Chapter 12: Health Insurance Essentials

beneficiary

A designated person who receives funds from an insurance policy.

capitation

A payment arrangement for healthcare providers in which providers receive a per person/per month payment regardless of how often the provider sees the patient.

claim

A formal request for payment from an insurance company for services provided.

explanation of benefits (EOB)

A document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services, and the patient’s financial responsibilities.

fee schedule

A list of fixed fees for services.

gatekeeper

The primary care provider, who is in charge of a patient’s treatment. Additional treatment, such as referrals to a specialist, must be approved by the gatekeeper.

health insurance exchange

An online marketplace where people can compare and buy individual health insurance plans. State health insurance exchanges were established as part of the Affordable Care Act.

indigent

Poor, needy, impoverished

online insurance web portal

An online service provided by various insurance companies that allow providers to look up a patient’s insurance benefits, eligibility, claims status, and explanation of benefits.

policy

A written agreement between two parties in which one party (the insurance company) agrees to pay another party (the patient) if certain specified circumstances occur.

preauthorization

A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services.

pre-existing condition

A health problem that was present before new health insurance coverage started.

premium

The amount paid or to be paid by the policyholder for coverage under the contract, usually in periodic installments.

provider network

An approved list of physicians, hospitals, and other providers.

Qualified Medicare Beneficiaries (QMBs)

Low-income Medicare patients who qualify for Medicaid for their secondary insurance.

referral

An order from a primary care provider for the patient to see a specialist or to get certain medical services.

resource-based relative value system (RBRVS)

A system used to determine how much providers should be paid for services provided by using three factors: physician work, practice expense, and malpractice expense. The geographic region is also taken into account. It is used by Medicare and many other health insurance companies.

third-party administrator (TPA)

An organization that processes claims and provides administrative services for another organization. Often used by self-funded plans.

utilization management

A decision-making process used by managed care organizations to control healthcare costs. It involves case-by-case assessments of the appropriateness of care.

waiting period

The length of time a patient waits for disability insurance to pay after the date of injury.