Glossary

Modern Healthcare is a complicated and oftentimes confusing business


Whether it’s patient care jargon or health insurance plan language, it can all appear to be alphabet soup. So we thought we would alleviate some of the possible confusion with our Healthcare Insurance Terms and Medical Specialties Terms below.

Healthcare Insurance Terms

Allowed Amount: The amount of the billed charge for medical services that the insurance company determines is payable by the plan.

Ambulatory Care: Outpatient medical care provided by emergency rooms, outpatient hospital clinics, and physicians’ offices, among other medical facilities.

Ambulatory Care Facility (ACF): This includes a wide range of facilities that are centrally located and provide preventative care, acute care, surgery, and outpatient care. An ambulatory care facility is also known as a medical center or medical clinic.

Ancillary Services: These services are used to support the diagnosis or treatment of a patient’s condition. Such services include physical therapy, occupational therapy, home health services, and diagnostic services. Ancillary services are also referred to as “supplemental services.”

Assignment of Benefits: This form, signed by the patient or his/her guardian, enables the physician or other medical provider to directly receive insurance payments for medical services.

Authorization: An approval required by health insurance plans for surgeries, medical supplies, or patient referrals to see a specialist.

Balance Billing: When a provider is trying to collect from a patient, the balance billing is known as the difference between what is allowed or covered by the patient’s health insurance company and what the medical provider charges. Balance billing is not permissible when an Encore network provider is used.

Birthday Rule: An informal method commonly used by the health insurance industry for determining the coordination of medical benefits — specifically, primary plan coverage — for dependents when children are listed under both parents’ health insurance plans.

Carve-Out: Medical services not included in a health plan contract and paid for under a separate arrangement.

Case Management: A method whereby a health plan attempts to ensure efficient, cost-effective, quality delivery of healthcare services by coordinating patient care through a nurse or other qualified healthcare professional.

Claim: An itemized statement of healthcare services and costs provided by a hospital, physician’s office, or other healthcare facility. The term “claim” generally refers to the liability for healthcare services received by covered persons.

COBRA: Consolidated Omnibus Budget Rehabilitation Act of 1985. COBRA requires the continuation of group insurance coverage to covered persons (employee, spouse, or dependents) who lose their health or dental coverage due to an event such as loss of plan coverage, divorce/legal separation, death of a covered employee, loss of dependent’s eligibility for coverage, etc.

Co-insurance: A fixed percentage of all remaining expenses a patient must pay after the deductible has been met.

Contracted Provider: A medical provider who has an agreement with a health plan to accept the plan’s patients at a previously agreed-upon payment rate.

Co-payment: A set amount that a member pays out of pocket for healthcare services at the time the services are rendered.

Covered Expense: A medical procedure or item deemed payable by an insurance plan.

CPT Codes: Current Procedural Terminology used by physicians and other healthcare providers to describe medical or psychiatric procedures they perform. CPT codes were developed by the federal Health Care Financing Administration (HCFA) to assist in the assignment of reimbursements to providers by Medicare carriers. Many managed care and other health insurance companies now base their reimbursements upon CPT Codes.

Deductible: An annual fixed out-of-pocket amount that must be met before the insurance company will pay benefits to a claim.

Exclusions: Medical services or items not covered by a health plan.

Exclusive Provider Organization (EPO): A health plan, such as Encircle EPO, that has similar characteristics to an HMO or PPO plan.

Explanation of Benefits: A statement sent to patients summarizing the payment made by a health plan to a medical provider.

Fee for Service: Refers to a method of payment for the rendering of medical services.

Fee Schedule: A pre-determined fee corresponding to CPT Codes that a provider is to be reimbursed by a healthcare insurer for patient services rendered. The provider agrees to accept this as payment in full. Also called “fee allowances” or “maximum allowable.”

Formulary: A list of pharmaceuticals that a health plan will pay for.

Fully Insured: Employers that purchase health insurance coverage from an insurance company that assumes all the coverage risk.

HMO: Health Maintenance Organization. This form of health insurance combines a range of coverage in a group basis. Physicians and other healthcare providers offer medical services through an HMO for a flat monthly rate with no deductibles. Patient visits to HMO network physicians are covered by the plan. Additional medical services, such as referral to a specialist or prescriptions, must be approved by the HMO. Referrals to specialists are handled by a primary care physician within the HMO network.

ICD-9: International Classification of Diseases. A standard three-digit code format for identifying illnesses, injuries, and diseases.

Integrated Delivery System: An organization that offers combined physician, hospital, and ancillary medical services as part of an overall health system.

Managed Care: A cost-containment method applied to a health plan that either limits the levels of reimbursement paid to providers or encourages reduced utilization.

Medical Necessity: Medical services or procedures performed only for the specific treatment of an injury or illness that is not considered experimental, investigational, or cosmetic in nature.

