice, data or video) to facilitate medical diagnosis, patient care, patient education and/or medical learning. Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site. Many rural areas are finding uses for telehealth and telemedicine in providing oncology, home health, ER, radiology and psychiatry among others. Telehealth services have been used between providers, to provide supervision of one another and to provide evaluation of patients. Medicaid and Medicare provide some limited reimbursement for certain services provided to patients via telecommunication. Telehealth is likely to serve greater purposes and populations in the future.
Termination Date - Date that a group contract expires or an individual is no longer eligible for benefits.
Termination Provision - A provider contract clause that describes how and under what circumstances the parties may end the contract.
Termination With Cause - A contract provision, included in all standard provider contracts, that allows either the MCO or the provider to terminate the contract when the other party does not live up to its contractual obligations.
Tertiary Care - Services provided by highly specialized providers such as neurosurgeons, thoracic surgeons and intensive care units. These services often require highly sophisticated technology and facilities.
TFL - See TRICARE for Life.
Therapeutic Alternatives – Drug products that provide the same pharmacological or chemical effect in equivalent doses. Also see Formulation Substitution.
Therapeutic Equivalency - Drug products that provide the same pharmacological or chemical effect in equivalent doses. Also see Formulation Substitution.
Therapeutic Substitution - The dispensing of a different chemical entity within the same drug class of a drug listed on a pharmacy benefit management plan's formulary. Therapeutic substitution always requires physician approval.
Third Party Administrator (TPA) - An independent organization that provides administrative services including claims processing and underwriting for other entities, such as insurance companies or employers. Often insurance companies will contract as TPAs with other insurance companies or health plans. TPAs are not always insurance companies. TPAs are organizations with expertise and capability to administer all or a portion of the claims process. Self-insured employers will often contract with TPAs to handle their insurance functions. Insurance companies will sometimes outsource the claims, UR or membership functions to a TPA. Sometimes TPAs will only manage provider networks, only claims or only UR. Hospitals or provider organizations desiring to set up their own health plans will often outsource certain responsibilities to TPAs. TPAs are prominent players in the managed care industry.
See also Fiscal Intermediary.
Third-Party Payment - Payment by a financial agent such as an HMO, insurance company or government rather than direct payment by the patient for medical care services. The payment for health care when the beneficiary is not making payment, in whole or in part, in his own behalf.
Third-Party Payer - Any organization, public or private that pays or insures health or medical expenses on behalf of beneficiaries or recipients. An individual pays a premium for such coverage in all private and in some public programs; the payer organization then pays bills on the individual's behalf. Such payments are called third-party payments and are distinguished by the separation among the individual receiving the service (the first party), the individual or institution providing it (the second party), and the organization paying for it (third party).
Three-Tier Copayment Structure - A pharmacy benefit copayment system under which a member is required to pay one copayment amount for a generic drug, a higher copay-ment amount for a brand-name drug included on the health plan's formulary, and an even higher copayment amount for a nonformulary drug. Also see Tiered Formulary.
Tiers - To have lower costs, many Prescription Drug Plans place drugs into different "tiers," which cost different amounts. Each plan can form their tiers in different ways. Here is an example of how a plan might form its tiers. One example may be: Tier 1 - Generic drugs, Tier 2 - Preferred brand-name drugs, Tier 3 - Non-preferred brand-name drugs. See also Prescription Drug Plan.
Tiered Formulary - List of preferred prescription drugs in which different drugs have different co-pays, according to the policies of Drug Plans or Prescription Drug Benefits. Each drug is assigned to a specific ‘tier’ within the formulary. The most cost-effective drugs, often generic drugs, belong to the most preferred tier and typically have the lowest co-pay, whereas the least cost effective drugs belong to the least preferred tier and have the highest co-pay. Tiered formularies encourage consumers to be cost-conscious in choosing their medications, and reward consumers for choosing generic medications by requiring lower co-pay. Tiered formularies may also provide some level of coverage for prescriptions that might not otherwise be covered. See also Formulary, Generic Drugs or Prescription Drug Plan.
Title XVIII (Medicare) - The title of the Social Security Act that contains the principal legislative authority for the Medicare program and therefore a common name for the program.
See also Medicare.
Title XIX (Medicaid) - The title of the Social Security Act that contains the principal legislative authority for the Medicaid program and therefore a common name for the program.
See also Medicaid.
