Medical Billing Terms
A fixed payment the patient pays each time he or she visits a health plan clinician or receives a covered service.
More typical in traditional health insurance, a fixed amount the patient must pay each year before the insurer will begin covering the cost of care.
The traditional method of paying for medical services. A doctor charges a fee for each service provided, and the insurer pays all or part of that fee. Sometimes the patient pays a copayment for each visit to the doctor.
Health Maintenance Organization (HMO):
An organization that provides health care in return for set monthly payments. Most HMO’s provide care through a network of doctors, hospitals, and other medical professionals that their members must use in order to be covered for that care.
Managed Care Organization:
An umbrella term for HMOs and all health plans that provides health care in return for set monthly payments and coordinate care through a defined network of primary care physicians and hospitals.
The doctors, clinics, health centers, medical group practices, hospitals, and other providers that an HMO, PPO, or other managed care plan has selected and contracted with to care for its members.
Not in the HMO’s network of selected and approved doctors and hospitals. HMO members who get care out-of-network (sometimes called out-of-area) without getting permission from the HMO to do so may have to pay for all or most of that care themselves. Exceptions are usually made for extreme emergencies or urgent care needed when traveling from home.
Point-of-Service (POS) plan:
A type of HMO coverage that allows members to choose to receive services either from participating HMO providers, or from providers outside the HMO’s network. In-network care is more likely to be fully covered; for out-of-network care, members pay deductibles and a percentage of the cost of care, much like traditional health insurance coverage.
Carefully developed information on diagnosing and treating specific medical conditions. Practice guidelines, usually based on clinical literature and expert consensus, are designed to help physicians and patients make decisions, and to help a health plan evaluate appropriateness and medical necessity of care.
Preferred Provider Organization (PPO):
A network of doctors and hospitals that provides care at a lower cost than through traditional insurance. PPO members get better benefits (more coverage) when they use the PPO’s network, and pay higher out-of-pocket costs when they receive care outside the PPO network.
Care designed to prevent disease altogether, to detect and treat it early, or to manage its course most effectively. Examples of preventive care include immunizations and regular screenings like Pap smears or cholesterol checks.
Preventive health care and routine medical care that is typically provided by a doctor trained in internal medicine, pediatrics, or family practice, or by a nurse, nurse practitioner, or physician assistant.
Primary Care Physician (PCP):
A physician, usually an internist, pediatrician, or family physician, devoted to the general medical care of patients. Most HMOs require members to choose a primary care physician, who is then expected to provide or authorize all care for that patient.
A formal process that authorizes an HMO member to get care from a specialist or hospital. To assure coverage, an HMO patient generally must get a referral from his or her primary care doctor before seeing a specialist.
A doctor or other health professional whose training and expertise are in specific area of medicine, like cardiology or dermatology. Most HMOs require members to get a referral from their primary care physician before seeing a specialist.