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Glossary O-Z

 
OB/GYN: A commonly used abbreviation. OB is short for obstetrics or for an obstetrician, a physician who delivers babies. GYN is short for gynecology or for a gynecologist, a physician who specializes in treating diseases of the female reproductive organs.

Omnibus Budget Reconciliation Act (OBRA) of 1990: A federal act which established the Medicare SELECT program, a Medicare supplement that uses a preferred provider organization to supplement Medicare Part B coverage.

 

Out-of-pocket maximums: Dollar amounts set by MCOs that limit the amount a member has to pay out of his or her own pocket for particular healthcare services during a particular time period.

 

Outpatient care: Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.

PA-C (Physician Assistant - Certified): A mid-level medical practitioner who works under the supervision of a licensed doctor (an MD) or osteopathic physician (a DO).

Patient Bill of Rights: Refers to the Consumer Bill of Rights and Responsibilities, a report prepared by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry in an effort to ensure the security of patient information, promote healthcare quality, and improve the availability of healthcare treatment and services. The report lists a number "rights," subdivided into eight general areas that all healthcare consumers should be guaranteed and describes responsibilities that consumers need to accept for the sake of their own health.

 

Pended: A claims term that refers to a situation in which it is not known whether an authorization has or will be issued for delivery of a healthcare service, and the case has been set aside for review.

 

Pre-existing condition: In group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage.

 

Premium: A prepaid payment or series of payments made to a health plan by purchasers, and often plan members, for medical benefits.

 

Primary care:³⁶ General medical care that is provided directly to a patient without referral from another physician. It is focused on preventative care and the treatment of routine injuries and illnesses.

 

Primary care provider (PCP): A physician or other medical professional who serves as a group member's first contact with a plan's healthcare system. Also known as a primary care physician, personal care physician, or personal care provider.

 

Prior authorization:³⁸ In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review.

 

Prospective authorization: Authorization to deliver healthcare service that is issued before any service is rendered. Also known as pre-certification.

RDH (Registered dental hygienists): Licensed oral health care professionals whose preventive services limit the extent of cavities and periodontal (gum) disease.

 

Subauthorization: The authorization of one healthcare service concurrently with the authorization of another service. For example, an authorization for hospitalization may cover surgery, anesthesia, pathology, and radiology performed during the hospitalization.

 

TRICARE: A healthcare plan, avail-able to more than 6 million military personnel and their families, which is administered by private contractors who are selected for participation through a competitive procurement process. TRICARE offers members three plan options: TRICARE Prime (a capitated HMO with nominal premiums and co-payments), TRICARE Extra (a PPO with standard CHAMPUS deductibles), and TRICARE Standard (the current fee-for-service CHAMPUS plan with provider choice and no premiums). See also Civilian Health and Medical Program of the Uniformed Services.

 

Usual, customary, and reasonable (UCR) fee: The amount commonly charged for a particular medical service by physicians within a particular geographic region. UCR fees are used by traditional health insurance companies as the basis for physician reimbursement.

 

Workers' compensation: A state-mandated insurance program that provides benefits for healthcare costs and lost wages to qualified employees and their dependents if an employee suffers a work-related injury or disease.

 

³⁶ Managed Care at a Glance: Common Terms (Boston, MA: Tufts Managed Institute, 1996), 5.

³⁸ Drug Benefit Trends [1995, 7(2): 6-10] 1997, SCP Communications, Inc.

 

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