A single payment for all services associated with treating an episode of care for a specific diagnostic course of treatment.
A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member’s health care services for a certain length of time. The payment is the same no matter how many services or what type of services each patient actually gets during that period.
A process whereby covered persons with specific health care needs are identified and a plan is developed which utilizes health care resources to achieve the optimum patient outcome in the most efficient, cost-effective manner. It typically integrates care provided by all stakeholders – the payer, the provider, the patient and the family – in an effort to find the most appropriate treatment for that person.
An approach of providing integrated services to consumers over changing levels of care.
A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management supports the physician or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes in an ongoing basis with the goal of improving overall health.
Detailed service records submitted by provider organizations to managed care plans that enable organizations to track the services received by members.
A database of consumer healthcare demographic, diagnostic and other date that is used to optimize care and identify patients who need services.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.
The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 promotes the adoption and meaningful use of health information technology.
An approach to improving the outcomes of a group of healthcare consumers by using demographic, diagnostic and other information to identify high risk individuals and determine the most effective interventions to improve their outcomes and reduce the total cost of care.
The administrative and clinical processes from the time a consumer appointment is scheduled through claims processes that ensure that all healthcare services are paid. The main stages of the revenue cycle include referral and intake, service provision and documentation, billing and collections, and analytics and performance improvement.
Assessment tools to assess health status, risks and habits to determine the most appropriate level of care and treatment plan.
Creation of a care plan that reflects the most appropriate level of care based on the status, risks and habits of a consumer.
A financial arrangement where an insurance payer and provider share the financial risk associated with healthcare services to a group of consumers.
A financial arrangement where an insurance payer and provider share the savings from reducing the total cost of care on a group of consumers by implementing services that reduce unneeded services and improving outcomes.
The process of using data (e.g., claims, survey, lab) to place patients into general categories of prioritization for resources or services. Organizations often conduct stratification in conjunction with patient assessment. Stratification systems are dynamic processes, and a patient’s stratification may change according to changes in status with respect to any factor. The frequency of patient restratification may vary.
The maximum cost for a service that provides a desired profit based based on an anticipated rate.
The direct and indirect healthcare costs for all services of all providers for episode of care of a consumer over a period of healthcare coverage.
The total direct and indirect costs of one unit of defined service that is calculated by dividing the total costs by the total services over a defined period of time.
