Ambulatory care refers to medical services that are provided on an outpatient basis, such as at an urgent care center, certain clinics and health centers. According to the Department of Health and Human Services (HHS), the term ambulatory care implies that the patient must travel to a location to receive services that do not require […]
A waiting period is the amount of time an individual or dependent must wait before insurance coverage becomes effective.
A subspecialist is a doctor who has a narrower area of expertise in a specialized area. For example, a pediatric oncologist is a doctor who takes care of children with cancer, and a geriatric oncologist is a doctor who takes care of elderly people with cancer.
A specialist focuses on a more narrow area of medical care such as a neurologist, a cardiologist, an oncologist or an otolaryngologist.
A primary care physician is a physician who handles the primary and general outpatient care needs of patients. Primary care physicians can be family physicians, internists, pediatricians and obstetrician-gynecologists. Primary care physicians tend to make less money than specialists, though they see more patients, but salary surveys show primary care physicians are taking on a […]
A pre-existing condition is any condition (physical or mental) including a disability that a patient was diagnosed with or received treatment for before their health insurance plan went into effect. Some states have pre-existing condition exclusions, such as six months or 18 months. The time an insurance company is allowed to exclude a patient varies […]
A nurse practitioner is a licensed health professional with an advanced degree who has the ability to perform basic primary care functions such as prescribing medication and making certain diagnoses. Regulations for their job duties, known as ???scope of practice??? rules, vary from state to state. They do have to have some physician supervision, but […]
A health savings account (HSA) is a medical savings account available to taxpayers to pay for medical expenses not covered by insurance. A consumer or a worker can set aside pretax dollars that can then be used to pay co-payments, coinsurance or prescriptions. There are some HSA accounts that allow account holders to use it […]
A network is the list of preferred health care providers who have contracts with an insurance company. Health care obtained within the network tends to be less expensive than if a patient goes outside the network, meaning outside the list of contracted doctors or hospitals.
Health insurance exchanges are a part of the Affordable Care Act (ACA) signed by President Obama in 2009. Exchanges are being set up in each state to work as a marketplace for consumers to shop for a menu of health insurance options. The Obama administration, in conjunction with the National Association of Insurance Commissioners (NAIC), […]
A generic drug is a chemically equivalent copy of an existing brand-name drug that is no longer under patent. According to the U.S. Food and Drug Administration (FDA), a generic drug must be identical to a brand name in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. The generic faces […]
A chronic illness is a long-term or permanent illness that can cause a disability and may require a person to need help with certain activities. Examples of a chronic illness or disease include heart disease, hypertension, diabetes, stroke and arthritis.
A brand-name drug is a drug marketed under a proprietary, trademark-protected name.
A deductible is the amount a patient is responsible for paying before insurance pays the rest. A high-deductible plan with a $2,000 deductible, for example, might offer a low monthly premium but requires the policy holder to spend $2,000 of his or her own money on medical care each year before insurance coverage kicks in.
If a person has insurance, he or she is responsible for a copayment, which is a set amount established between the insurance company and the provider. A copayment is a portion of the total cost of a drug or medical treatment. If a doctor???s office visit costs $100, and the patient pays $25, then the […]
A claim is a request for payment that a patient or health care provider submits to a health insurer when a patient receives services or products that are thought to be covered. Claims by health care providers are submitted to health plans in order to be paid.
A benefit is a health care service or product covered by a health insurance plan or an employer. Covered benefits and excluded services are detailed in each health insurance plan.
Out-of-network refers to a patient seeking care outside the network of doctors, hospitals or other health care providers that the insurance company has contracted with to provide care. It usually applies to health maintenance organizations (HMOs) and preferred provider organizations (PPOs). If a patient does seek out-of-network care, those services may only be partially covered […]
A variety of factors affect what an insurance company will cover, but if an employer is small and does not have enough budget to spend on benefits, then the workers’ premiums and deductibles might be higher. While doctors and patients may express dissatisfaction about insurance companies not covering certain things, in reality, insurance companies will […]
Allied health professionals include occupational therapists, physical therapists, speech-language pathologists, psychologists and other health care professionals who are not physicians, nurses, dentists or pharmacists. Depending on how broad the definition being used, allied health professionals could also include scores of other professionals, including athletic trainers, dietitians or mammographers.
Insurance companies are regulated differently. Large insurance companies are self-funded, so they are regulated by federal laws. Individual or small group policies are regulated by the states; it is the states that will set up exchanges where uninsured Americans will be able to purchase health care coverage starting in 2014, under the Affordable Care Act […]
Yes. The new health care bill calls for: – Increasing the sentencing guidelines by 20-50 percent for crimes that involve a fraud of more than $1 million. – Strengthening civil and monetary penalties for committing Medicare fraud. – The Affordable Care Act (ACA) makes it a crime to obstruct a fraud investigation. Related FAQs How […]
The Department of Justice (DOJ) and the Department of Health and Human Services (HHS) are in charge of Medicare fraud at the Cabinet level, where the Attorney General (AG) and the Secretary of HHS are directly involved. The Centers for Medicare & Medicaid Services (CMS), which operates the two programs, is within HHS. The Health […]
There are 12 members of Congress to watch. They have all introduced bills on Medicare fraud: ??? Sens. Charles Grassley (R-Iowa) and Ron Wyden (D-Ore.) are sponsors of a bipartisan bill to allow public access to a Medicare claims database that details what every provider earns from Medicare. ??? Sen. Charles Grassley (R-Iowa) is a […]