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Rate: Refers to the cost of enrollment classification provided to the insurer for medical coverage. Typically, rates are paid on a monthly basis.
Rating Process: Process used to evaluate the premium rate for an individual or group to evaluate its medical risks. Essential components used in this rating formula include gender / age, location, industry type, base capitation factor, average family size, plan design, and administration allowance.
Reasonable and Customary (R&C): Refers to a term for health services charges used within a geographic area. The fee is deemed reasonable if it falls within a prescribed range of a fee average associated with a specific community.
Rebate: Refers to a monetary amount returned to a payer of a prescription drug from the manufacturer.
Recidivism - the frequency of the same patient returning to the hospital for the same presenting problems. Refers to inpatient hospitalization.
Reciprocity: Refers to an HMO member who uses an affiliated HMO network when they are beyond their service area.
Referral: When a physician formally recommends that a covered individual see another physician or visit a different medical facility. Typically, a covered individual will not be covered to visit the other provider without the referral.
Referral Provider: Refers to when a healthcare provider delivers a service to a patient who has been referred by another healthcare provider.
Rehabilitate: Refers to the improvement of physiological functionality. It is usually accompanied by physical therapy.
Rehabilitation: Medical services intended to change the behavior of substance abusers. The process of rehabilitation does not typically occur until medical detox is completed. Services may be offered on an inpatient or outpatient basis.
Reinsurance: HMO-purchased insurance from an alternate insurer to guard against losses associated with honoring claims of enrollees. This may also be referred to as risk control insurance or stop loss insurance.
Renewal: Occurs when coverage is continued under an insurance policy in accordance with its original terms for a brand-new policy coverage term.
Reserve: See Physician Contingency Reserve
Reserves: Funds that are incurred for health services but have not yet been reported to the insurer.
Resource Based Relative Value Scale (RBRVS): Refers to a fee schedule initiated by HCFA to reimburse healthcare providers' Medicare fees. The fees are based on the amount of time and the medical resources used to treat patients. Adjustments may be made in reference to geographical locations and overhead costs.
Retention: A.) The amount of a benefit program cost retained by the insurer to cover internal costs or maintained for profit. B.) The measurement used to indicate the number of members or groups that are renewing coverage with their health insurance provider.
Retiree Benefits: Retiree benefits typically refer to the health benefits that employees provide to retired employees in order to supplement Medicare for those people who are eligible for Medicare. Recently, new requirements have led to higher employer interest associated with Medicare + Choice plans that lower the employer's liability for future medical care costs.
Retrospective Rate Derivation: Refers to an addendum health coverage that offers risk sharing. In this model, the employer takes responsibility for a part or even all of the risk. In this arrangement, the employer can take risk for a pre-negotiated percentage of the healthcare costs for a group that are in excess of the premium paid by the employer during the active policy year. The insurer may be contracted to refund a negotiated amount of premium dollars for the period of the contract year.
Retrospective Review: Determines the appropriateness of medical care and billing that have already be provided.
Rider: Refers to a set of benefits that a group can purchase to supplement its base policy. A rider often includes benefits for vision and dental care.
Risk: Refers to the probability of financial loss.
Risk Analysis: Refers to the process of assessing expect medical costs for a group and then using this information to determine a benefit level and appropriate product selection.
Risk Control Insurance: See Reinsurance
Risk Pool: See Pool
Risk Sharing: For this model, the provider takes some of the financial risk associated with managing a patient's healthcare. One example of risk sharing is capitation.