Insurance Terms
Accreditation—An evaluative
process in which a health care organization undergoes
an examination of its operating procedures to determine
whether its procedures meet criteria designated by
the accrediting body, and to ensure that the organization
meets a specified level of quality.
Ancillary services—Auxiliary or supplemental
services, such as diagnostic services, home health services, physical
therapy, and occupational therapy, that support diagnosis and treatment
of a patient's condition.
Annual maximum benefit amount—The maximum
dollar amount set by a managed care organization (MCO) that limits
the total amount the plan must pay for all health care services
provided to a subscriber in a year.
Appropriateness review—An analysis of
health care services with the goal of reviewing the extent to which
necessary care was provided and unnecessary care was avoided.
Case management—A process of identifying
plan members with special health care needs, developing a health
care strategy that meets those needs, and coordinating and monitoring
the care with the ultimate goal of achieving the optimum health
care outcome in an efficient and cost-effective manner. Also known
as large-case management (LCM).
Claim—An itemized statement of health
care services and their costs provided by a hospital, physician's
office, or other provider facility. Claims are submitted to the
insurer or managed care plan by either the plan member or the provider
for payment of the costs incurred.
Claim form—An application for payment
of benefits under a health plan.
Claimant—The person or entity submitting
a claim.
Claims administration—The process of
receiving, reviewing, adjudicating, and processing claims.
Clinical practice guideline—A utilization
and quality management tool that helps doctors decide the most
appropriate course of treatment for a specific clinical case.
Co-insurance—A method of cost-sharing
in a health insurance policy that requires a group member to pay
a stated percentage of all remaining eligible medical expenses
after the deductible amount has been paid.
Consolidated Omnibus Budget Reconciliation Act
(COBRA)—A federal act that requires each group health
plan to allow employees and certain dependents to continue their
group coverage for a stated period of time following a qualifying
event that causes the loss of group health coverage. Qualifying
events include reduced work hours, death or divorce of a covered
employee, and termination of employment.
Co-payment—A specified dollar amount
that a member must pay out of pocket for a specified service at
the time the service is rendered.
Credentialing—The process of obtaining,
reviewing, and verifying a provider's credentials—the documentation
related to licenses, certifications, training, and other qualifications—for
the purpose of determining whether the provider meets a managed care
organization's pre-established criteria for participation in the
network.
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Deductible—A flat amount a group member
must pay before the insurer will make any benefit payments.
Diagnostic and treatment codes—Special
codes that consist of a brief, specific description of each diagnosis
or treatment and a number to identify each diagnosis and treatment.
Disease management (DM)—A coordinated
system of preventive, diagnostic, and therapeutic measures intended
to provide cost-effective, quality health care for patient populations
who have, or are at risk for, a specific chronic illness or medical
condition. Also known as disease state management.
Employee Retirement Income Security Act (ERISA)—A broad-reaching law that establishes the rights of pension
plan participants, standards for the investment of pension plan
assets, and requirements for the disclosure of plan provisions
and funding.
Fee-for-service (FFS) payment system—A
system in which the insurer will either reimburse the group member
or pay the provider directly for each covered medical expense after
the expense has been incurred.
Fee schedule—The fee determined by a
managed care organization to be acceptable for a procedure or service,
which the physician agrees to accept as payment in full. Also known
as a fee allowance, fee maximum, or capped fee.
Formulary—A listing of drugs, classified
by therapeutic category or disease class, that are considered preferred
therapy for a given managed population and that are to be used
by a managed care organization's providers in prescribing medications.
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Generic substitution—The dispensing
of a drug that is the generic equivalent of a drug listed on a
pharmacy benefit management plan's formulary. In most cases, generic
substitution can be performed without physician approval.
Health Insurance Portability and Accountability
Act (HIPAA)—A federal act that protects people who change
jobs, are self-employed, or have pre-existing medical conditions.
HIPAA standardizes an approach to the continuation of health care
benefits for individuals and members of small group health plans.
It also establishes parity between the benefits extended to these
individuals and those benefits offered to employees in large group
plans. The act contains provisions designed to ensure that the
plan does not discriminate against prospective or current enrollees
in a group health plan based on health status.
Health maintenance organization (HMO)—A
health care system that assumes or shares risks associated with
providing comprehensive medical services to a voluntarily enrolled
population in a particular geographic area, usually in return for
a fixed, prepaid fee.
Indemnity insurance—Traditional indemnity
insurance is sometimes referred to as "fee for service." This type
of insurance plan allows patients to go to any doctor or hospital
that they select, anywhere in the United States or abroad. Although
insurance plans vary, generally patients are responsible for a
deductible and co-payments.
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Lifetime maximum benefit amount—The
maximum dollar amount, set by a managed care organization, that
limits the total amount the plan must pay for all health care services
provided to a subscriber in the subscriber's lifetime.
Managed care—The integration of both
the financing and the delivery of health care within a system that
seeks to manage the accessibility, cost, and quality of that care.
