Critical Healthcare Terms You Need to Know

Healthcare consumers need to know the basic healthcare terms to discuss any financial issue with healthcare providers.  The following are the terms:

Balance Bills Balance billing is when a doctor bills you the difference between their charge and what your health insurance pays.
Billed charges Billed charges mean the total charges billed by health care service providers.
Co-insurance The amount (typically a percentage) you are obligated to pay for covered medical services after you’ve satisfied any co-payment or deductible required by your health insurance plan.
Co-payment The set or fixed dollar amount you are required to pay each time a particular medical service is used. A co-payment for services may be $10 per visit.
Contractual adjustments Contractual adjustments generally reduce the amount of the service charge, thus reducing the amount owed on the claim.

 

Deductible The cumulative amount that you must pay annually before benefits will be paid by the insurance company. If the insurance policy indicates a “$250 deductible,” the insurance company pays as agreed after you pay the first $250.
Explanation of Benefits (EOB) The statement you receive from the insurance company showing the services, amounts paid by the plan and total for which you are being billed.
health insurance denial A health insurance denial happens when your health insurance company refuses to pay for something. If this happens after you’ve had the medical service and a claim has been submitted, it’s called a claim denial.
In Network A group of medical providers that are contracted with a specific insurance company for highest payment levels.
Insurance Payments The amount your insurance company has contractually agreed to pay for the service.

 

No Surprises Act  The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.
Out-of-network care Healthcare rendered to a patient outside of the health insurance company’s network of preferred providers. In many cases, the health insurance company will not pay for these services.
Patient Balance The amount the consumer owes the provider.
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