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Patients' Rights Glossary

Managed care. HMO. Drug formulary. Grievance. What does it all mean?

The following is a list of some words and phrases commonly used in the patients' rights debate:



  • MANAGED CARE
    Refers to techniques used by health insurers to manage both the cost and quality of medical treatments for consumers.
  • HEALTH MAINTENANCE ORGANIZATION (HMO)
    A health plan that arranges or provides health care services to consumers in exchange for a fixed, prepaid monthly premium. HMOs usually use designated doctors or hospitals, and assume the costs of medical treatments that are higher than the consumers' basic fees and co-payments.
  • POINT-OF-SERVICE PLAN (POS)
    HMOs whose patients may choose to see outside doctors under certain circumstances, and for higher fees.
  • PREFERRED PROVIDER ORGANIZATION (PPO)
    HMOs offer patients incentives like lower costs for certain doctors. But patients are allowed to seek outside doctors.
  • PROVIDER
    A doctor, hospital, or other health care professional or facility such as home health nurse or dialysis center.
  • PROVIDER NETWORK
    The doctors, hospitals, and other health care providers under contract with a health plan. They are often called "in-network" or "participating" providers.
  • PRIMARY CARE PROVIDER
    Doctors who provide general health care services. They usually include family practitioners, general practitioners, pediatricians, and internists. Some HMOs require patients to seek approval from these physicians before going to a specialist.
  • DRUG FORMULARY
    A list of prescription medicines that are preferred for use by the health plan. Closed formulary limits coverage to those drugs in the plan's formulary. Open formulary allows coverage for medicines, but patients might have to pay extra for them.
  • PRE-AUTHORIZATION
    A health plan's advance approval for a patient to seek specific medical treatments.
  • UTILIZATION REVIEW
    The process a health plan uses to examine treatments to make sure they are medically necessary and appropriate.
  • PROSPECTIVE REVIEW
    Plans conduct this review before they approve or deny coverage.
  • CONCURRENT REVIEW
    Plans conduct this review during the course of treatment.
  • RETROSPECTIVE REVIEW
    Plans conduct this review after treatment is completed.
  • NONCERTIFICATION
    A formal decision, made through a plan's internal review process, to deny reimbursement for a requested service.
  • APPEAL
    A request by a patient for a health plan to reverse its decision to deny coverage for a medical treatment or other service.
  • GRIEVANCE
    A written complaint from a patient about an insurer's decisions, policies, or actions. Grievances generally address the availability, delivery, or quality of health care services; payment of claims or reimbursement for services.

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