MA: Ch.15-Health Insurance Billing Procedures

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Premium

The charge for keeping the insurance policy in effect.

Benefits

Payments for medical services.

Lifetime maximum benefit

A total sum that the health plan will pay out over the patient's life.

Deductible

A fixed dollar amount that must be paid or "met" once a year, in addition to the premium, before the third-party payer begins to cover medical expenses.

Copayment

A small fixed fee that is collected at the time of the visit.

Elective procedure

Describes a medical procedure that is medically necessary but is not required to sustain life by the patient or the physician.

Precertification (preauthorization)

Describes the process of the provider contacting the insurance plan to see if the proposed procedure is a covered service under the patient's insurance plan.

Liability insurance

Covers injuries that are caused by the insured or that occurred on the insured's property.

Fee-for-service

The oldest and most expensive type, repay policyholders for costs of health care due to illnesses and accidents.

Participating physicians

Physicians who enroll with managed care plans.

Capitation

Managed care plans pay their participating physicians in one of two ways-either by contracted fees or a fixed prepayment.

Preferred provider organization (PPOs)

A managed care plan that establishes a network of providers to perform services for plan members.

Health maintenance organization (HMO)

Physicians with these contracts are often paid a capitated rate, or they may be employees of the organization who are paid salaries.

Medicare

Provides health insurance for citizens aged 65 and older.

Original Medicare Plan

Allows the beneficiary to choose any licensed physician certified by Medicare.

Medicaid

Is a health-benefit program designed for low-income, blind, or disabled patients; needy families; foster children; and children born with birth defects.

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