Tort Reform - Legislative limits or changes or judicial reform of the rules governing medical malpractice lawsuits and other lawsuits. Tort simply refers to lawsuit. Reform implies that limits can be placed on individual rights to sue or on the amounts or situations for which they can seek relief. Tort is considered to be by some as the primary cause of the rising costs of health care. Reform, then, would lower health care costs. On the other hand, patient advocates are against tort reform, claiming that the health care industry and managed care industries require monitoring and that lawsuits keep health care providers and payers in check. Advocates explain that law suits may be the patients' only avenue for redress or restitution from healthcare providers that have been negligent, fraudulent, abusive or careless. The US Congress debates tort reform and many state legislatures have enacted tort reform laws.
Total Budget - Otherwise known as a "global" budget, a cap on overall health spending.
Total Margin - A measure that compares total hospital revenue and expenses for inpatient, outpatient, and non-patient care activities. The total margin is calculated by subtracting total expenses from total revenue and dividing by total revenue.
Total Quality Management (TQM) - Related to quality management, TQM identifies required system elements to measure, design, and select processes that consistently deliver superior outcomes. These fundamentals make up the basis for TQM. See also Quality Improvement.
TPA - See Third Party Administrator.
TQM - See Total Quality Management.
Tracking of Disclosures - The HIPAA Privacy Rule gives individuals the right to request an accounting of disclosures of protected health information over the previous six years. If an individual authorizes uses or disclosures for research, the disclosures do not need to be tracked, but disclosures must be tracked if the researcher receives an IRB-approved waiver of authorization. The accounting of disclosures generally must include: the date of the disclosure, the name of the entity or person (and address if known) who received the protected health information, a brief description of the information disclosed, and a brief statement of the purpose of the disclosure. The Rule allows for an alternative tracking option is available for research involving 50 or more people.
Transaction – Usually refers to the exchange of information for administrative or financial purposes such as health insurance claims or payment.
Under HIPAA, this is the exchange of information between two parties to carry out financial or administrative activities related to health care.
Transfer - Movement of a patient between hospitals or between units in a given hospital. In Medicare, a full DRG rate is paid only for transferred patients that are defined as discharged. In managed care, transfers are often suggested by UR entities to move patients to lower cost care facilities.
Treatment - The provision of health care by one or more health care providers. Treatment includes any consultation, referral or other exchanges of information to manage a patient's care. The HIPAA Privacy Notice explains that the HIPAA Privacy Rule allows Partners and its affiliates to use and disclose protected health information for treatment purposes without specific authorization.
Treatment Episode - The period of treatment between admission and discharge from a modality, e.g., inpatient, residential, partial hospitalization, and outpatient, or the period of time between the first procedure and last procedure on an outpatient basis for a given diagnosis. Many healthcare statistics and profiles use this unit as a base for comparisons.
Trending - Methods of estimating future costs of health services by reviewing past trends in cost and utilization of these services. Also see Actuarial.
Triage - Triage is the act of categorizing patients according to acuity and by determining that need services first. Most commonly occurs in emergency rooms, but, can occur in any healthcare setting. Classification of ill or injured persons by severity of condition. Designed to maximize and create the most efficient use of scarce resources of medical personnel and facilities.
Triage Center - Managed care organizations, health plans and provider systems are setting up programs or clinics called "triage centers". These centers serve as an extension of the utilization review process, as diversions from emergency room care or as case management resources. These triage centers also serve to steer patients away from more costly care (for example, a child with a cold is steered away from an emergency room). Triage can also be handled on the telephone and be called a pre-authorization center, crisis center, call center or information line.
See also Referral Center or Pre-Authorization or Prior Approval.
Triage Providers - Medical personnel who classify ill or injured persons by severity of condition. When providers or insurance companies manage triage on the telephone, this service may be referred to as pre-authorization center, crisis center, call center or information line. Providers may also manage triage in emergency rooms, walk-in centers, disaster scenes or outreach centers.
TRICARE - A health care program for active duty and retired uniformed services members and their families.
TRICARE Extra - A reduced fee-for-service (FFS) plan similar to the network portion of a PPO.
TRICARE for Life (TFL) - Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses.
TRICARE Prime - An enrollment-based managed care option designed to provide coordinated care managed by a primary care manager, who is similar to a primary care provider in a commercial HMO.
TRICARE Standard - A fee-for-service plan that allows participants to use TRICARE authorized providers or non-network providers.Triple Option Plan - A plan (usually offered by a single carrier or a joint venture between two or more carriers) that gives subscribers or employees a choice among HMO, PPO and traditional indemnity plans. Also see Cafeteria Plan.
Two-Tier Copayment Structure - A pharmacy benefit copayment system under which a member is required to pay one copayment amount for a generic drug and a higher copayment amount for a brand-name drug. See Tiered Formulary.
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.