|
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
Rate Band - The allowable dissimilarity in insurance premiums as distinct in state regulations. Acceptable variation may be expressed as a ratio from highest to lowest or as a percent from the community rate.
Back to top
Rate Review - Review by a government or private agency of a hospital's budget and financial data, performed for the reason of determining the reasonableness of the hospital rates and evaluating planned rate increases.
Back to top
Rate Spread - The difference between the highest and lowest rates that a health plans which charges for small groups. The National Association of Insurance Commissioner's Small Group Model Act limits a plan's allowable rates extend to 2 to 1.
Back to top
Rating- The process of calculating the suitable premium to charge purchasers, given the degree of risk represented by the individual or group, the expected costs to deliver medical services, and the expected marketability, profitability and competitiveness of the MCO's plan.
Back to top
Real Value - Measurement of an economic amount corrected for alter in price over time thus expressing a value in terms of constant prices.
Back to top
Rebate- A decrease in the price of a particular pharmaceutical obtained by a PBM from the pharmaceutical manufacturer.
Back to top
Receivership- A situation in which the state insurance commissioner, acting for a state court, takes controls of and administers the assets and liabilities of an MCO.
Back to top
Recredentialing- An MCO's periodic review of the qualifications of a present network provider to verify that the provider still meets the standards for participation in the network.
Back to top
Referral- The procedure of sending a patient from one practitioner to another for health care services. Health Plans may require that designated primary care providers approve a referral for coverage of specialty services. Normally, this type of transfer means a written order from the enrollee's primary care doctor for the enrollee to see a specialist or get certain services. In many HMOs or Health Plans, an enrollee must get a referral before the enrollee can obtain care from anyone except the primary care doctor.
Back to top
Referral Authorization - A verbal or written approval of a demand for a Member to receive medical services or supplies.
Back to top
Referral Center - This is a mechanism recognized by health plans to direct patients to approved hospitals and doctors. Often the Referral Center serves a UR function and expert or pre-certifies the care. These centers are also used by hospitals to refer patients to certain doctors, decrease use of the emergency room or to provide follow-up patient contact.
Back to top
Referral Pool - An amount set away to pay for non-capitated services provided by a PCP, services provided by a referral specialist and/or emergency services.
Back to top
Referral Services - Medical Services agreed for by the physician and provided outside the physician's office other than Hospital Services.
Back to top
Refinement- The correction of relative values in Medicare's relative value scale that was originally set incorrectly.
Back to top
Regional Home Health Intermediary (RHHI) - A private company that contracts with Medicare to reimburse home health and hospice bills under Original Medicare and ensure on the quality of home health care.
Back to top
Registered Nurses (RN) - Registered nurses are answerable for carrying out the physician's instructions. They supervise practical nurses and other supplementary personnel who perform routine care and treatment of patients. Registered nurses provide nursing care to patients or perform particular duties in a variety of settings from hospital and clinics to schools and public health departments.
Back to top
Rehabilitation- Rehabilitative services are usually ordered by a doctor to help a patient recover from an illness or injury. These services are set by nurses and physical, occupational, and speech therapists.
Back to top
Reinsurance- An insurance arrangement whereby the MCO or provider is reimbursed by a third party for costs exceeding a pre-set limit, usually an annual maximum. A method of warning the risk that a provider or managed care organization assumes by purchasing insurance that becomes effectual after set amount of health care services have been provided. This insurance is planned to protect a provider from the extraordinary health care costs that just a few beneficiaries with extremely extensive health care needs may incur.
Back to top
Relative Value Scale (RVS) - An index conveying various weights to various medical services. Each weight represents a comparative amount to be paid for each service. The RVS used in the development of the Medicare Fee Schedule for physicians consists of three cost components such as physician work, practice expense, and malpractice expense.
Back to top
Relative Value Unit (RVU) - It is a unit of measure for a relative value scale. RVUs must be multiplied by a dollar exchange factor to become payment amounts. This is a common expression in economics. RVUs are often used in physician practice management to evaluate performance of doctors within a group.
Back to top
Renewal Underwriting - The method by which an underwriter reviews each year all the selection factors that were measured when the contract was issued, then compares the group's actual use rates to those the MCO predicted to determine the group's new renewal rate.
Back to top
Report Card - An accounting of the quality of services, used to compare among providers over time. The report card measures and compares providers on predetermined, quantifiable quality and other outcome indicators. Hospitals and insurance companies may issue their report card results if favorable. Generally, consumers use report cards to select a health plan or provider, while policy makers may use report card results to determine overall program effectiveness, efficiency, and financial stability.
Back to top
Repricer- A person, an organization, or a software package that reviews procedures, diagnoses, fee schedules, and other data and determines the entitled amount for a given health care service or supply. Additional criteria can then be applied to decide the actual allowance, or payment, amount.
Back to top
Research- When used by HIPAA, this term refers to a methodical investigation, including research development, testing and evaluation, designed to develop or add to generalizable knowledge.