Network: A group of selected healthcare providers that managed care program participants use as their source of healthcare services.

Off-Label Use: The prescribing of medication for use not approved by the Federal Drug Administration (FDA). Drugs can only be prescribed for off-label use if recognized for that use by qualified, authoritative drug compendia or scientific evidence for the off-label use exists.

Out-of-Pocket Expense: The cost of a medical service not covered by a health plan for which the patient is responsible.

Participating Provider: Medical providers that have agreed to accept set fees for services to members of a specific health plan or network. These providers are referred to as being “in network.”

PPO: Preferred Provider Organization. A healthcare organization comprised of physicians, hospitals, and ancillary service providers that offers medical services at a reduced fee. PPO members pay for care on an as-needed basis. PPOs allow members to receive out-of-network medical services, but at a reduced rate of reimbursement. Typically, the member pays a deductible and higher co-payment when receiving out-of-network care.

Pre-Existing: A medical condition that has been diagnosed before the effective date of a healthcare plan.

Self-Insured: Employers who underwrite their own risk are known in the insurance industry as self-insured entities. Groups with favorable claims history are the best candidates for self-insured healthcare plans.

Usual and Customary: A reduction in the reimbursement of benefits paid on a claim justified by “the going rate” for medical services paid in a certain geographical area.

Medical Specialty Terms

Allergy and Immunology: Diagnosis and treatment of conditions involving the immune system, including allergic reactions to foods, drugs, chemicals, insect stings, and pollens. Conditions include hay fever, asthma, hives, dermatitis, eczema, and acquire immune deficiency disease.

Anesthesiology: Administering of drugs (anesthetics) for relief of pain during surgery. The anesthesiologist may use a regional anesthetic, including spinal or local, which dulls sensation in part of the body, or a general anesthetic, when a patient is rendered unconscious.

Cardiology: Diagnosis and treatment of diseases of the heart and blood vessels, such as heart attacks and life-threatening abnormal heartbeats.

Critical Care Medicine: Intensive care of life-threatening disorders, such as shock, coma, heart failure, trauma, respiratory arrest, drug overdoses, diabetic acidosis, and kidney failure.

Dermatology: Diagnosis and treatment of benign and malignant disorders of the skin, mouth, external genitalia, hair, and nails. Skin cancers, melanomas, moles, and other tumors of the skin, contact dermatitis, and other manifestations of systemic infectious diseases are treated. Also, includes management of cosmetic disorders of the skin, such as hair loss and scars.

Emergency Medicine: Primarily hospital emergency treatment that is focused on the immediate decision-making and action necessary to prevent death or any further disability; immediate initial recognition and evaluation of acute illness or injury and provision of appropriate short-term care and treatment.

Endocrinology: Evaluation and treatment of disorders of the internal glands, such as the thyroid and adrenal glands. Also deals with such illness as diabetes, metabolic and nutritional disorders, pituitary diseases, and menstrual and sexual problems. Endocrinology is a subspecialty of internal medicine.

Family Practice: The prevention, diagnosis, and treatment of a wide variety of common illnesses and injuries. Family practice physicians place a special emphasis on care of families on a continuing basis, utilizing consultations and community services when appropriate.

Gastroenterology: Management and treatment of disorders associated with the digestive organs, including the stomach, bowel, liver, and gall bladder.

Geriatric Medicine: The prevention, diagnosis, and treatment of diseases and disorders of the elderly.

Hematology and Oncology: Diagnosis and treatment of human solid tumors, including lung, breast, colon, rectum, anus, small bowel, liver, biliary system, pancreas, stomach, esophagus, kidney, bladder, prostate, testes, uterus, ovary, cervix, skin, and head and neck cancers. Diagnosis and treatment of hematologic (blood) malignancies, including Hodgkin’s lymphomas, myeloproliferative disorders, myelodysplastic syndromes, and leukemias.

Diagnosis and treatment of nonmalignant hematologic disorders, including anemias, thalasemias, clotting disorders, sickle cell disease, and hemophilia.

Outpatient and inpatient administration of chemotherapy, colony stimulating factors, IV fluids, and antibiotics.

Coordination with surgical and radiation specialists, including combined modality chemo-radiotherapy.

Infectious Disease: Diagnosis and treatment of infectious diseases of all types. Treatment of patients with HIV infection and AIDS is common. Diagnosis and management of unusual infections or unexplained fevers.

Internal Medicine: Emphasis on diagnosis and comprehensive care management of internal illnesses and problems, and on preventive healthcare and wellness. There are many subspecialties within internal medicine.

Nephrology: Disorders of the kidney and related body fluid and chemical imbalances are diagnosed and treated.

Neurology: Diagnosis and treatment of disorders of the nervous system, including their supporting structure and blood vessels. Encompasses treatment of disorders involving the brain, spinal cord, peripheral nerves, muscles, and autonomic nervous system. Strokes, epilepsy, multiple sclerosis, and spinal cord disorders are typical problems that are treated and diagnosed.

