A - B
The re-submission of a claim that has been denied. Claims can be denied for several reasons, and the success of the appeal depends on understanding these reasons, and how to remedy them. For example, a claim that has been for lack of medical need may be successfully through physician intervention. MCL manages the appeal process and secures necessary information to re-submit claim.
C - D
A request for payment from the health plan for services provided. “In-network” providers will generally file claims on your behalf. For “out-of-network” providers – it is often the patient’s responsibility to file the claim for reimbursement. Each carrier has a different claim form, and even within a carrier these can vary by provider and type of medical service. It goes without saying that the filing of claims can be very confusing and time-consuming for patients; and without the requisite expertise, it is very easy to make mistakes that result in real financial costs. MCL’s experts file claims on client's behalf, and strive to maximize reimbursement.
The percentage you pay towards a medical service once you have met your deductible. For example, many plans pay 80% of the bill, while your co-insurance is the remaining 20%. While not a major burden in most cases, for expensive or recurring treatments, co-insurance can represent a major financial burden. MCL determines if co-insurance is applied towards deductible or can be billed to supplemental insurer. There are also certain non-profit organizations that help patients with certain diseases meet their co-insurance
Coordination of Benefits
Two or more health plans pay a percentage of a claim, one plan is deemed primary and the other secondary. For example your health plan may pay 80% of your medical bill and spouse's plan pays the remaining 20%. Alternatively, your insurance plan may pay 80% of the bill, and a supplemental insurance plan may pay the remaining 20%. On the other hand, it may not – the high level of administration involved in coordinating benefits can often lead to confusion. MCL makes sure that if you have multiple applicable policies, all of them provide the appropriate level of coverage.
A fixed amount that you pay when receiving a medical service. For example, many plans stipulate that you pay $20 -30 for an office visit.
The yearly amount of money that you need to pay out-of-pocket before a health plan pays for medical services. Certain costs do not apply to your deductible – for example, visits to your PCP. Deductibles, and what is and is not applied to them, vary greatly by policy. MCL helps clients understand these differences, and ensures that out-of-pocket costs are minimized.
A determination that a health plan will not pay for a covered medical service. Claims can be denied for various reasons, including lack of medically necessity, timeliness of filing or several other reasons.
A determination by a health plan that a patient cannot engage in activities of daily living without assistance. Usually, insurance plans have extraordinary benefits that apply in cases of a traumatic and disabling condition, for example paralysis. For these patients, MCL ensures that clients receive the full amount of benefits from their health plan.
E - F
Explanation of Benefits (EOB)
A document sent by the health plan to the patient in response to a claim outlining the amount the health plan will pay to the provider and the amount for which the patient is responsible. Due to the complexities associated with healthcare insurance and payment, EOBs are notoriously difficult to read, and usually require another level of “explanation.” MCL helps clients truly understand their EOBs, and ensures that they only pay what they truly owe.
Services not covered under the health plan. These are often charges one does not immediately think of - for example, a health plan may not pay for phone and TV charges during hospital stay. MCL provides a clear understanding of health plan exclusions for our clients.
G - H
The amount of time you have to pay your health insurance premium after the due date before the plan cancels the policy. For example, a carrier may cancel a policy if monthly premium is not paid after 30 days. If there are extenuating circumstances, this period can be extended – MCL ensures that this takes place, if need be.
The Health Insurance Portability and Accountability Act which protects the privacy and security of health information.
For more information on HIPAA, please visit the Department of Health and Human Services web site: http://www.hhs.gov/ocr/privacy
K - L
The maximum amount of money that a health plan pays for the entire time you have coverage under that plan. For example, a health plan does not pay for medical care costs once $2 million maximum is used. For younger, healthy people, there is little risk associated with the lifetime maximum. However, for those facing major medical costs associated with a disease such as cancer – this can be a serious challenge. MCL assists these patients in managing reimbursement for catastrophic costs.
M - N
A state run health coverage program for the indigent and children with certain chronic conditions.
One of the standards used by a health plan to determine whether or not to reimburse a medical service. For example, procdures such as cosmetic surgery are usually not covered by healthcare plans, and they are not generally considered medically necessary. However, this represents a significant “grey area” in coverage, and can often require intervention from the provider and the carrier’s medical team. MCL collaborates with provider to ensure that medical necessity is documented appropriately.
The federal health coverage program for the aged and disabled.
O - P
Refers to a health care provider who is not part of the health plan's list of providers (i.e. under contract with the carrier). While HMOs usually do not allow or restrict visits to out-of-network providers, PPOs allow visits, but they usually result in decreased coverage and increased costs. Speicalist doctors and surgery centers tend to be out-of-network more than PCPs. Also, even though a surgeon may be in network, an anesthesiologist may not. Services from out-of-network providers usually result in additional out-of-pcoket costs to patients – and require the filing of claims in order to be reimbursed. MCL fully manages out-of-network claims for its clients, and seeks to maximize reimbursements on their behalf.
Any healthcare costs that a patient is responsible for, including payments for deductible, coinsurance, copayment, nonprescription drugs, and excluded services. For the average family, approximately 30% of all healthcare costs are out-of-pocket. MCL works to minimize out-of-pocket expenses for our clients.
Notification and approval required by insurer for a medical service prior to date of service. For example, a carrier will not pay for services like cat scans, chemotherapy, knee replacements and organ transplants without first approving that the service is medically necessary and appropriate. Procuring pre-authorization, especially for rare and expensive therapies, can require a significant level of intervention. Based on the healthcare plan and treatment, MCL can determine which services require pre-authorization and obtains approval on behalf of client.
A medical condition that you have before obtaining health insurance. This is a “hot topic” in health insurance, as many patients are denied coverage for treatment based on a carriers assessment that it was a pre-existing condition. For example, a new insurance policy may not cover conditions like – and costs arising from - a current pregnancy, obesity, arthritis or high blood pressure, which can leave that patient in a bind. MCL ensures that the carrier’s definition of pre-existing is in line with reality, and can negotiate with health plan to pay for services related to a pre-existing condition.
The money you pay, usually monthly, to purchase health care insurance.
S - T
Additional health insurance that pays for expenses not covered by your primary insurer. Supplemental insurance can cover costs of deductibles, co-insurance and co-payments. In addition to primary insurers, MCL submits claims to supplemental insurers, ensuring coordination of benefits.
U - V
Usual and Customary (UCR) Charges
The maximum amount that the health plan will pay for a medical service. These charges are determined by several factors, most notably provider type and geography. For example, a visit to a dermatologist in New York City could result in a $220 charge. However, even though the physician is “in-network” the UCR is $175. Thus, if the plan covers 80% of the visit, the patient’s out-of-pocket cost will be the co-insurance (20% of $175 = $35) plus the difference in the bill and UCR ($220 - $175 = $45). UCRs can vary greatly by how the physician codes the procedure. MCL ensures that clients’ out-of-pocket costs are minimized in these situations.
W - X
The time you have to wait to be eligible for insurance coverage. For example, in certain cases, you have to be employed for 3 months before you can join the employer’s health care plan. However, during this time, you may be entitled to certain benefits – MCL can determine what coverage may be available.