A glossary of generally used acronyms in Florida Managed Care | Akerman LLP – Well being Regulation Rx
Anyone who interacts with third party payers will come across acronyms on a regular basis. While acronyms are designed to facilitate efficient communication, their use often creates confusion. This blog is intended to provide a brief overview of some commonly used acronyms in managed care. Please note that while some of the acronyms are specific to Florida, most are used nationwide. Also, note that the following general descriptions are intended to provide a general understanding of the acronyms. Please check your jurisdiction for more information. To simplify reference, we may have included links to the legal definitions for Florida 2020.
Types of companies and types of coverage
ACO – Accountable Care Organization
An organization of physicians, which may include hospitals and other health care providers, that provides coordinated care to Medicare beneficiaries and paid for by the Centers for Medicare and Medicaid Services based on their patients ‘quality metrics and the reduction in the cost of their patients’ care becomes .
DMPO – Discount Plan Organization
A company that provides medical providers with access to a discount from the providers’ usual rates.
See Section 636.202 (2), FS
EPA – Exclusive Provider Organization
A product that is offered by a health insurance company that, like an HMO, partially controls the costs by generally restricting access only to health care providers who have contracts with the health insurance company (contract providers are also referred to as network-internal providers).
See Section 627.6472, FS for definitions of exclusive vendor and exclusive vendor deployment.
FISO – Fiscal Intermediary Services Organization
A company that contracts with an HMO’s on-network providers and collects payments on behalf of the providers from the HMOs.
See Section 641.316 (2) (b), FS
HMO – Health Maintenance Organization
An MCO that offers comprehensive health insurance and partially controls costs by generally restricting access only to healthcare providers who have contracts with the HMO.
See sections 110.123 (2) (d), 641.19 (11) and 766.105 (1) (e), FS
MCO – Managed Care Organization
A company (usually a health insurer or an HMO) that provides health insurance mechanisms with mechanisms to control costs and reduce excessive or inadequate care.
See sections 409.901 (13), 409.920 (1) (e) and 409.962 (10). FS for definitions of managed care plans.
PBM – Pharmacy Benefits Manager
A company that negotiates with drug manufacturers on behalf of MCOs or similar companies to control prescription drug costs and gain prescription drug benefits.
See sections 624.490 (1), 627.64741 (1) (b), 627.6572 (1) (b) and 641.314 (1) (b), FS
PHC – Prepaid Health Clinics
An MCO that provides comprehensive health insurance except that it does not cover inpatient hospital costs and controls costs in part by generally restricting access only to healthcare providers who have contracts with the PHC.
See Section 641.402 (4), FS
PHO – Organization of the hospital for doctors (or providers)
A company that contracts with doctors and hospitals to form a single organization to contract with MCOs and similar entities.
PLHSO – Prepaid Limited Health Services Organization
An MCO that restricts itself to providing only certain types of coverage (e.g. dental, visual, etc.) and that partially controls costs by generally restricting access only to healthcare providers who have contracts with the PLHSO to have.
See Section 636.003 (7), FS
POS – Point of Service (type of HMO product)
An MCO product offered by an HMO that allows a member to access providers outside the network, but at a higher cost than providers within the network (this is similar to an insurance company’s PPO product).
See Section 641.31 (38), FS for point of service requirements.
PPO – Preferred Provider Organization
A product offered by a health insurance company that offers financial incentives for the use of health care providers that are contractually affiliated with the insurance company, but also allows access to non-contractual providers (also known as providers outside the network) at higher costs.
See Section 627.6471, FS for definitions of the preferred provider network and preferred provider.
PSN – Provider Service Network
In Florida, an MCO, majority-owned and controlled by Medicaid providers, that contracts with the Florida Agency for Healthcare Administration to provide comprehensive health coverage to Medicaid recipients.
See sections 409.912 (1) (b), 409.962 (14) and 641.19 (22), FS
TPA – Third Party Administrator (also known as Insurance Administrator)
A company that contracts with health insurers or similar entities such as HMOs, typically to provide claims handling services. However, in Florida, a TPA can also apply for coverage and collect premiums.
See Section 626.88 (1), FS
Additionally, the following are some commonly used state and federal acronyms and what they mean:
Federal Regulators & State Insurance Commission Associations
CMS – Centers for Medicare and Medicaid Services
HHS – U.S. Department of Health
NAIC – National Association of Insurance Commissioners
ACA / PPACA – Patient Protection and Affordable Care Act (ObamaCare)
ERISA – Employee Retirement Income Security Act
HIPAA – Health Insurance Portability and Accountability Act
AHCA – Florida Agency for Health Administration
DFS – Florida Department of Financial Services
OIR – Florida Office of Insurance Regulation