Glossary

Data Use Agreement – DUA

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.

Database Management System – DBMS

The separation of data from the computer application that allows entry or editing of data.

Day Outlier

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.

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.

Department of Health and Human Services – HHS

The federal agency that oversees Medicare, Medicaid and other federal health care programs. Also see DOJ, Fraud and FBI.

Department of Justice – DOJ

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.

Diagnosis Related Groups – DRG

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.

Disease Management

A type of product or service now being offered by many large pharmaceutical companies to get them into broader healthcare services. Bundles use of prescription drugs with physician and allied professionals, linked to large databases created by the pharmaceutical companies, to treat people with specific diseases. The claim is that this type of service provides higher quality of care at more reasonable price than alternative, presumably more fragmented, care. The development of such products by hugely-capitalized companies should be all the indicator necessary to convince a provider of how the healthcare market is changing. Competition is coming from every direction–other providers of all types, payers, employers who are developing their own in-house service systems, the drug companies.

Disproportionate Share Adjustment

A payment adjustment under Medicare’s PPS for Medicaid utilization at hospitals that serve a relatively large volume of low-income patients, pregnant patients or other patients under the Medicaid program. Disproportionate share has been a continuing topic in Congress. Some wish to eradicate to reduce costs. Rural facilities, teaching hospitals and hospitals in poverty areas claim that the reduction or elimination of disproportionate share payments would cause hospitals to close, move or reduce care to the poor. DSH is a method whereby the government recognizes that hospitals treating high percentages of Medicaid payments would not be able to cover their costs and remain in service without additional government subsidy.

DRG

Diagnosis Related Groups: Diagnosis codes used to bill hospital services and visits.

Drug Formulary

Varying list of prescription drugs approved by a given health plan for distribution to a covered person through specific pharmacies. See also Formulary.

Drug Risk Sharing Arrangements

Provider organizations may be at partial, full or no risk for drug costs. Providers at partial risk share in the proportion of savings and / or cost overruns. Groups at full risk realize all the savings or absorb all of the losses. Groups at no risk absorb none of the profits or losses. These arrangements are normally made between HMOs and providers (doctors/hospitals) in the HMO’s attempt to discourage the overuse of drugs which will cause a loss of profit for the HMO. In a shared risk arrangement, the HMO and provider share the losses and profits, thus aligning their incentives with one another.

Dual Choice, Multiple Choice, Dual Option, DC

Section 1310 of the HMO Act provides for dual choice. A choice given to employees to select between two or more health plans offered by an employer. The opportunity for an individual within an employed group to choose from two or more types of health care coverage such as an HMO and a traditional insurance plan. Many states also have legislated mandates regarding choices offered within employer packages.

Dual Eligible

A Medicare beneficiary who also receives the full range of Medicaid benefits offered in his or her state. Medicare usually pays the charges for inpatient while Medicaid will pay the co-pay for inpatient care in hospitals. Medicare will be considered the primary insurer for inpatient care for the Care/Caid patient.

Duplicate Coverage Inquiry – DCI

Method used by an insurance company or group medical plan to inquire about the existing coverage of another insurance company or group medical plan.

Duplication of Benefits

When a person is covered under two or more health plans with the same or similar coverage.

Durable Medical Equipment (DME)

Items of medical equipment owned or rented which are placed in the home of an insured to facilitate treatment and/or rehabilitation. DME generally consist of items which can withstand repeated use. DME is primarily and customarily used to serve a medical purpose and is usually not useful to a person in the absence of illness or injury.