Health Insurance Essentials

Chapter 12

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 requests 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 Affordable Care Act

indigent

Poor, needy, improvised

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 occurs

preauthorization

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

preexisting 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 approval list of physicians, hospitals, and other providers

Qualified Medicare Beneficiaries (QMBs)

Low-income Medicare patients who qualifies 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 process claims and provides administrative services for another oirginization. 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-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

ACA

The Affordable Care Act

STI

sexually transmitted infection

CHAMPVA

Civilian Healthcare and Medical Program of the Department of Veterans Affairs

ESRD

end-stage renal disease

CMS

Centers of Medicare and Medicaid Services

HHS

Department of Health and Human Servies

RBRVS

resource-based relative system

UCR

usual, customary, and reasonable

EOB

explanation of benefits

QMBs

Qualified Medicare beneficiaries

CHIP

Children’s Health Insurance Program

TPA

third-party administrator

MCO

managed care organization

PCP

primary care provider

HMO

health maintenance organization

PPO

preferred provider organizations

EPO

exclusive provider organization

IPA

independency practice association

PAR

participating provider