Mindblown: a blog about philosophy.

A term with no consistent or agreed upon meaning. Most occupational groups in the health field aspire to being considered professions. There are a number of usual components: formal education and examination are required for membership in the profession; certification or licensure is required for membership, reflecting community sanction or approval; there exist regional or…

An indicator of the quality of medical care used to assess the activities of health manpower and programs in the management of patients. Process measures document the process of care used for various populations or diagnoses; for example, the fraction of people with hypertension who receive an intravenous pyelogram or the percentage of cases of…

A medical in which the information and conclusions contained in the record arc organized to describe each of the patients problems. The description properly includes subjective, objective and significant negative information, discussion and conclusions, and diagnostic and treatment plans with respect to each problem. The record, which was developed by Lawrence Weed, M.D., has gained…

Medical practice in which the practitioner and his practice are independent of any external policy control. It usually requires that the practitioner be self-employed, except when he is salaried by a partnership in which he is a partner with similar practitioners. It is sometimes wrongly used synonymously with either fee-for-service practice (the practitioner may sell…

A patient whose care is the responsibility of an identifiable, individual health professional (usually o. physician) who is paid directly (by the patient or a third-party) for his service to the patient. The physician is called a personal physician and the patient is his private patient. Private patients are contrasted with public, service or ward…

Similar to prior authorization but less restrictive in that payment will be made if prior authorization is not sought, provided that it would have approved the service as needed.  

Requirement imposed by a third party, under some systems of utilization review, that a provider must justify before a peer review committee, insurance company representative, or State agent the need for delivering a particular service to a patient before actually providing the service in order to receive reimbursement. Generally, prior authorization is required for non-emergency…

That part of an insurance company’s reserves set aside for losses incurred but not reported (IBNR).  

Denotes insurer obligated to pay losses prier to any liability of other, secondary insurers. Under current law, Medicare is a primary payer with respect to Medicaid; for a person eligible under both programs, Medicaid pays only for benefits not covered under Medicare, or after Medicare benefits are exhausted.  

A charge which falls within the range of charges most frequently used in a locality for a particular medical service or procedure. The top of this range establishes an over-all limitation on the charges which a carrier, which considers prevailing charges in reimbursement, will accept as reasonable for a given service, without adequate special justification.…