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You are here > Home > Managed Care Terminology > U 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.
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 | Search | U UB-92
(Uniform
Billing Code of 1992) - Bill form used to submit hospital insurance
claims for payment by third parties. Similar to legacy HCFA 1500, but reserved for the
inpatient component of health services. UCR - See Usual, Customary and Reasonable. UM - See Utilization Management. Unassigned Claim - A claim submitted for a service or supply by a provider who does not accept assignment. Also see Assignment of Benefits. Unbundling - A coding inconsistency that involves
separating a procedure into parts and charging for each part rather than using a
single code. The practice of providers billing for a
package of health care procedures on an individual basis when a single procedure
could be used to describe the combined service. Uncompensated Care
- Service provided by
physicians and hospitals for which no payment is received from the patient or
from third-party payers. Some costs for these services may be covered through
cost-shifting. Not all uncompensated care results from charity care. It also
includes bad debts from persons who are not classified as charity cases but who
are unable or unwilling to pay their bill. See cost shifting. Underinsured - People with public or private insurance
policies that do not cover all necessary health care services, resulting in
out-of-pocket expenses that exceed their ability to pay. See cost shifting. Underwriting - Process of selecting, classifying, analyzing and assuming risk according to insurability. The insurance function bearing the risk of adverse price fluctuations during a particular period. Analysis of a group that is done to determine rates or to determine whether the group should be offered coverage at all. Underwriting Impairments - Factors that tend to increase an individual's risk above that which is normal for his or her age. Underwriting Manual - A document that provides background information about various underwriting impairments and suggests the appropriate action to take if such impairments exist. Underwriting Requirements - Requirements, sometimes relating to group characteristics or financing measures, that MCOs at times impose in order to provide healthcare coverage to a given group and which are designed to balance a health plan's knowledge of a proposed group with the ability of the group to voluntarily select against the plan. Also see Antiselection. Uninsured - People who lack public or private health
insurance. Universal Access -
The right and ability to
receive a comprehensive, uniform, and affordable set of confidential,
appropriate, and effective health services. Universal service is a reality in
countries with national medicine programs or socialized healthcare, such as the
UK, Canada, France and most countries in the world. Few countries have the
private insurance programs as the primary form of healthcare, as in the US. See
Universal Coverage. Universal Coverage - A type of government sponsored health plan
that would provide healthcare coverage to all citizens. This is an aspect of
Clinton's original health plan in the mid 1990s and is an attribute of national
health insurance plans similar to those offered in other countries such as the
UK or Canada. While government sponsored health care is not likely to be
universal, politicians in Washington continuously discuss the concept of
providing healthcare to all Americans. Expect to see more and more discussion of
modified universal coverage ideas in the years to come. See also National Health
Insurance. Update Factor - The year-to-year increase in base payment amounts for PPS and excluded hospitals and dialysis facilities. The update factors generally are legislated by the Congress after considering annual recommendations provided by ProPAC and HHS. Upcoding - A coding inconsistency that involves using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider. UR - See Utilization Review. URO - See Utilization Review Organization. Urgently Needed Care - A CMS term, it refers to care that an enrollee receives for a sudden illness or injury that needs medical care right away, but is not life threatening. Primary care doctor generally provides urgently needed care if the enrollee is in a Medicare health plan other than the Original Medicare Plan. If the enrollee is out of your plan's service area for a short time and cannot wait until returning home, the health plan must pay for urgently needed care. Urgent Services - Benefits covered in an Evidence of Coverage
that are required in order to prevent serious deterioration of an insured's
health that results from an unforeseen illness or injury. Use – Under HIPAA, this term refers to the sharing
of individually identifiable health information within a covered entity. For
Partners' purposes, a use is the sharing of such information within the Partners
affiliated covered entity. U.S. Per Capita
Cost (USPCC) - The national
average cost per Medicare beneficiary, calculated annually by CMS’s Office of
the Actuary. See also Capitation or CMS. Usual, Customary
and Reasonable (UCR) - Referring to charges for medical services,
the UCR is the amount a health plan will recognize for
payment for a particular medical procedure. It is typically based on what is
considered "reasonable" for that procedure in your service area.
Commonly charged fees for health services in a certain area. The use of fee
screens to determine the lowest value of provider reimbursement based on: (1)
the provider's usual charge for a given procedure, (2) the amount customarily
charged for the service by other providers in the area (often defined as a
specific percentile of all charges in the community), and (3) the reasonable
cost of services for a given patient after medical review of the case. Most
health plans provide reimbursement for usual and customary charges, although no
universal formula has been established for these rates. Utilization - Use of services and supplies. Utilization is
commonly examined in terms of patterns or rates of use of a single service or
type of service such as hospital care, physician visits, and prescription drugs.
Measurement of utilization of all medical services in combination is usually
done in terms of dollar expenditures. Use is expressed in rates per unit of
population at risk for a given period such as the number of admissions to the
hospital per 1,000 persons over age 65 per year, or the number of visits to a
physician per person per year for an annual physical. See also UR, UM. Utilization
Management (UM) - The
process of evaluating the necessity, appropriateness and efficiency of health
care services against established guidelines and criteria. Evaluation of the
necessity, appropriateness, and efficiency of the use of health care services,
procedures, and facilities. UM usually includes new actions or decisions based
on the overall analysis of the utilization. Utilization Management Committee - The MCO committee that reviews and updates the MCO's utilization management program, establishes utilization review protocols, reviews referral and utilization patterns, and reviews utilization decisions for medical appropriateness. Utilization Review
(UR)
- A formal review of utilization for appropriateness of health care services
delivered to a member on a prospective, concurrent or retrospective basis. In a
hospital, this includes review of the appropriateness of admissions, services
ordered and provided, length of a stay, and discharge practices, both on a
concurrent and retrospective basis. A peer review group, or a public agency can
do utilization review. UR is a method of tracking, reviewing and rendering
opinions regarding care provided to patients. Usually UR involves the use of
protocols, benchmarks or data with which to compare specific cases to an
aggregate set of cases. Those cases falling outside the protocols or range of
data are reviewed individually. Managed care organizations will sometimes refuse
to reimburse or pay for services that do not meet their own sets of UR
standards. UR involves the review of patient records and patient bills primarily
but may also include telephone conversations with providers. The practices of
pre-certification, re-certification, retrospective review and concurrent review
all describe UR methods. UR is one of the primary tools utilized by IDS, MCO and
health plans to control over-utilization, reduce costs and manage care. 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. |