Back to top
Reserves- Monies earmarked by health plans to cover expected claims and operating expenses. A fiscal method of withholding a sure percentage of premiums to provide a fund for committed but undelivered health care and such uncertainties are longer hospital utilization levels than expected, over-utilization of referrals, accidental catastrophes and the like.
Back to top
Resource-Based Relative Value Scale (RBRVS) - A schedule of values assigned to health care services that give weight to procedures based upon resources wanted by the provider to efficiently deliver the service or perform that procedure. Unlike other relative value scales, RBRVS ignore historical charges and includes factors such as time, effort, technical skill, practice cost, and training cost.
Back to top
Retiree- An individual who is providing coverage under a group health plan after that individual has retired.
Back to top
Retrospective Rating - Insurance coverage that provides for premium purpose at the end of the coverage period, focus to a minimum and maximum based upon actual experience.
Back to top
Retrospective Review Process - System for analyzing medical requirement and correctness of services rendered. The review focuses on determining the appropriateness, necessity, quality, and sensibleness of health care services provided. Becoming seen as least attractive method supplanted by concurrent reviews. When conducted by an MCO, this occurs after treatment is finished in order to authorize payment and medical necessity and appropriateness of care.
Back to top
Revenue Share - The amount of a practice's total revenue devoted to a particular type of expense. For instance, the practice expense revenue share is that proportion of revenue used to pay for practice expense.
Back to top
Risk- The chance or opportunity of loss. Potential financial liability, particularly with respect to whom or what is legally responsible for that liability. With insurance, the patient and insurance company distribute risk but the company's risk is limited by the policy's dollar limitations.
Back to top
Risk-Adjusted Capitation - An actuarial term, this refers to method of payment to providers which reflects fixed payment amounts per member per month and then is attuned further to take into account the lower or higher costs of providing care to individuals or groups of individuals, based on health position or characteristics.
Back to top
Risk Adjuster - A measure used to regulate payments made to carriers or payers on behalf of a group of enrollees in order to recompense for spending, that is probable to be lower or higher than average, based on the health status or demographic characteristics of the enrollees.
Back to top
Risk Adjustment - The way that payments to health plans are altered to take into account a person's health status. A system of adjusting rates remunerated to managed care providers to account for the differences in beneficiary demographics, such as age, gender, race, ethnicity.
Back to top
Risk Assessment - Anticipating the cost to provide health care to groups of enrollees. Actuarial assessments examine use history, demographics, health characteristics, environmental attributes, and other sociological, economic and market characteristics. Risk assessment can also comprise, less commonly, the identification of etiology of health problems.
Back to top
Risk-Bearing Entity - An organization that assumes financial liability for the provision of a defined set of benefits by accepting prepayment for some or all of the cost of care. A risk-bearing entity may be an insurer, a health plan or self-funded employer; or a PHO or other type of PSN.
Back to top
Risk Contract - A risk contract is largely any contract that results in any party assuming insurance or business risk. Normally this means, in health care, that if the employer, health plan or provider assumes risk, it is approving to cover the expense of increased utilization beyond the projected costs or payment provided. Normally risk is understood by the health plan or insurance carrier but can be accepted by the provider in capitated arrangements or by the employer in self-insured arrangements.
Back to top
Risk Corridor - A financial agreement between a payer of health care services, such as a state Medicaid agency, and a provider, such as a managed care organization that spreads the risk for providing health care services. Risk corridors protect the provider from extreme care costs for individual beneficiaries by instituting stop-loss protections and they defend the payer by limiting the profits that the provider may earn.
Back to top
Risk Factor - Any characteristic, behavior, or form which, based on history, utilization, or theory, is thought to directly manipulate susceptibility to a specific health problem, increase costs or result in increased utilization.
Back to top
Risk Selection - Occurrence when a disproportionate allocate of high or low users of care joins a health plan.
Back to top
Risk Sharing - The sharing of financial risk among parties furnishing a service. Methods by which medical insurance premiums which can be shared by plan sponsors and participants. In contrast to traditional protection plans in which insurance premiums belonged solely to insurance company that assumed all risk of using these premiums.
Back to top
Routine Exams/Routine Examinations - Any physical exam or assessment done, in accordance with our guidelines for age and sex, when an exam is otherwise not indicated for the treatment of an existing or known injury or sickness.
Back to top
Rural Health Clinic (RHC)- A public or private hospital, clinic or physician practice chosen by the federal government as in compliance with the Rural Health Clinics Act. The practice must be situated in a Medically Underserved area or a Health Professions Shortage Area and use a physician assistant and/or nurse practitioners to deliver services. A rural health clinic must be approved by the state and provide preventive services. These providers are usually capable for special compensations, reimbursements and exemptions.
Back to top
Rural Health Clinics Act - Establishes a reimbursement mechanism to maintain the provision of primary care services in rural areas. Public Law 95-210 was enacted in 1977 and authorizes the extended use of physician assistants, nurse practitioners and certified nurse practitioners extends Medicare and Medicaid reimbursement to designated clinics and raises Medicaid reimbursement levels to those set by Medicare.
Back to top
|
