Glossary of Common Billing & Insurance Terms
Some of the terminology used in healthcare and managed care can be confusing. To assist in your understanding, we’ve provided a glossary of frequently used words and phrases. Click on the terms below to view more information.
Capitation
The insurance company pays physicians or medical groups a certain amount each month for each patient.
Co-payment
An amount of money the insured person pays each time he or she sees a doctor, gets a prescription, or has a medical service rendered.
Enroll
A term to describe the process of signing up with a managed care health plan
Fee for Service
Paying for medical services when they are provided or when a bill is received. Payment can be in cash or as an insurance reimbursement.
HMO Plan
A benefit plan in which you must chose a primary care physician and you must use the physicians who are signed up with that group and HMO for any care or the HMO will not pay for the care.
Independent Physician Association (IPA)
An organization in which private practice physicians agree to work together to negotiate with insurance companies but the physicians run their own offices.
Managed Care
A concept of overseeing the use of medical services to keep the cost of providing care low while at the same time keeping the quality of the care high, typically by having the patient go through a primary care physician before seeing specialists, thus ensuring the proper use of specialty care.
Medicare
A government-funded insurance program that covers people over age 65 and some people with certain diseases or disabilities.
Member
A person who has signed up with a managed care health plan.
Medical Group
A group of physicians who have created an organization devoted to providing medical care.
Open Enrollment
A period of time in which a person can change insurance plans offered by his or her employer.
Out of Pocket
Any fee paid by the patient; can be a co-payment, deductible or the entire bill.
Point-of-Service
Members have an HMO and a PPO option. When you need care, you choose to activate either the HMO or PPO option.
Preferred Provider Organization (PPO) Plan
The insurance company will give you a list of physicians you can go to and still be covered; if you go to a physician outside of that list, the insurance company might pay for some of the care, but will usually require you to pay a larger amount.
Primary Care Physician
A doctor who coordinates the care for a person with managed care insurance. All managed care insurance plans require members to choose a primary care physician or medical group before seeking care.
Referral or Authorization
What the primary care physician writes if you need specialized medical care.
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