Managed care organization (MCO)—Any
entity that utilizes certain concepts or techniques to manage the
accessibility, cost, and quality of health care. Also known as
a managed care plan.
Medicaid—A jointly funded federal and
state program that provides hospital expense and medical expense
coverage to the low-income population and certain aged and disabled
individuals.
Medical advisory committee—A group whose
purpose is to review general medical management issues brought
to it by the medical director.
Medical director—Manager in a health
care organization responsible for provider relations, provider
recruiting, quality and utilization management, and medical policy.
Medicare—A federal government hospital
expense and medical expense insurance plan primarily for elderly
and disabled people. See Medicare Part A, Medicare Part B, Medicare
Part C, and Medicare Part D below.
Medicare Part A—The part of Medicare
that provides basic hospital insurance coverage automatically for
most eligible people. See also Medicare.
Medicare Part B—A voluntary program
that is part of Medicare and provides benefits to cover the costs
of physicians' services. See also Medicare.
Medicare Part C—The part of Medicare
that expands the list of different types of entities allowed to
offer health plans to Medicare beneficiaries. Also known as Medicare
Advantage. See also Medicare.
Medicare Part D (Medicare Prescription Drug Benefit)—Effective in 2006, Part D is an outpatient prescription
drug benefit for Medicare beneficiaries for products not reimbursed
under Medicare Part A or Medicare Part B. See also Medicare.
Medicare supplement—A private medical
expense insurance plan that supplements Medicare coverage. Also
known as a Medigap policy.
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Omnibus Budget Reconciliation Act (OBRA) of 1990—A federal act that established the Medicare SELECT program,
a Medicare supplement that uses a preferred provider organization
to supplement Medicare Part B coverage.
Outcomes measures—Health care quality
indicators that gauge the extent to which health care services
succeed in improving patient health.
Patient Bill of Rights—Refers to the
Consumer Bill of Rights and Responsibilities, a report prepared
by the President's Advisory Commission on Consumer Protection and
Quality in the Health Care Industry in an effort to ensure the
security of patient information, promote health care quality, and
improve the availability of health care treatment and services.
The report lists a number of "rights," subdivided into eight general
areas, that all health care consumers are guaranteed, and also
describes responsibilities that consumers must accept for the sake
of their own health.
Peer review—The analysis of a doctor's
care by a group of the doctor's professional colleagues. The provider's
care is generally compared to applicable standards of care, and
the group's analysis is used as a learning tool for the members
of the group.
Pharmacy and therapeutics committee—A
committee that develops a formulary, reviews changes to that formulary,
and reviews abnormal prescription utilization patterns by providers.
Pharmacy benefit management (PBM) plan—A
type of managed care specialty service organization that seeks
to contain costs while promoting safer and more efficient use of
prescription drugs. Also known as a prescription benefit management
plan.
Preferred provider organization (PPO)—A
PPO allows patients to see a doctor from the plan's network of
physicians for a small co-payment. Patients who choose to see a
doctor out of the network must pay the balance between the PPO's
scheduled fee and the billed amount.
Premium—A prepaid payment or series of
payments made to a health plan by purchasers, and often plan members,
for medical benefits.
Prior authorization—In the context of
a pharmacy benefit management (PBM) plan, this is a program that
requires physicians to obtain certification of medical necessity
prior to drug dispensing. Also known as a medical necessity
review.
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Therapeutic substitution—The dispensing
of a different chemical entity within the same drug class of a
drug listed on a PBM plan's formulary. Therapeutic substitution
always requires physician approval.
Usual, customary, and reasonable (UCR) fee—The
amount commonly charged for a particular medical service by physicians
within a particular geographic region. UCR fees are used by traditional
health insurance companies as the basis for physician reimbursement.
Utilization management (UM)—Managing
the use of medical services to ensure that a patient receives necessary,
appropriate, and high-quality care in a cost-effective manner.
Utilization review (UR)—The evaluation
of the medical necessity, efficiency, and/or appropriateness of
health care services and treatment plans.
Utilization review committee—A committee
that reviews utilization issues brought to it by the medical director,
often approving or reviewing policy regarding coverage, reviewing
utilization patterns of providers, and approving or reviewing the
sanctioning process against providers.
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By keeping track of expenses and deducting qualified items on your
tax returns, you may be able to partially recover some of the out-of-pocket
medical expenses not covered by your insurance. Find out how
to handle medical costs on your tax returns.
UNDERSTANDING CANCER
TREATING CANCER WITH CHEMOTHERAPY
CHEMOTHERAPY SIDE EFFECTS
TREATING CANCER IN OTHER WAYS
TRACKING YOUR TEST RESULTS
UNDERSTANDING INSURANCE AND TAX ISSUES: INSURANCE TIPS
WEB RESOURCES AND ORGANIZATIONS
TOOLS FOR ORGANIZING YOUR CANCER INFORMATION
FOR CAREGIVERS
GLOSSARY OF CANCER TERMS
REGISTER FOR PROGRAMS
FOR HEALTHCARE PROFESSIONALS
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