Learn the Managed Care Lingo?
Here are a few phrases and terms to help you navigate the managed care maze.
Services provided in facilities that are not hospitals; also called outpatient health care services
Physician who has been certified as a specialist in a specific medical area
Fixed dollar amount that an insurance plan pays to a health care provider, no matter how many or few services a consumer uses
System that monitors health services to ensure that individuals receive appropriate, reasonable care
Request to an insurance company to pay for health care services
Money that an individual is required to pay for services after a deductible has been paid. In some health care plans, co-insurance is called co-payment. Co-insurance is often a certain percentage (usually 20 percent) of the cost of a service. The employer or insurance company pays the remainder.
The part of a bill that the patient pays in a cost-sharing arrangement with the insurance plan
Refusal by an insurance company to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional
Health insurance plans in which individuals pay less for the services on a predetermined list of health providers and hospitals than they pay for health providers and hospitals not on the list
Similar to HMOs, except that individuals receive care in a own office rather than in an HMO facility
Services provided to a patient staying in a hospital
A medical delivery system that attempts to manage the quality and cost of medical services that individuals receive. Most managed care systems offer HMOs, PPOs and other plans that individuals are encouraged to use for their health care services. Some managed care plans attempt to improve health quality by emphasizing prevention of disease.
Physicians, hospitals or other health care providers who are not part of a predetermined list offered by an insurance plan. Patients often must pay more for out-of-plan services.
The group of health professionals that a health insurance plan will pay at its maximum rate. Patients often must pay a higher co-payment when a doctor, etc., is out-of-network.
health care professional (usually a physician) who is responsible for monitoring an overall health care
A health professional providing health care services. Sometimes the term refers only to physicians. The word can also refer to hospitals, nurse practitioners, chiropractors, physical therapists and other health care specialists.
