Glossary of Terms
Advance Beneficiary Notice (ABN), some services are not payable by Medicare or other insurance companies. If your physician orders these tests you will be asked to sign an ABN. The ABN is notification that you understand that payment for the listed services will be your responsibility, if Medicare or your insurance company denies payment. If you do not sign the ABN the test should not be performed. If patient decides to receive the service but refuses to sign, the registrar will indicate on the ABN that the “Patient Refused to Sign,” and the patient will then be responsible for the bill.
Authorization, many insurance companies require an authorization to be issued prior to tests or procedures being performed. Without an authorization the insurance company will not reimburse Bayhealth and it may be your responsibility to pay the bill depending on the contract between your insurance company and the hospital. Your physician will request the authorization from your insurance company. When authorizations cannot be verified at the point of registration, you have two options: 1) sign a letter accepting financial responsibility or 2) postpone the test until authorizations are verified.
Consolidated Omnibus Budget Reconciliation Act (COBRA), gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan.
Co-Pays, this is a fixed fee that the subscriber must pay for their use of specific medical services covered by their plan.
Deductibles, this is the amount not covered by the insurance plan for covered services.
Explanation of Benefits (EOB), all insurance companies are required to send you an explanation of benefit form, which explains what they are paying and shows the amount you owe. This amount should be the same as the hospital bill.
Hospitalists are licensed physicians that are assigned to hospital medicine, like emergency medicine, and is a specialty organized around a site of care (the hospital), rather than an organ (like cardiology), a disease (like oncology), or a patient’s age (like pediatrics). Most hospitalists help manage patients throughout the continuum of care as well as organizing post-acute care.
Late charges, these are charges for services rendered to you that were omitted on the first bill. They are not charges being added to the account for late payment.
Medicare Explanation of Benefits (EOB), Medicare sends summaries of their payments (EOB) to the patient on a monthly basis. These summaries may show a different amount than the hospital bill. This difference is created by the hospital’s agreement with Medicare. Medicare payment is not based on the hospital charges but on Medicare’s established payment schedule. Medicare determines the amount that is the patient’s responsibility. This amount should correspond for the amount due from either the patient or your secondary insurance. Please keep in mind that if Medicare does not pay for a hospital service, often the secondary insurance company will also not pay for that service. There could be more than one EOB from Medicare per visit. Inpatient stays will usually generate a Part A and Part B EOB.
Medicare take home drugs are drugs that are usually self-administered by the patient, such as those in pill form, or are used for self-injection, and are not normally paid by Medicare. However, there are some self-administered drugs that are explicitly covered by Medicare.
Primary Care Physician (PCP), this is the doctor that you have chosen to treat you. This doctor will make referrals to specialists, obtain authorization for your treatment, and advise you where to go for treatment so that your insurance will pay.
Referrals are recommendations made by your physician as to where to go for treatment. Referrals do not guarantee payments by the insurance company. Please see “Authorization” in this section of the Billing Guide. Secondary Insurance is a supplemental insurance plan that will pay some deductibles and co-pays after the primary insurance has paid.
Secondary insurance cannot be billed until the primary insurance has paid or denied the claim.