#1
What is a co-payment in medical insurance?
A fixed amount paid by a patient for covered services
ExplanationFixed patient payment for covered services
#2
What does the term 'out-of-pocket maximum' refer to in health insurance?
The most a patient will have to pay for covered services in a plan year
ExplanationMaximum patient payment in a plan year
#3
What does 'fee-for-service' (FFS) mean in healthcare?
A payment model where services are unbundled and paid for separately
ExplanationPayment model for unbundled services
#4
What is 'Medicare'?
A federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease
ExplanationFederal insurance for seniors, disabled, and ESRD patients
#5
What does 'Medicaid' cover?
Healthcare services for individuals and families with low income and resources
ExplanationHealthcare services for low-income individuals and families
#6
What is a 'deductible' in an insurance policy?
The amount paid out-of-pocket before an insurer pays any expenses
ExplanationOut-of-pocket amount before insurance coverage
#7
What is a 'Health Maintenance Organization' (HMO)?
A healthcare system that provides care through a network of physicians for a monthly or annual fee
ExplanationPhysician network-based care system
#8
What does 'provider network' mean in health insurance?
A group of healthcare providers that an insurance plan has contracted with to provide services at negotiated rates
ExplanationContracted healthcare provider group
#9
What is the 'Affordable Care Act' (ACA)?
A healthcare reform law enacted to increase health insurance quality and affordability, lower the uninsured rate, and reduce the costs of healthcare
ExplanationHealthcare reform law for quality, affordability, and coverage
#10
What is 'premium' in the context of health insurance?
The amount that must be paid for your health insurance or plan
ExplanationAmount paid for health insurance or plan
#11
What does capitation mean in healthcare financing?
A system where providers are paid for each patient enrolled over a period of time
ExplanationProviders paid per patient over time
#12
What is DRG (Diagnosis-Related Group)?
A system to classify hospital cases into one of initially 467 groups
ExplanationClassification system for hospital cases
#13
What is 'balance billing' in the context of healthcare services?
Sending a bill to the patient for the remaining balance after insurance payment
ExplanationBilling patient for remaining balance after insurance
#14
What does 'prior authorization' in health insurance entail?
Approval from an insurance company before receiving certain healthcare services
ExplanationInsurance approval before certain services
#15
In medical billing, what is an 'explanation of benefits' (EOB)?
A statement from an insurance company explaining what treatments and services were paid for
ExplanationInsurance statement on paid treatments and services
#16
What does 'coinsurance' mean in health insurance terms?
A percentage of the cost that the insured pays after the deductible has been met
ExplanationPercentage of cost paid after deductible
#17
What is 'utilization management' in healthcare?
The process of evaluating the necessity, appropriateness, and efficiency of healthcare services
ExplanationEvaluation of healthcare service necessity and efficiency
#18
What is 'bundled payments' in the context of healthcare?
A single combined payment for multiple services during a single hospital stay or treatment course
ExplanationSingle payment for multiple services during treatment
#19
What is 'third-party administration' (TPA) in healthcare?
An independent organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity
ExplanationIndependent organization processing insurance claims
#20
What does 'point-of-service' (POS) plan mean in health insurance?
An insurance plan that offers lower medical costs to patients who use doctors, hospitals, and other healthcare providers that belong to the plan's network
ExplanationLower cost for using plan's network providers
#21
What is the principle of 'managed care'?
A healthcare delivery system designed to manage cost, utilization, and quality
ExplanationSystem managing cost, utilization, and quality
#22
What is the significance of the Resource-Based Relative Value Scale (RBRVS) in healthcare?
It determines the prices for medical services based on the resources required to provide them.
ExplanationDetermines medical service prices based on resources
#23
What is the primary goal of 'value-based care'?
To improve patient outcomes by linking payments to the quality of care
ExplanationLinking payments to care quality to improve outcomes
#24
What is 'risk adjustment' in health insurance?
A financial adjustment applied to insurance premiums to reflect the health status of enrolled individuals
ExplanationPremium adjustment for enrolled individuals' health status
#25
What is 'stop-loss insurance' in the context of health care?
A type of reinsurance that provides protection for insurers against large claims
ExplanationInsurance protection against large claims for insurers