Preferred Provider Organizations: Arrangements negotiated between a third-party payer (often a self-insured company or union trust fund) and a group of health-care providers (hospitals and physicians) who furnish services at lower than usual fees, and, in return, receive prompt payment and an expectation of an increased volume of patients.Medical Savings Accounts: Tax-exempt trusts or custodial accounts established by individuals with financial institutions for saving money for future medical expenses.Managed Care Programs: Health insurance plans intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as HEALTH MAINTENANCE ORGANIZATIONS and PREFERRED PROVIDER ORGANIZATIONS.Blue Cross Blue Shield Insurance Plans: Prepaid health and hospital insurance plan.Reimbursement, Incentive: A scheme which provides reimbursement for the health services rendered, generally by an institution, and which provides added financial rewards if certain conditions are met. Such a scheme is intended to promote and reward increased efficiency and cost containment, with better care, or at least without adverse effect on the quality of the care rendered.Provider-Sponsored Organizations: Entities sponsored by local hospitals, physician groups, and other licensed providers which are affiliated through common ownership or control and share financial risk whose purpose is to deliver health care services.Health Benefit Plans, Employee: Health insurance plans for employees, and generally including their dependents, usually on a cost-sharing basis with the employer paying a percentage of the premium.Cost Sharing: Provisions of an insurance policy that require the insured to pay some portion of covered expenses. Several forms of sharing are in use, e.g., deductibles, coinsurance, and copayments. Cost sharing does not refer to or include amounts paid in premiums for the coverage. (From Dictionary of Health Services Management, 2d ed)Fees, Dental: Amounts charged to the patient as payer for dental services.Health Maintenance Organizations: Organized systems for providing comprehensive prepaid health care that have five basic attributes: (1) provide care in a defined geographic area; (2) provide or ensure delivery of an agreed-upon set of basic and supplemental health maintenance and treatment services; (3) provide care to a voluntarily enrolled group of persons; (4) require their enrollees to use the services of designated providers; and (5) receive reimbursement through a predetermined, fixed, periodic prepayment made by the enrollee without regard to the degree of services provided. (From Facts on File Dictionary of Health Care Management, 1988)Employer Health Costs: That portion of total HEALTH CARE COSTS borne by an individual's or group's employing organization.Economic Competition: The effort of two or more parties to secure the business of a third party by offering, usually under fair or equitable rules of business practice, the most favorable terms.Insurance Selection Bias: Adverse or favorable selection bias exhibited by insurers or enrollees resulting in disproportionate enrollment of certain groups of people.Deductibles and Coinsurance: Cost-sharing mechanisms that provide for payment by the insured of some portion of covered expenses. Deductibles are the amounts paid by the insured under a health insurance contract before benefits become payable; coinsurance is the provision under which the insured pays part of the medical bill, usually according to a fixed percentage, when benefits become payable.Insurance Claim Review: Review of claims by insurance companies to determine liability and amount of payment for various services. The review may also include determination of eligibility of the claimant or beneficiary or of the provider of the benefit; determination that the benefit is covered or not payable under another policy; or determination that the service was necessary and of reasonable cost and quality.United StatesConsumer Participation: Community or individual involvement in the decision-making process.Insurance, Health: Insurance providing coverage of medical, surgical, or hospital care in general or for which there is no specific heading.Quality Assurance, Health Care: Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.Insurance Coverage: Generally refers to the amount of protection available and the kind of loss which would be paid for under an insurance contract with an insurer. (Slee & Slee, Health Care Terms, 2d ed)Health Services Research: The integration of epidemiologic, sociological, economic, and other analytic sciences in the study of health services. Health services research is usually concerned with relationships between need, demand, supply, use, and outcome of health services. The aim of the research is evaluation, particularly in terms of structure, process, output, and outcome. (From Last, Dictionary of Epidemiology, 2d ed)Health Personnel: Men and women working in the provision of health services, whether as individual practitioners or employees of health institutions and programs, whether or not professionally trained, and whether or not subject to public regulation. (From A Discursive Dictionary of Health Care, 1976)World Health Organization: A specialized agency of the United Nations designed as a coordinating authority on international health work; its aim is to promote the attainment of the highest possible level of health by all peoples.Organizations: Administration and functional structures for the purpose of collectively systematizing activities for a particular goal.
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