An entity, contracted with the federal government to identify and recover improper Medicare payments paid to healthcare providers.

A provision in some insurance plans that continues disability payments if an employee attempts to return to work but is unable to because of their disability. For example, if a worker injures their back and has to take disability leave, recurrent disability provisions would allow them to try to go back to work, and if they find that they have not yet sufficiently healed, they can go back on disability leave and continue to receive payments - including those from the period they attempted to work.

The process wherein individuals that are currently enrolled in an exchange plan (either state or federal) must re-establish their eligibility on an annual basis.

A pricing scheme for prescription drugs that is designed to lower the overall expenditures on pharmaceuticals. The programs lump drugs that target specific issues into groups, and set rates for the group as a whole - usually based on the cost of the cheapest drug. For example, there are a variety of drugs designed to lower blood pressure. Under reference based pricing, the insurance provider would only pay for the cost of the cheapest blood pressure medicine. While these programs do not limit the specific drugs patients may purchase, they only cover a portion of the cost of more expensive drugs in any given category.

Process through which a health care provider can recommend a patient visits another doctor - generally when a condition requires the attention of a specialist.

Process of restoring a patient's ability to function effectively in their daily lives. Examples include physical therapy or substance abuse consultations.

Payments to health care providers for services rendered.

Insurance for insurance providers that have higher than anticipated health care claims. This program seeks to lower the premium insurers charge by limiting the high health costs they are exposed to. The Affordable Care Act establishes a reinsurance program for insurers participating on the exchanges, and if an enrollees costs reaches a certain amount (the “attachment point”) the program with reimburse for a portion of the costs above that amount.

Basis of payment for the Medicare physician fee schedule.

Insurance that continues to pay a portion of an individual's disability payments if they are able to return to work in a limited capacity.