Healthscience

Insurance Claim

A request made by a patient or healthcare provider to the insurance company for payment of services.

Copay

A fixed amount a patient pays for a healthcare service, usually at the time of the visit.

Coinsurance:

The percentage of healthcare costs a patient pays after meeting their deductible.

CPT Codes

Current Procedural Terminology codes used to describe medical, surgical, and diagnostic services.

Insurance Deductible

The amount a patient must pay out-of-pocket before insurance starts covering expenses.

Diagnostic Related Groups (DRGs)

A classification system that groups hospital cases to standardize payments to hospitals.

EPO (Exclusive Provider Organization)

A type of health insurance plan that covers services only if providers are within a specific network, except in emergencies.

Expenditures

The total amount of money spent on healthcare services.

Fee-for-Service Insurance Plan

A plan where providers are paid for each service rendered to the patient.

Financing: The process of funding healthcare services, often involving insurance premiums, government funding, or direct payments.

Healthcare or Medical Fraud

The act of submitting false claims or information to obtain financial gain in healthcare.

HMO (Health Maintenance Organization)

A health insurance plan that usually requires members to use a network of doctors and get referrals for specialists.

ICD-10 Codes:

International Classification of Diseases codes used to classify and code all diagnoses, symptoms, and procedures.

Managed Care

A healthcare system that aims to reduce costs and improve quality by managing access to services.

Medicaid

A state and federal program that provides health coverage for low-income individuals.

Medicare

A federal program providing health insurance to people aged 65 and older or with certain disabilities.

Negotiated Fees

Rates agreed upon between insurance companies and healthcare providers for specific services.

Point of Service (POS)

A plan where patients pay less if they use providers in the network but may choose out-of-network providers at a higher cost.

Pre-existing Condition

 A health issue that existed before an individual’s health insurance coverage started.

Preauthorization

Approval from an insurance company before a healthcare service is provided, often required for specific procedures.

PPO (Preferred Provider Organization):

 A type of plan that allows patients to use out-of-network providers at a higher cost but has a network for lower costs.

Premium:

The amount a patient or employer pays for health insurance coverage, usually monthly.

Prepaid Plans

Insurance plans where premiums cover most or all services without additional out-of-pocket costs.

PCPs (Primary Care Physicians):

Doctors who provide general medical care and coordinate specialty care.

Primary Care Physician

Another term for a PCP, a doctor focused on general healthcare and preventive services.

Profit

The financial gain after all healthcare costs have been subtracted from revenue.

Reimbursement

Payment to providers for healthcare services, often from insurance companies.

Veterans Health Administration: 

A federal healthcare system providing services to military veterans.