Terminology Flashcards
For Profit
-any profit generated from the enterprise can be paid to shareholders (owners)
-pay property & sales taxes
Ex: insurance companies, HCA, most physician offices or private practice PT clinics
Not For Profit
-any profit generated from the enterprise is put back into the business
-NO shareholders (owners)
-do NOT pay property & sales taxes
Ex: most hospitals, some insurers (e.g., Blue Cross/Blue Shield), some nursing homes
Deductible
-the amount the patient must pay before the insurer will pay anything
Co-Pay
-amount patient pays at time of service ALL YEAR (even after deductible is met)
Ex: $40 per visit co-pay for outpatient & $150 co-pay for hospital
Co-Insurance
-a percentage of the total cost that the patient must pay
-usually ranges from 10-20% for in-network services
Ex: 20% co-insurance. Patient may pay 20% of what provider bills, patient may pay 20% of what insurer pays, depends on patient’s coverage
Private Insurance vs. Public Insurance
-private insurance = non-government insurance
Ex: Humana, Aetna, BCBS, United Healthcare, etc.
-public insurance = government insurance
Ex: Medicare, Medicaid, Veterans Administration, Tri-Care (military)
FFS
- fee for service (sometimes still called “indemnity”
- provider billed insurer & insurer paid the claim
- patient usually paid 20% after the fact
- new idea = cost responsibility borne by the insurers
- dominant payment system until 1990’s
Managed Care
- largely an irrelevant term now, “managed care” dominated the 1990’s first with PPO’s (not very successful), then with HMO’s
- HMO’s were successful in reducing healthcare inflation for the first time in American history
PPO
- preferred provider organization
- a form of “managed care” begun in the 1980’s whereby providers sign contracts governing payment
- insurers offer lower premiums by restricting the provider panel (number of physicians in the network)
- new ideas: DFFS & utilization review
HMO
- health maintenance organization
- new idea = cost responsibility borne by PCP’s through capitation
- gained popularity in 1990’s for: reduced premium costs, reduced health care costs
- unpopular due to methods used to gain those results and patient loses choice
PCP
-primary care practitioner/provider
Ex: family practice physician, internal medicine physician, pediatrician, OB/GYN
CDHP
- consumer directed health plan
- usually combination of medical savings account (MSA) & a high deductible health plan
- new idea = cost responsibility borne by the patient
Claim
- what the provider submits to the insurer
- is a “claim” for payment
- mainly electronic now
- used to be paper based & some still are
- each private insurer can (and does) have different claim submission & adjudication systems
EOB
- explanation of benefits
- will define the allowable = what the insurer will pay
- is the definitive document of what the provider will be paid by insurer & patient
- example for an EOB for a $49,000 outpatient procedure
Allowable
-the amount the insurer will pay
-will be defined on the EOB
Ex: per visit rate; Your contract calls for you to be paid $60 per outpatient visit, the $60 is the allowable, even if the visit lasts one hour & you will $450 then you will be paid $60.
