Author: Glossary

A term used in long-term care in which efforts are made to avoid institutionalization of patients by having them directed (“channeled”) to community based long-term care services. From 1980 to 1985, the Health Care Financing Administration (HCFA) and other federal agencies financed a demonstration of the concept, which used comprehensive case management, but ended the…

A term sometimes given to a computer network system in which computer terminals in a number of locations are tied into a central location and information system. An example of a channel system is an airline network serving travel agents who can use their terminals in the system to do scheduling, determine fares, and sell…

A health care facility or department which has gained a reputation for superior quality in a special area (or areas) of care. Such a facility can bring in patients from great distances, and so can increase its expertise in its specialty while lowering the cost of care. A COE can also be used as a…

An illness which requires very costly treatment; one which is catastrophic to the patient’s or family’s finances. The illness may be either acute or chronic, and it may run its course quickly or over a protracted period. Severe illness resulting in the need for prolonged hospitalization, extended recuperation, or both. After recovery, there may be…

A term which, when used in connection with managed care, covers all the activities of evaluating the patient, planning treatment, referral, and follow-up, so that care is continuous and comprehensive and payment for the care is obtained.  

A traditional term for all the activities which a physician normally performs to insure the coordination of the medical services required by a patient. This is not the same function as that of the gatekeeper in managed care. Under ordinary circumstances, the American Medical Association (AMA) does not consider case management a separately reimbursable service.…

A controversy which is contested in a court of law. In common usage, a legal “case” refers to the particular facts of the controversy and the legal theories, allegations, and defenses being applied to those facts.  

A patient and his medical problem. Used alone, the term “patient” does not indicate whether the individual is ill or well. However, the term “case” denotes that the patient is ill, injured, or otherwise presents a problem to the health care provider. With a modifier or additional information, “case” describes the patient’s problem, as, for…

A practice by insurers of providing group coverage only to healthy individuals in a small business, while permitting sicker co-workers to purchase only expensive high risk pool coverage. Carving out is a method of avoiding adverse selection. The practice is questionable and sometimes illegal.  

An individual who carries, and can transmit, a contagious disease without himself showing symptoms or signs of the disease.