Components of Health Insurance
“I provide medical services to patients. Who am I?
Provider
What type of care focuses on preventing illness before it occurs?
Preventive care
Which type of plan generally emphasizes using a network of providers and may require a PCP to coordinate care?
HMO
What is a medical bill?
A statement showing the healthcare services received and the amount charged/owed.
I help pay for covered healthcare services. Who am I?
Health insurance
What type of care is focused on treating an illness or condition that a patient already has?
Curative/Treatment care/Non-Preventive care
Which type of plan generally gives members more flexibility to see providers outside the network, although at a higher cost?
PPO
Who typically sends a medical bill for services provided?
The healthcare provider or facility.
What is the difference between a provider and the health insurance?
The provider delivers healthcare services; the payer/insurance helps pay for covered services.
What type of care helps a patient recover or regain function after an illness, injury, or surgery?
Rehabilitative care
Which type of plan combines characteristics of an HMO and a PPO?
POS
What is the difference between the amount charged and the amount the patient owes?
The amount charged is what the provider billed for the service; the patient's responsibility is what remains for the patient to pay after applicable insurance processing and adjustments.
Who is the person who receives healthcare services?
The member
What type of healthcare professional is primarily responsible for diagnosing and treating medical conditions?
Physician/Doctor
What is a provider network?
A group of healthcare providers that have an agreement with an insurance plan to provide services to its members.
Why can two members receive the same medical service but receive different amounts on their bills?
Their insurance plans, benefits, network status, deductibles, copays, coinsurance, or other cost-sharing may be different.
Two members receive the same medical service from the same provider, but their insurance companies handle the payment differently. What could explain this?
Their insurance coverage/plans may have different benefits, rules, or cost-sharing requirements.
Why might a patient need more than one healthcare professional during their treatment?
Because different healthcare professionals have different areas of expertise and work together to meet the patient's needs.
A member says "I don't understand why my insurance works differently from my coworker's. We both have insurance from the same company."
Give THREE things you would want to verify before explaining the difference.
-Specific plan
-Provider/network status
-Benefits/coverage
-Cost-sharing
-Member eligibility
-Plan rules
Why is understanding a medical bill important for someone working in insurance?
Because it helps us explain charges, insurance payments, adjustments, and member responsibility accurately instead of assuming that the amount originally charged is what the member owes.