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Referral Pool
An amount set aside to pay for non-capitated services provided
by a PCP, services provided by a referral specialist and/or emergency
services.
Referral Services
Medical Services arranged for by the physician and provided outside
the physician's office other than Hospital Services.
Registered Nurses (R.N.'s)
Registered nurses are responsible for carrying out the physician's
instructions. They supervise practical nurses and other auxiliary
personnel who perform routine care and treatment of patients.
Registered nurses provide nursing care to patients or perform
specialized duties in a variety of settings from hospital and
clinics to schools and public health departments. A license to
practice nursing is required in all states. For licensure as a
registered nurse (R.N.), an applicant must have graduated from
a school of nursing approved by the state board for nursing and
have passed a state board examination.
Reinsurance
One of the following:
- A contract by which an insurer procures a third party to insure
it against loss or liability by reason of such original insurance.
- The practice of an HMO or insurance company of purchasing
insurance from another company to protect itself against part
or all the losses incurred in the process of honoring the claims
of policy-holders. Also referred to as "stop loss" or
"risk control" insurance.
Reserves
One of the following:
- A fiscal method of withholding a certain percentage of premium
to provide a fund for committed but undelivered health care and
such uncertainties as: longer hospital utilization levels than
expected, overutilization of referrals, accidental catastrophes
and the like.
- The fiscal method of providing a fund for committed but undelivered
health services or other financial liabilities. A percentage of
the premiums supports this fund.
Resource-Based Relative Value Scale (RBRVS)
A Medicare weighting system to assign units of value to each CPT
code (procedure) performed by physicians and other providers.
The number of units or value for each procedure includes a portion
for physician skill, expenses associated with the procedure, and
geographic area.
Retrospective Review Process
A review that is conducted after services are provided to a patient.
The review focuses on determining the appropriateness, necessity,
quality, and reasonableness of health care services provided.
Becoming seen as least desirable method; supplanted by concurrent
reviews.
Risk
The chance or possibility of loss. For example, physicians may
be held at risk if hospitalization rates exceed agreed upon thresholds.
The sharing of risk is often employed as a utilization control
mechanism within the HMO setting. Risk is also defined in insurance
terms as the possibility of loss associated with a given population.
Risk Load
In underwriting, a factor that is multiplied into the rate to
offset some adverse parameter of the group.
Risk Pool
A pool of money that is to be used for defined expenses. Commonly,
if the money that is put at risk is not expended by the end of
the year, some or all of it is returned to those managing the risk.
Risk Sharing
A method by which medical insurance premiums are shared by plan
sponsors and participants. In contrast to traditional indemnity
plans in which insurance premiums belonged solely to insurance
company that assumed all risk of using these premiums. Key to
this approach is that the premiums are only payment providers
receive; provides powerful incentive to be parsimonious with care.
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