Method that uses market information for establishing payment rates that reflect the costs of an efficient managed care plan or health care provider (e.g., competitive bidding that obtains information on costs through the process of bidding).

Expression of dissatisfaction about a certain problem encountered by the member of a managed care plan, or about a decision by the insurance company. A complaint must include a request for action to resolve the problem or change the decision. Also see grievance.

Statement, oral or written, alleging that a provider or beneficiary received a Medicare benefit of monetary value, directly or indirectly, overtly or covertly, in cash or in kind, to which he or she is not entitled under current Medicare law, regulations, or policy. Included are allegations of misrepresentation and violations of Medicare requirements applicable to persons or entities that bill for covered items and services.

List of consumer complaints created by the state insurance department. It may be used for enforcing unfair trade practice laws.

Group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. It is therapy using complementary medicine together with conventional medicine (e.g., using aromatherapy to help lessen a patient’s discomfort after major surgery) or conventional medicine in place of alternative medicine (e.g., use of a special diet to treat cancer instead of major surgery or chemotherapy). Also see National Center for Complementary and Alternative Medicine (NCCAM).

Supplementary medical insurance for individuals who participate in Medicare Parts A and B. Also known as Medigap (MG) policy, gap fill, Medifill, Medicare supplement policy, or wraparound plan.

Hospital facilities and providers that work together to give medical care within a community.

1. Comprehensive diagnostic service when a radiological procedure can be separated into a professional component performed by a physician and a technical component that is supplied by technical staff, equipment, overhead, and supplies. See also separate procedure to learn the difference between complete versus separate. 2. Main or large surgical procedure performed. See partial procedure to learn the difference between complete versus partial.