Healthcare

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Reasonable and Customary (R &C)

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a term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. This term can also be referred to as "Prevailing Rate", "Covered Charge", "Allowable Charge" and/or "Usual" "Reasonable" and "Customary" amount.

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Diagnosis Related Group (DRG)

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DRGs form the cornerstone of the prospective payment system. A DRG is a cluster of diagnoses that are expected to require comparable hospital resources and lengths of stay.

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Durable Medical Equipment (DME)

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Devices which are very resistant to wear and may be used over a long period of time. DME includes items such as wheelchairs, hospital beds, artificial limbs, etc.

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IPA

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Independent Practice Association (IPA) IPAs are networks of independent physicians that contract with MCOs and employers. IPAs may be organized as sole proprietorships, partnerships, or professional corporations.

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Medicare + Choice

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Medicare + Choice (M+C) Also known as Medicare Part C. The Balanced Budget Act of 1997 (BBA) established the Medicare+Choice program. Under this program, an eligible individual may elect to receive Medicare benefits through enrollment in a Medicare+Choice plan, which generally takes the form of a MCO.

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PHO

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Physician-Hospital Organization (PHO) A PHO is a joint venture between a hospital and some or all of the physicians who have admitting privileges at the hospital.

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TPA

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Third-Party Administrator (TPA) A firm that performs administrative functions (e.g., claims processing, membership) for a self-funded plan or a start-up MCO.

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ARM

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Adjusted Community Rate (ACR)

Health plans and insurance companies estimate their ACRs annually and adjust subsequent year supplemental benefits or premiums to return any excess Medicare revenue above the ACR to enrollees. This are the estimated payment rates that health plans with Medicare risk contracts would have received for their Medicare enrollees if paid their private market premiums, adjusted for differences in benefit packages and service use.

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Admissions per 1000

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Admissions Per 1,000

Number of patients admitted to a hospital or hospitals per 1,000 health plan members. An indicator calculated by taking the total number of inpatient and/or outpatient admissions from a specific group, e.g., employer group, HMO population at risk, for a specific period of time (usually one year), dividing it by the average number of covered members in that group during the same period, and multiplying the result by 1,000. This indicator can be calculated for behavioral health or any disease in the aggregate and by modality of treatment, e.g., inpatient, residential, and partial hospitalization, etc.

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Alternative Delivery System

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Alternate Delivery Systems

Health services provided in other than an inpatient, acute-care hospital or private practice. Examples within general health services include skilled and intermediary nursing facilities, hospice programs, and home health care. Alternate delivery systems are designed to provide needed services in a more cost-effective manner. Most of the services provided by community mental health centers fall into this category.