Understanding Reimbursement Terms
Articles written about insurance and reimbursement can read like a foreign language text if you are not familiar with the terminology.  With the advent of managed care, patient’s can only see providers who are part of the insurer's network.  Regardless of the provider's fee, payments are limited to a set maximum allowable amount by the insurance company. Either the provider or the patient is responsible for the difference.  Typically in the Rhode Island, the managed care contract has a "hold harmless" clause, so the provider is responsible for the remaining balance and cannot collect that money from the patient.  Therefore the patient cannot be "balance billed" for the remainder. 

Here is a glossary of common terms associated with insurance companies:

	balance billing: the practice of holding the patient financially responsible for the remainder of medical service charges, beyond the insurer's allowed amount.  Does not apply when a managed care contract contains a "hold harmless" clause, which is typically the case.
	CMS: Centers for Medicare and Medicaid Services.
	co-insurance: the monetary amount to be paid by the patient, usually expressed as a percentage of charges
	co-payment: the monetary amount to be paid by the patient, usually expressed in terms of dollars
	CPT-4: Current Procedural Terminology, Fourth Edition.  5-character, numeric codes assigned to nearly every health care service/treatment.
	deductible: the portion of medical costs to be paid by the patient before insurance benefits begin, usually expressed in dollars.
	denial: refusal by insurer to reimburse services that have been rendered; can be for various reasons
	eligibility: the process of determining whether a patient qualifies for benefits, based on factors such as enrollment date, pre-existing conditions, valid referrals, etc.
	fee for service: reimbursement method in which each health service is paid on an individual basis.  Charges may be paid in full by the insurer but in most instances are paid on a percentage basis.
	fee schedule: a pre-determined list of payment amounts for various services; may be based on UCR, RBRVS or other method
	gatekeeper: in managed care, it refers to the provider designated as one who directs an individual patient's care.  In practical terms, it is the one who refers patients to specialists and/or sub-specialists for care.
	ICD-9: International Classification of Diseases, Ninth Edition.  Numeric and alphanumeric codes for numerous diagnoses
	managed care: a method of providing health care, in which the insurer and/or employer (policyholder) maintain some level of control over costs and utilization by various means.  Typically refers to HMOs and PPOs
	payer: the party who actually makes payment for services under the insurance coverage policy.  In the majority of cases, the payer is the same as the insurer.  But, as in the case of very large self-insured employers, the payer is a separate entity under contract to handle the administration of the insurance policy
	policyholder: purchaser of an insurance policy; in group health insurance, this is usually the employer who purchases policy coverage for its employees
	provider: one who delivers health care services within the scope of a professional license
	RBRVS: Resource Based Relative Value System.  Reimbursement method used by the U.S. Health Care Finance Administration (HCFA) for its Medicare program.  Values for each medical procedure are based on the amount of resources required to perform the procedure, then the values are weighed against each other to compute relative values.
	reimbursement: refers to the payment by the patient (first-party) or insurer (third-party), to the health care provider, for services rendered
	UR: utilization review.   Retrospective review of a patient's course of treatment, to evaluate the appropriateness of care based on medical necessity.