Managed Care Glossary of Terms

(DUA) Data Use Agreement
HIPAA Regulation states that a health care entity may use or disclose a "limited data set" if that entity obtains a data use agreement from the potential recipient and can only be used for research, public health or healthcare operations. Relates to privacy rules of HIPAA.

(DBMS) Database Management System
The separation of data from the computer application that allows entry or editing of data.

Day Outlier
A patient with an atypically long length of stay compared with other patients in a particular diagnosis related group.

Days (Or Visits) Per Thousand
A standard unit of measurement of utilization. Refers to an annualized use of the hospital or other institutional care. It is the number of hospital days that are used in a year for each thousand covered lives. The formula used to calculate days per thousand is as follows: (# of days/member months) x (1000 members) x (# of months). An indicator calculated by taking the total number of days (for inpatient, residential, or partial hospitalization) or visits (for outpatient) received by a specific group for a specific period of time (usually one year). A measure used to evaluate utilization management performance.

Decision Support Systems
Computer technologies used in healthcare which allow providers to collect and analyze data in more sophisticated and complex ways. Activities supported include case mix, budgeting, cost accounting, clinical protocols and pathways, outcomes, and actuarial analysis.

Deductible Carry Over credit
Charge incurred during the last three months of a year that may be applied to the deductible and which may be carried over into the next year.

Deductibles
Amounts required to be paid by the insured under a health insurance contract, before benefits become payable.

Defensive Medicine
Doctors in recent years have admitted to and have been accused of prescribing additional tests or procedures to justify their care, strengthen support for their decisions or simply to corraborate their diagnosis. This defensiveness is a result of law suits, malpractice claims and the onslaught of external UR entities questioning care decisions. Defensive medicine is said to be one of the primary causes of the increasing cost of health care. Many physicians and the AMA fight for tort reform to reduce the need for defensive medicine.

Defined Contribution Coverage
A payment process for procurement of health benefit plans whereby employers contribute a specific dollar amount toward the costs of insurance coverage for their employees. Sometimes this includes an undefined expectation of guarantee of the specific benefits to be covered.

(HHS) Department of Health and Human Services
The federal agency that oversees Medicare, Medicaid and other federal health care programs. (also see DOJ, Fraud and FBI)

(DOJ) Department of Justice
The federal agency that enforces the law and handles criminal investigations. As the nation's largest law firm, the DOJ protects citizens through effective law enforcement, crime prevention and crime detection. It is the agency that prosecutes those in the health care system guilty of proven "fraudulent" activity. (also see Fraud and FBI)

Dependent
Person covered by someone else's health plan. In a payer's policy of insurance, a person other than the subscriber eligible to receive care because of a subscriber's contract.

Designated Mental Health Provider
Person or place authorized by a health plan to provide or suggest appropriate mental health and substance abuse care.

(DRG) Diagnosis Related Groups
An inpatient or hospital classification system used to pay a hospital or other provider for their services and to categorize illness by diagnosis and treatment. A classification scheme used by Medicare that clusters patients into 468 categories on the basis of patients' illnesses, diseases and medical problems. Groupings of diagnostic categories drawn from the International Classification of Diseases and modified by the presence of a surgical procedure, patient age, presence or absence of significant comorbidities or complications, and other relevant criteria. System involving classification of medical cases and payment to hospitals on the basis of diagnosis. Used under Medicare's prospective payment system to reimburse inpatient hospitals, regardless of the cost to the hospital to provide services.

Direct Contracting
Providing health services to members of a health plan by a group of providers contracting directly with an employer, thereby butting out the middleman or third party insurance carrier. This can be provider heaven, since middleman-MCO-is cut out and provider gets some portion of the money usually made by it. Key is to price services correctly, since provider is usually at full risk in this situation. Takes a strong IDS, MSO or AHP to do this successfully.

Direct Payment Subscriber
A person enrolled in a prepayment plan who makes individual premium payments directly to the plan rather than through a group. Rates of payment are generally higher, and benefits may not be as extensive as for the subscriber enrolled and paying as a member of the group.

Disallowance
When a payor declines to pay for all or part of a claim submitted for payment.

Discharge Planning
Required by Medicare and JCAHO for all hospital patients. A procedure where aftercare services are determined for after discharge from the inpatient facility.

Discounted Fee-For-Service
A financial reimbursement system whereby a provider agrees to supply services on an FFS basis, but with the fees discounted by a certain percentage from the physician's usual and customary charges. An agreed upon rate for service between the provider and payer that is usually less than the provider's full fee. This may be a fixed amount per service, or a percentage discount. Providers generally accept such contracts because they represent a means to increase their volume or reduce their chances of losing volume.