Basic Terms You Need to Know When Navigating the Healthcare Billing Process


Healthcare uses a language foreign to all of us and can be complicated to understand and navigate.  Knowing the language will help us communicate with physicians, hospitals, insurance companies and all other healthcare companies and professionals. This section is designed to provide you with basic terms and information to navigate the healthcare.

Healthcare Consumer Navigator:  Healthcare Terms and Definitions You Should Know

Advanced Beneficiary Notice…(ABN) For consumers that have Medicare as their primary insurance; A form used by hospitals when services are not covered by Medicare. Physicians order services that are not medically necessary.  Hospitals are required to tell the consumer the cost of the service.  The ABN, if signed, transfers all payment responsible to the consumer.  The consumer can refuse to sign the form and not have the service. 
Allowed Charge The amount your insurance company will pay a physician, hospital and other healthcare companies and professionals in their network.  The amount is less than the full charge with insurance company discounts up to 50% to 60%.  It is important to understand that allowed charges can differ between in network and out of network providers. For consumers, this is important because the consmer pay less out of pocket monies for healthcare if they are in network versus out of network.
Allowed Maximum Benefit Insurance companies have limits as to the amount they pay each year.  As a consumer, you need to be aware of the amount because if you exceed the limit, it will be out of pocket expense.
Benefits Each healthcare insurance policy has definitions of what they will cover. Insurance policies usually define what services and supplies are covered and those that are not covered.  Consumers need to be fully educated because services and supplies not covered will be out of pocket expense.
Billing Statement A monthly bill sent to the consumers by medical providers asking for payment of monies due or away to communicate to consumers about the status of their bill. 
Catastrophic Coverage Insurance plans with extremely high deductibles starting at $15,000 or more.  These plans are designed to insure the consumer, if a significant healthcare event occurs. Premiums are generally lower than a more traditional healthcare insurance plan.
Claim Health insurance claims are billing forms submitted to your insurance company for payment of services or supplies by your healthcare provider. There are several different claim forms for hospital and physician.  In rare instances, the consumer will be required to submit a claim to be paid if the healthcare provider does not accept your insurance or if your provider requires payment in full prior to   service rendered.                                                                
Co-Insurance A percentage for the medical service charge you are required to pay out of pocket.  The amount can vary but is usually 20% or more.  Consumers need to be aware what services or supplies fall into this category of payment.  The potential out of pocket amount could be substantial.
Consent Forms Forms that consumers sign that allow healthcare providers to treat you. 
Coordination of Benefits If your family has two health insurance plans, one plan is considered primary and the other secondary. When applying for a health insurance plan, you are required to tell the plan if you have any other insurance coverage.  Rules determine which plan is primary.  Other examples are; if you were hurt at work, involved in an auto accident, etc…these events may be considered primary.
Copay A flat dollar amount you pay for covered services each time you use the service.  Examples are:  Primary Care Physician: $25; Specialty Care Physician; $40; Urgent Care; $60; Emergency Room; $150, Prescriptions; can vary, etc…   Copays can differ from insurance plan to insurance plan as can the monthly premium.  Consumers should review each plan to determine which fits the best.
Cost Sharing The process insurance companies maintain to include the consumer to pay a certain share.  Cost sharing includes, co pays, so insurance, deductibles, etc…
Deductible Many insurance plans have deductibles which is the amount the consumer pays per calendar year.  The amount can vary.  The deductible is an out of pocket for consumers.
Explanation of Benefits;(EOB) The confirmation consumers receive when their insurance company processes the medical claim. Information on EOB’s includes the date of service, your healthcare provider name, gross charges, allowed charges, payment made to your healthcare provider, how much you owe.  In addition, EOB’s are used to inform consumers the claim has been denied and for what reasons.
Emergency Room A service generally offered by hospitals to treat life threatening healthcare conditions. 
Essential Health Benefits Services defined by the Affordable Care Act that requires insurance plans to cover.  Consumers should understand the services because many of the services require no out of pocket expense.
Exclusions Services or supplies your health plan will not pay.  Consumers need too be aware of any insurance policy exclusions before purchasing the plan.  All exclusions become out of pocket expenses for the consumer.
Flexible Spending Accounts A consumer elected benefit that allows you to save money tax free to pay for health expenses.  There is no restriction on the type of health plan you purchased.  The major drawback is that you “use it or lose it” if not spend within a given fiscal year.

