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Glossary Of Terms Used By Insurance and Medical Billing

Friday, July 10, 2009

Following are some of the most common terms you may hear that are associated with your insurance plans and medical billing.

Ambulatory Surgery Surgery done in the doctor’s office or at a surgical center, and not requiring an overnight stay.
Ancillary Providers Services over and above physician services, including laboratory, radiology, home health and skilled nursing facilities.
Authorization Approval of care required before a service is provided. Pre-authorization may be necessary before hospital admission, or before care is given by non-HMO providers.
Balance Billing Billing a patient for charges not paid by their insurance plan because the charges are above the Usual and Customary Rate or because the insurer considered a procedure medically unnecessary.
Carve-out Policy A contracted agreement between an insurance company and another company which provides special services to its members, such as prescription drugs or cancer treatment.
Claim A record of medical services provided to a patient and submitted by the provider to the insurance company for payment.
Claims Review The method by which a patient’s health care service claims are reviewed before reimbursement is made. This is done to validate the appropriateness of services given and that the cost is not excessive.
Coinsurance A provision which limits the amount of the coverage paid by an insurance plan to a certain percentage, with the remaining costs paid by the member.
Co-payment The portion of a claim that a member must pay out-of-pocket.
CPT-4 A 5-digit code that applies to medical services delivered.
Deductible The amount an insured member must pay before the insurance company pays benefits.
EOB (Explanation of Benefits)

A statement describing medical benefits and account activity, including explanation of why certain claims may or may not have been paid.

Exclusion Services or supplies not covered under a health plan.
Fee Schedule A listing of the maximum fee which a health plan will pay for services based on CPT billing codes.
ICD-9 A 3 to 5-digit number code describing a diagnosis or medical procedure.
Inpatient A patient who is admitted to a hospital and receives medical services from a physician during at least a 24-hour period.
In-Network Provider Physicians and other service providers who are contracted with a managed care plan.
Out-of-Network Provider Physicians who are not contracted with a managed care plan.
Outpatient A patient who receives health care services, but is not admitted to a hospital during a 24-hour period.
Primary Care Physician A physician, usually a general, family practitioner or internist, who delivers general health care, and is most often the first doctor a patient sees. This physician treats the patient directly, refers them to a specialist (or secondary care physician) or admits them to the hospital.
Provider A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.
Pre-Certification Also known as pre-admission certification, is the process of obtaining authorization from the health care plan for routine inpatient and outpatient admissions. Failure to obtain pre-certification may result in penalty to the provider or the subscriber.
Referral Authorization Approval for a member to see a physician or access services outside of the participating medical group.
Referral Physician A physician who sees a patient after another doctor has sent them for specialty care or services.
Referring Physician A physician who sends a patient to another doctor for specialty care or services.
Subscriber A person who enrolls in a health care plan and agrees to pay for premiums, co-payments and deductibles that are part of the plan.
Treating Physician A physician who provides care to the patient while in the hospital, and usually works at the hospital or comes in as a specialist.

Informed Consent for Treatment of Mesothelioma Cancer

Informed Consent is the term used to describe the communication between health providers and patients, particularly in clinical trials for new treatments. Informed Consent laws vary greatly from state to state, and also according to the specific case. In many states, Informed Consent laws may be more stringent in cases that involve experimental treatment. Additionally, some informed consent laws require written documents, while others do not.

Most laws require that patients be physically and mentally capable of understanding their condition and the ramifications of the proposed treatment. Therefore, in cases where the patient is unable to give their consent, the legal guardian of the patient makes treatment decisions for the patient. In the case of minors, parents are involved in any Informed Consent issues.

The primary purpose of informed consent is for the patient to have a complete understanding of their treatment, the possible risks of treatment, and the long term consequences of treatment. The goal is for the patient to have reasonable expectations of the effectiveness of treatment, and to understand any possible limitations there may be. As with nearly all cancer treatments, there are usually significant side effects that must be discussed and understood, as there may be instances where patients may find possible side effects too severe when compared to the potential benefits.

Costs associated with treatment are also a major factor when considering possible treatments. Some patients may need time to determine the financial impact. Additionally, the treatment itself may have logistical issues that the patient might want to consider. Certain treatments may be too draining for some malignant mesothelioma patients, who may prefer to spend their time and energy with friends and family.

With Informed Consent, patients are given alternative treatment options as well, helping to give them a full perspective on their available options. Although offering alternative options is a part of Informed Consent, many doctors encourage patients to independently research and explore all their options. Informed Consent does not stop after the initial pre-treatment dialogue. The process of Informed Consent is ongoing, which is essential because patients may change their feelings about a treatment during the clinical trial. These trials are highly regulated, including by the FDA, which has many regulations applicable to trials regardless of whether they have received federal funding. Additionally, many hospitals have Institutional Review Boards that monitor and regulate the clinical trials conducted under their supervision. Clinical trials may also be subjected to peer reviews prior to patient trials. All of these measures are part of the Consent process, and help ensure that the trials run smoothly and safely.

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