Glossary

Benchmark - For particular indicator or performance goal, the industry measure of best performance. The benchmarking process identifies the best performance in the industry (healthcare or non-healthcare) for a particular process or outcome, determines how that performance is achieved, and applies the lessons learned to improve performance.

Capitation - A method of paying for medical services on a per-person rather than a per-procedure basis. Under capitation, an HMO pays a participating doctor a fixed, predetermined amount in advance of the delivery of service for every HMO member he or she takes care of, regardless of how many times the member uses the service.

Carve-outs - One or more services an HMO may separate (or "carve-out") from those they require to be provided under the capitation rates. These services may be paid on a fee-for-service or other basis.
Claim A request by an individual (or his or her provider) to an individual's insurance company for the insurance company to pay for services obtained from a healthcare professional.

Copayment - A fixed payment the patient pays (often between $5 to $25) each time he or she visits a health plan physician or clinician or receives a covered service.

Credentialing - A process of review to approve a provider who applies to participate in a health plan. Specific criteria and prerequisites are applied in determining initial and ongoing participation in the health plan.
Deductible More typical in traditional health insurance, a fixed amount the patient must pay each year before the insurer will begin covering the cost of care.

Exclusions - Specific conditions or circumstances listed in the contract or employee benefit plan for which the policy or plan will not provide benefit payments.

Fee-for-service - The traditional method of paying for medical services. A doctor charges a fee for each service provided, and the insurer pays all or part of that fee. Sometimes the patient pays a copayment for each visit to the doctor.

HMO (health maintenance organization) - A public or private organization that provides healthcare in return for pre-set monthly payments. Most HMOs provide care through a network of doctors, hospitals and other medical professionals that their members must use to be covered for that care.

IPA (independent physicians association) - IPAs generally include large numbers of individual private practice physicians who are paid either a fee or a fixed amount per patient to care for the IPA's members.

Managed Care - A system of healthcare delivery that influences the utilization and cost of services and measures performance. The goal is a system that delivers value by giving people access to quality, cost-effective healthcare.

Network - The doctors, clinics, health centers, medical group practices, hospitals, and other providers that an HMO, PPO, or other managed care network plan has selected and contracted with to care for its members.

Open enrollment period - A time during which members in a health benefit program have an opportunity to re-enroll or select an alternate health plan being offered to them, usually without evidence of insurability or waiting periods.

Outcome measurement - A process of systematically measuring individual or collective clinical treatment and response to that treatment.

Out-of-network - Not in the HMO's network of selected and approved doctors and hospitals. HMO members who get care out-of-network (sometimes called out-of-area) without getting permission from the HMO to do so may have to pay for all or most of that care themselves. Exceptions are usually made for extreme emergencies or urgent care needed when traveling away from home.

PPO (preferred provider organization) - A network of doctors and hospitals that provides care at a lower costs than through traditional insurance. PPO members get better benefits (more coverage) when they use the PPO's network, and pay higher out-of-pockets costs when they receive care outside the PPO network.

Practice guidelines - Carefully developed information on diagnosing and treating specific medical conditions. Practice guidelines --- usually based on clinical literature and expert consensus --- are designed to help physicians and patients make decisions, and to help a health plan evaluate appropriateness and medical necessity of care.

Pre-existing condition (PEC) - Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage under the master group contract.
Preventive care - Care designed to prevent disease altogether, to detect and treat it early, or to manage its course most effectively. Examples of preventive care include immunization and regular screenings (such as Pap smears or cholesterol checks).

Primary care physician (PCP) - A physician --- usually an internist, pediatrician, or family physician --- devoted to general medical care of patients. Most HMOs require members to choose a primary care physician, who is then expected to provide or authorize all care for that patient.

Prior authorization - The process of obtaining prior approval as to the appropriateness of a service or medication. Prior authorization does not guarantee coverage.

Referral - A formal process that authorizes an HMO member to get care from a specialist or hospital. To assure coverage, an HMO patient generally must get a referral from his or her primary care doctor before seeing a specialist.

Specialist - A doctor or other health professional whose training and expertise are in a specific area of medicine, like cardiology or dermatology. Most HMOs require members to get a referral from their primary care physician before seeing a specialist.

Utilization review (UR) - Health care services and treatment plans are formally assessed according to the medical necessity, efficiency, or appropriateness on a prospective, concurrent, or retrospective basis.

Contact RPA

RPA Doctors
5860 West Higgins
Chicago, IL 60630
(773) 868 2000 ph
(773) 864-9437 fax
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Office Hours

Monday through Friday
8:30 a.m. to 4:30 p.m.

24-hour answering service available after hours at (773) 868-2000

 

For Patients

RPA offers a wide selection of primary care physicians who are near your home, and who are friendly and compassionate. Each physician has access to a larger hospital network that combines the best of both worlds...More >>

For Doctors

RPA can help your practice in many ways. If you are a primary care doctor, RPA can negotiate with insurance companies on your behalf to offer you competitive capitation rates and increase your volume of patients. More >>