 Prescriptions and Medications

Prescriptions and medications that your insurance will cover.  Generally, most insurance plans have tiers; Generic, Brand Name and Brand Name compounding.  Each tier has a copay amount; the lower the tier, the greater amount co pay required.
Health Saving Account A consumer elected health benefit that allows you to save money tax free to pay for health expenses if you are enrolled in a high deductible health plan. Savings are allowed to roll over year to year.
High Deductible Health Plans A health insurance plan with a high deductible, usually $1,200 or more, that requires you to pay for all health expenses up to the designated deductible.  Premiums are lower than a traditional health insurance plan.  The consumer assumes a greater financial risks and should be prepared if an unexpected medical event occurs.
Hospitalist Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.
Individual Health Insurance Health insurance plans purchased by consumers who can’t purchase a plan from their employer. The Affordable Care Act, through the insurance exchanges, offers many choices and guarantees coverage for any preexisting conditions.
In Patient Services Services provided to consumers by hospitals when a consumer spends one or more nights in the hospital.  This should not be confused with Observation Services.
Intern Medical intern is a term used in some countries to describe a physician in training who has completed medical school and has a medical degree, but does not yet have a full license to practice medicine unsupervised.
Lifetime Maximum The benefit an insurance company will pay during your lifetime.
Medical Necessity Services that are ordered by your physician that do not meet accepted standards of care that are essential to your diagnosis and treatment.  Consumers must be told that services have not met Medical Necessity.  Consumers should ask their physician to document more information on the order to meet the requirement.  If not, the consumers will be responsible to pay for the service.  SEE ABN ABOVE.
Meets Proposed Out of Pocket Cap Limits in network and out of pocket consumer spending to $6,600 for an individual and $13,200 for a family. The intent of these caps is to make health insurance affordable as defined by the Affordable Care Act.
Observation Services Traditionally, patients who require services beyond the first hours in the emergency department (ED) have been admitted to the acute care hospital.  Observation units transitional units between the ED and In Patient Care. The goal of the observation unit is to lower health care costs by creating incentives for efficient, effective health care.
Out of Pocket Costs As defined by your health insurance plan, the maximum amount you pay. Consumers should fully understand costs before purchasing a health plan.  There is a possibility of hidden costs that you may experience.
Out Patient Services Services provided to consumers by hospitals, laboratories, radiology companies, etc. for testing.  Most insurance plans will define outpatient services.
Precertification of Health Services A process defined by your insurance company that: 1. Identifies specific services that require pre certification and 2.  The process by insurance companies to pre certify services. Typically,  the insurance companies process is to certify services from 1 day to weeks prior to service rendered.  Consumers can experience delays of services that could not be certified.  Either way, this a high risk process for consumers.
Premium Payments The amount a consumer pays each month for their health insurance plan.
Primary Care Visits A physician that performs routine medical exams, screenings, etc… and manages your healthcare.  Primary care physicians have designations as Family Practice, Internists, Pediatricians, etc….  Consumers should select a primary care physician they trust.
Release of Medical Information The process of releasing your medical information to you or other providers.
Series Services A service that is reoccurring such as, Physical Therapy, Oncology, etc….  Consumers should be aware series services may require Precertification and have service limits.
Specialist Visits A physician who specializes in a specific medical area, like Cardiologists, Oncologists, etc… 
Resident resident or house officer is a physician (one who holds the degree of M.D., D.O., etc…..) who practices medicine usually in a hospital or clinic under the direct or indirect supervision of an attending physician.
Urgent Care A service that specializes in medical conditions that require immediate care that is not life threatening.  Consumers should be aware that hospitals and other healthcare providers offer this type of service.
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