Managed Care Terminology


The best Guide For Managed Care Terminalogy that we have found is from Pohly’s Net Guide

It Starts out with:

AAPCC – see Adjusted Average Per Capita Cost.

ABC – see Activity-Based Costing.

Abuse – When used as a legal term in the business of healthcare, it normally refers to actions that do not involve intentional misrepresentations in billing but which, nevertheless, result in improper conduct. Consequences can result in civil liability and administrative sanctions. An example of abuse is the excessive use of medical supplies. (Also see Fraud, OIG, FBI, and Compliance)

Access – The patient’s ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care. An individual’s ability to obtain appropriate health care services. Barriers to access can be financial (insufficient monetary resources), geographic (distance to providers), organizational (lack of available providers) and sociological (e.g., discrimination, language barriers). Efforts to improve access often focus on providing/improving health coverage.

Accountable Health Plan (AHP) – AHPs can be IDSs, MCOs, Health Networks, partnerships or joint ventures between practitioners, providers or payers that would assume responsibility for delivering medical care and managing the funds required to pay for the services rendered. Physicians and other providers would work for, contract with or own these health plans. When an IDS or hospital group or IPA operates one or more health insurance benefit products, or a managed care organization acquires a large scale medical delivery component, it qualifies as an Accountable Health System or Accountable Health Plan.

Accountable Health Partnership – An organization of doctors and hospitals that provides care for people organized into large groups of purchasers.

Accreditation–The process by which an organization recognizes an institution as meeting predetermined standards

Accrual – The amount of money that is set aside to cover expenses. The accrual is the plan’s best estimate of what those expenses are, and (for medical expenses) is based on a combination of data from the authorization system, the claims system, lag studies, and the plan’s prior history.

ACR – see Adjusted Community Rate.

Actively-at-Work – Describes insurer’s policy requirement indicating that coverage will not go into effect until the employee’s first day of work on or after the effective date of coverage. May also apply to dependents disabled on the effective date.

Activities of Daily Living (ADL’s, ADL) – An individual’s daily habits such as bathing, dressing and eating. ADLs are often used as an assessment tool to determine an individual’s ability to function at home, or in a less restricted environment of care.

Activity-Based Costing (ABC) – Activity-based costing defines healthcare costs in terms of a healthcare organization’s processes or activities. The costs are then associated with significant activities or events. It relies on the following 3 step process: 1) Activity mapping, which involves mapping activities in an illustrated sequence; 2) Activity analysis, which involves defining and assigning a time value to activities; and, 3) bill of activities, which involves generating a cost for each main activity.

Actuarial – Refers to the statistical calculations used to determine the managed care company’s rates and premiums charged their customers based on projections of utilization and cost for a defined population.

Actuarial Equivalent – Relates to the statistical calculation of risk and used to describe a health plan that has an equivalent statistical calculation of risk as another plan. For example, under Medicare rules, A plan sponsor must offer a prescription drug plan that is actuarially (a term relating to the statistical calculation of risk) the same or better than the Medicare Part D prescription drug pl

Actuarial Soundness–The requirement that the development of capitation rates meet common actuarial principles and rules.

Acute Care – A pattern of health care in which a patient is treated for an acute (immediate and severe) episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Specialized personnel using complex and sophisticated technical equipment and materials usually give acute care in a hospital. Unlike chronic care, acute care is often necessary for only a short time.

Adjudication – Processing claims according to contract.

Adjusted Admissions – Adjusted admissions are equivalent to the sum of inpatient admissions and an estimate of the volume of outpatient services. This is a measure of all patient care activity undertaken in a hospital, both inpatient and outpatient. This estimate is calculated by multiplying outpatient visits by the ratio of outpatient charges per visit to inpatient charges per admission.

Claire Goldsmith MidPage