insurance essentials Health insurance essentials

Beneficiary

a designated person who receives funds for an insurance policy

Claim

a formal request for a payment from an insurance company for services provided

Fee schedule

A list of fixed fees for services

Gatekeeper

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

Premium

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

Referral

An order from 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 provider 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

Deductible

A set dollar amount that the policy holder must pay before the insurance company starts to pay for services. It can be as low as 100 and as high as 5000 the higher, the deductible, the lower the premium.

Co Insurance

After that, the deductible has been met The policyholder may need to pay a certain percentage of the bill and the insurance company pays the rest. A typical split is 8020. The insurance company pays 80% and the policyholder pays 20.

Call payment

A dollar amount that the policyholder must pay for each office visit

Medically necessary

Services are those that are proper and needed for the diagnosis or treatment of the medical condition

Elective procedures

Are medical procedures that are not deemed medically necessary, such as a facelift or another cosmetic procedure

Preventative care

Service provides to help prevent certain illnesses or that led to an early diagnosis

Medicare

Provide healthcare coverage for individuals who are 65 or older people who are disabled and patients who have been diagnosed with end stage renal disease ESRD

Medicare part A

Covers inpatient hospital charges. It is financed with special contributions deducted from employed individual salaries with matching contributions

From their employers and Social Security contributions, there is no monthly premium for part a

Medicare part B

Covers ambulatory care and all professional services, including primary care and specialist. Beneficiaries are required to pay a monthly premium and can visit any specialist without a referral.

Medicare part C

Is a managed care option for Medicare qualified patients to turn their part a part B benefits into a private plan that can offer some additional benefits. A private plan must cover everything that would be covered under part a and b

Medicare part D

Is a prescription drug program offered to Medicare qualified individuals that require an additional monthly premium basic medical coverage Medicare part B is 80% of the allowed amount after the deductible. This means that patients are responsible for remaining 20%. The lot amount is determined using a RBRS.

medigap policies

The supplemental health insurance plan

Fee schedule for Medicare part B

Provider work

Charge base, professional liability expenses

Charge based overhead

Using RBRVS

Explanation of benefits, EOB

Insurance payments are received. The medical assistance should close seven the EOB to ensure that all benefits have been reimbursed correctly.

Medicaid

Is the government program that provides medical care for the indigent This program is funded by both federal and state governments to provide medical care for people being specific eligibility criteria

Mandatory Medicaid benefits

Family planning service services

Nurse midwife service services

Transportation, medical care

TRICARE

Comprehensive healthcare program for uniform service members and re-Tyrees and their families

CHAMPVA

Similar to TRICARE provides coverage for the families of veterans who were permanently disabled or killed in the line of duty VA shares the cost of certain healthcare services and supplies with eligible beneficiaries

Group policy

A private health insurance plan purchased by an employer for a group of employees in addition to covering the employee. These plans can cover, employees, spouse, children, etc. typically an employer pays a certain percentage of the premium for full-time employee employees.

PARS participating providers

These providers are contracted with the insurance plan and have agreed to accept the contracted fee schedule as payment in full

Credentialing

Is the process of confirming the healthcare providers qualifications

Traditional health insurance

Pay for all or a share of the cost of covered services regardless of which provider hospital or other licensed healthcare provider is used this was the first type of health insurance

MCOS manage care organizations

A health insurance companies whose goal is to provide quality cost-effective care to their members

Referrals

Patient seeking specialized care must first visit their assigned PCP to obtain a referral to a specialist or from more specialist therapy or care

Regular referral

Takes 3 to 10 working days for review and approval. This type of referral is used when the provider believes that the patient must see a specialist to continue treatment.

Urgent referral

Takes about 24 hours for approval this step referral is used one urgent, but not life-threatening situation occur occurs

Stat referral

Approved online with it is submitted to the utilization review department through the providers web portal. A referral is used in an emergency situation As indicated by the provider

A regular referral

Most common and can be inconvenient for the patient with managed care plans pre-authorization needs to be obtained for a referral

Utilization review committee

Reviews individual cases to ensure that the medical care services are medically necessary

Workers compensation

Is an insurance plan for individuals injured on the job or become ill due to job related circumstance