RELEVANT TERMS -CLASS 10

ANTITRUST

The United States has certain laws governing monopolies and other issues that fall under the antitrust area.  Providers are subject to such antitrust laws and have tried to create certain laws to allow providers to organize in a manner that would otherwise be considered in violation of antitrust type of laws.

ANY WILLING PROVIDER  (AWP)

A form of state law that requires Managed Care Organizations (MCOs) to accept any provider willing to meet the terms and conditions in the MCO’s contract, whether or not the MCO wants or needs that provider.

CORPORATE PRACTICE OF MEDICINE ACTS OR STATUTES

State laws that prohibit a physician from working for a corporation; in other words, a physician can only work for himself or herself or another physician.  A corporation cannot practice medicine.  Often created through the effort on the part of certain members of the medical community to prevent physicians from working directly for managed care plans or hospitals.

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)

A federal law that, among other things, requires employers to offer continued health insurance coverage to certain employees and their beneficiaries who have had their group health insurance coverage terminated.

FRAUD AND ABUSE LAWS

Certain laws effecting providers dealing with, among other things, upcoding, overbilling, billing for services not rendered for Medicare and Medicaid patients.

MANDATED BENEFITS

Those benefits which health plans are required by state or federal law to provide to policy holders and eligible dependents.  This is generally used to refer to benefits above and beyond routine insurance type benefits, and it generally applies at the state level.

PATIENT PROTECTION RIGHTS

Legislation has passed at both the state and federal level aiming to give patients certain rights in their dealings with managed care companies.  This type of legislation is commonly known as patient protection rights and may be referred to as such in many such laws.  Examples of patient rights protected include:  right to see specialists, grievance procedures to determine benefits in certain time frames in which decisions may be required to be made by the MCO in a very short time frame, physicians determining best medical care, etc.

QUI TAM ACTIONS

Qui tam actions are defined by Black’s Law Dictionary as “an action brought by an informer under a statute which establishes a penalty for the commission or omission of a certain act, and provides that the same shall be recoverable in a civil action, part of the penalty to go to any person who will bring such action and the remainder to the state or some other institution…because the plaintiff states that he sues as well for the state as for himself.”

SILENT PPO

A silent PPO is an unauthorized entity using information that it has access to for its own benefit, such as a third party administrator having knowledge of provider’s rates and automatically paying providers  lowest rates based on contracts not applicable to the services rendered.  In this example, many providers are not equipped to identify this problem of receiving reduced rates that they have not agreed upon because the provider has other contracts referring to that amount.  In this example, the third party administrator is acting like a hidden PPO, hence the term “Silent PPO”.

SMART CARD

Computer chip in card personalized for individuals with health care history data, pharmaceutical information, insurance carrier information, and other information.

UNBUNDLING

The practice of provider billing for multiple components of servie theat were previoulsy included in a single fee.

UNIVERSAL HEALTHCARE COVERAGE

Health care coverage for all Americans proposed in the Health Security Act recommended by President Clinton in 1994.

UPCODING

The practice of a provider billing for a procedure that pays better than the service actually performed.