Obstetrics and Gynecology: Involves the female reproductive system, the fetus, and the newborn. Some physicians specialize in obstetrics or gynecology, rather than both. Obstetrics involves care of the woman during pregnancy, delivery of babies, and follow-up treatment. Gynecology is the diagnosis and treatment of disorders of the female reproductive organs and the reproductive process.

Conditions treated are infertility, infections of the genital tract, cancer of the genital organs, and complications of pregnancy.

Ophthalmology: Diagnosis and treatment of disorders of the eye. Surgery is performed to repair ailments such as cataracts and retinal detachments.

Orthopaedic Surgery: Treatment of bones, joints, and muscles. Treatment of injuries, disorders, and diseases related to the function of the extremities, spine, and associated structures by surgical and physical procedures. Congenital deformities, trauma, infections, tumors, and metabolic disturbances of the muscular and skeletal systems are diagnosed and treated. Treatment may involve arthroscopic examinations and surgery of the joints.

Otolaryngology: Diagnosis, medical, and surgical treatment of diseases and disorders of the ear, nose, and throat, respiratory and upper alimentary systems and related structures; hearing evaluation and treatment.

Pathology: The diagnosis of disease through the study of body tissues, secretions, and fluids. Includes use of scientific instruments and analytical measurement and procedures. Tissues and blood are examined chemically and microscopically to arrive at the diagnosis.

Pediatrics: the prevention, diagnosis, and treatment of diseases of children from birth to adolescence.

Physical Medicine and Rehabilitation: Evaluation and treatment of impairments caused by stroke, arthritis, head injury, spinal cord injury, multiple sclerosis, Parkinson’s disease, and cerebral palsy. Includes pain management, disability evaluations, and adjunctive treatment following orthopaedic procedures or surgery.

Plastic Surgery: Surgery to correct functional and cosmetic deformities of the face, head, body, and extremities. Repairs scars or burned skin, reconstructs structures destroyed by cancer or accidents, performs surgery to correct congenital abnormalities or to improve the appearance of a part of the body.

Podiatry: The diagnosis and treatment of diseases and disorders of the foot, including soft tissue disorders such as corns, bunions, and ingrown toenails. Podiatrists may specialize in podiatric surgery.

Psychiatry: The diagnosis and treatment of mental and emotional disorders, including depression, anxiety disorders, substance abuse, development disabilities, and sexual dysfunctions.

Pulmonary Disease: Diagnosis and treatment of diseases of the lungs and airways.

Radiology (Imaging Science): The use of various modalities, such as X-ray, mammography, ultrasound, MRI, CAT, and nuclear medicine to diagnose and treat disease.

Rheumatology: Diagnosis and non-surgical treatment of disease of the joints, muscle, bones, and tendons. Included are such conditions as arthritis, back pain, muscle strains, and collagen diseases.

Surgery: The pre-operative, operative, and post-operative care of surgical patients in a broad span of surgical conditions; affects most areas of the body.

Urology: Treatment of diseases of the urinary tract, both male and female, and of the reproductive system of the male. Organs include the kidneys, bladder, prostate gland, adrenal gland, penis, and testes.

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If you have any questions, please contact webmaster@encoreconnect.com
Special Authorization is required to access the Payor Updates.
Please contact one of the following Account Executives for access:
· Holly Joyce at (317) 621-4263 or hjoyce@encoreppo.com, or
· Kevin McShay at (317) 621-4264 or kmcshay@encoreppo.com

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Notice

Encore has entered into a new arrangement for chiropractic services with HSM, Inc. HSM, Inc., a Minnesota-based specialty network services organization, will administer the chiropractic network for our Encore and Encircle service areas.

HSM will directly hold contracts with all participating chiropractors; therefore, there are some changes of which you should be aware. Regarding billing, chiropractors will now send their claims directly to HSM. HSM will collect the data in their system, including treatment plans for case management, and forward claims to the appropriate Encore payor. The payor will send all payment directly to HSM, who will in turn reimburse the chiropractor according to the negotiated rates.

If you are interested in becoming a participating chiropractor in the Encore Health Network, please contact HSM at 800-432-3640 or visit their web-site at www.hsminc.com.

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Current Worker's Comp Payors

Arete USA D/B/A The Covenant Companies
HealthSmart
HFN, Inc
Indiana University
InterPlan Health Group
IU Health Plan
MCMC LLC
ASU Group
Major Hospital
ACS CompIQ Corporation, A Xerox Company

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Payor and Provider Resources

Payors please contact Account Executive Kevin McShay at (317)621-4264 or kmcshay@encoreppo.com for access.

For any provider issue, please contact Provider Contracting Coordinator, Tina Bilodeau at (317)621-4269 or tbilodeau@encoreppo.com.