Trying to understand hospital bills and health insurance can sometimes feel like trying to speak a different language. To provide some help with hospital bills and how to understand them, we’ve compiled a list of hospital billing terms you may come across and what they mean.
Beneficiary/Insured: Someone who is eligible to receive benefits under an insurance policy or plan.
Beneficiary/Insured Liability: The amount beneficiaries must pay for covered services. These include co-payments, coinsurance, deductibles and balance billing amounts.
Coinsurance: A type of cost sharing in which the beneficiary/insured and insurance provider share payment of the approved charge for covered services in a specified ratio after payment of the deductible by the insured. For example, for Medicare doctors' services, the beneficiary pays coinsurance of 20 percent of allowed charges.
Coordination of Benefits (COB): A provision in health care that determines the insurances’ and patient’s share of the expenses.
Co-payment : (1) A fixed dollar amount paid for a covered service by a beneficiary/insured (see Coinsurance and Deductible). (2) Amount that a member of a health plan has to pay for specific health services, such as visits to a doctor (see Beneficiary Liability and Coinsurance).
Date of service (DOS): The date(s) health care services were provided
Deductible: The amount of eligible expense a beneficiary/insured person must pay each year out of pocket before the plan will make payment for eligible benefits.
Explanation of Benefits (EOB): The insurance company’s statement that lists services rendered, amount billed and payment made. This normally would include any amounts due from the patient, such as Beneficiary/Insured Liability, Coinsurance, Deductible and/or Co-payment amount.
Health insurance: Coverage that provides for the payment of benefits as a result of sickness or injury. This includes insurance for losses from accident, medical expense, disability or accidental death and dismemberment.
Health Maintenance Organization (HMO): An entity that provides, offers or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium.
Medicaid/AHCCCS: A state/federal benefit program for the poor who are aged, blind, disabled or members of families with dependent children. Each state sets its own eligibility standards. Only 40 percent of individuals with income below the poverty level currently are covered.
Medicare: A federal health benefit program for people over 65 and disabled Americans.
Out of network (OON): Coverage for services obtained from a non-participating provider. Typically, it requires payment of a deductible and higher co-payments and coinsurance than for treatment from a participating provider.
Part A Medicare: Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, critical access hospitals and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions.
Part B Medicare: Medicare Part B (Medical Insurance) helps cover your doctors’ services and outpatient hospital care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
Primary care doctor: A doctor, the majority of whose practice usually is devoted to internal medicine, family/general practice and pediatrics. An obstetrician/gynecologist sometimes is considered a primary care doctor, depending on coverage.