Table 1 Definitions of Key Terms
From: Discovering healthcare provider behavior patterns through the lens of Medicare excess charge
Term | Definition |
|---|---|
Medical Procedure or Service | Any medical service or doctor visit, coded as per the Healthcare Common Procedure Coding System (HCPCS). |
Healthcare Provider | Physicians, laboratories, and clinics providing diagnostic services, etc. |
Medical Practice | The entire gamut of medical services provided by the healthcare provider. |
Price/Charge | The amount a provider bills (for a specific service) to the insurance or to an uninsured or out-of-network patient. |
Payment | The amount a healthcare provider received (i.e., reimbursement) for a medical procedure. For insured patients, the insurer pays a pre-negotiated amount. Uninsured or out-of-network patients often pay the full price. |
Allowable Limit | The maximum total amount for a specific service, including the insurance payment, co-pay, and/or coinsurance, and any other third-party payments, if applicable. |
Premium | Monthly fee paid to the health insurer in order to be covered by a specific health insurance plan. |
Deductible | (optional) Yearly amount to be paid by the insured before the health insurance plan covers the medical bills. |
Copay | A predetermined amount/rate paid to a healthcare provider at the time of care may vary by provider specialty. |
Coinsurance | (optional) A percentage of medical charges paid by the insured; the rest is paid by the health insurance plan. A 20% coinsurance means that 20% of each medical bill is paid by the insured, and the health insurance covers 80%. |
Out of pocket | The total amount the insured pays. This includes the copay, coinsurance, and deductibles, if any. Federal rules limit the maximum out-of-pocket expenses for insured patients for every plan year. |
Network/in-Network | Individual or group of healthcare providers recognized by the health insurance plan. Private health insurers negotiate confidential payment terms (i.e., prices for each service rendered) with these providers, who agree to accept patients covered by the insurer. |
Out of network | Individual or group of healthcare providers who do not have a negotiated a price contract with the health insurer. In case the insured gets care from an out-of-network provider, they may have to pay the entire medical bill, or a portion thereof, as indicated in their healthcare plan. |