Deductibles

Amounts required to be paid by the insured under a health insurance contract, before benefits become payable.

Deductible carry over credit

Charge incurred during the last three months of a year that may be applied to the deductible and which may be carried over into the next year.

Defensive Medicine

Doctors in recent years have admitted to and have been accused of prescribing additional tests or procedures to justify their care, strengthen support for their decisions or simply to corraborate their diagnosis. This defensiveness is a result of law suits, malpractice claims and the onslaught of external UR entities questioning care decisions. Defensive medicine is said to be one of the primary causes of the increasing cost of health care. Many physicians and the AMA fight for tort reform to reduce the need for defensive medicine.

Defined Contribution Coverage

A payment process for procurement of health benefit plans whereby employers contribute a specific dollar amount toward the costs of insurance coverage for their employees. Sometimes this includes an undefined expectation of guarantee of the specific benefits to be covered.

Department of Health and Human Services (HHS)

The federal agency that oversees Medicare, Medicaid and other federal health care programs. (also see DOJ, Fraud and FBI)

Department of Justice (DOJ)

The federal agency that enforces the law and handles criminal investigations. As the nation's largest law firm, the DOJ protects citizens through effective law enforcement, crime prevention and crime detection. It is the agency that prosecutes those in the health care system guilty of proven "fraudulent" activity. (also see Fraud and FBI)

Dependent

Person covered by someone else's health plan. In a payer's policy of insurance, a person other than the subscriber eligible to receive care because of a subscriber's contract.

Designated mental health provider

Person or place authorized by a health plan to provide or suggest appropriate mental health and substance abuse care.

Direct Contracting

Providing health services to members of a health plan by a group of providers contracting directly with an employer, thereby butting out the middleman or third party insurance carrier. This can be provider heaven, since middleman-MCO-is cut out and provider gets some portion of the money usually made by it. Key is to price services correctly, since provider is usually at full risk in this situation. Takes a strong IDS, MSO or AHP to do this successfully.

Disallowance

When a payor declines to pay for all or part of a claim submitted for payment.

Discharge planning

Required by Medicare and JCAHO for all hospital patients. A procedure where aftercare services are determined for after discharge from the inpatient facility.

Discounted Fee-For-Service

A financial reimbursement system whereby a provider agrees to supply services on an FFS basis, but with the fees discounted by a certain percentage from the physician's usual and customary charges. An agreed upon rate for service between the provider and payer that is usually less than the provider's full fee. This may be a fixed amount per service, or a percentage discount. Providers generally accept such contracts because they represent a means to increase their volume or reduce their chances of losing volume.

Disease Management

A type of product or service now being offered by many large pharmaceutical companies to get them into broader healthcare services. Bundles use of prescription drugs with physician and allied professionals, linked to large databases created by the pharmaceutical companies, to treat people with specific diseases. The claim is that this type of service provides higher quality of care at more reasonable price than alternative, presumably more fragmented, care. The development of such products by hugely-capitalized companies should be all the indicator necessary to convince a provider of how the healthcare market is changing. Competition is coming from every direction--other providers of all types, payers, employers who are developing their own in-house service systems, the drug companies.

Dual Choice (Multiple Choice, Dual Option, DC)

Section 1310 of the HMO Act provides for dual choice. A choice given to employees to select between two or more health plans offered by an employer. The opportunity for an individual within an employed group to choose from two or more types of health care coverage such as an HMO and a traditional insurance plan. Many states also have legislated mandates regarding choices offered within employer packages.

Duplicate coverage inquiry (DCI)

Method used by an insurance company or group medical plan to inquire about the existing coverage of another insurance company or group medical plan.

Duplication of benefits

When a person is covered under two or more health plans with the same or similar coverage.

Durable Medical Equipment (DME)

Items of medical equipment owned or rented which are placed in the home of an insured to facilitate treatment and/or rehabilitation. DME generally consist of items which can withstand repeated use. DME is primarily and customarily used to serve a medical purpose and is usually not useful to a person in the absence of illness or injury.

Drug Formulary

Varying list of prescription drugs approved by a given health plan for distribution to a covered person through specific pharmacies. See also Formulary.

Drug Utilization Review (DUR)

Review of an insured population's drug utilization with the goal of determining how to reduce the cost of utilization. Reviews often result in recommendations to practitioners, including generic substitutions, use of formularies, use of copayments for prescriptions and education. In some cases, practitioners are now penalized or rewarded depending on their drug prescription related costs and utilization. Some speculate that these incentives can adversely effect doctor decisions.