Coinsurance
An amount owed by the patient to the provider under insurance benefits. Coinsurance is based on a percentage of the Insurance Price.
Copayment
An amount owed by the patient to the provider under insurance benefits. Copayment is set amount owed towards a particular benefit service, such a primary care physician visit.
Cost-to-Charge Ratio
The portion of a hospital’s billed charges that is comprised of the cost to render the service. For example, a Cost-to-Charge Ratio of .25 means for every $100 in billed charges, $25 is the cost to render the service, and $75 is profit. Cost-to-Charge Ratios are determined by Medicare cost reports submitted annually by hospitals.
Crucial Issues
An issue in your dispute that is fundamental to resolving the dispute as a matter of fairness to the customer. A Crucial Issue may require the provider to reduce the medical bill to rectify the issue.
Deductible
An amount owed by the patient to the provider under insurance benefits. Deductible is an amount the patient must pay for benefits before the insurance plan begins to pay towards benefits. A deductible amount is determined by the insurance plan EOB.
Explanation of Benefits (EOB)
A statement from an insurance plan detailing what benefits were applied to a claim, including amounts paid to the provider, and coinsurance, copayment and deductible amounts owed by the patient.
Facility Fee
Medical bill charges for the use of a building or facility as a physician office. A facility fee is charged in addition to professional/physician services, and may be charged by a hospital on a separate bill, or on the same bill as professional/physician services.
Good Faith Estimate (GFE)
The list of expected charges from a provider for items or services or facility shared with a patient in advance of services, and required under the No Surprises Act. The No Surprises Act and Centers for Medicare & Medicaid Services have detailed requirements for the content, format, and timing of a GFE.
Hospital Price Transparency
Federal regulation establishing enforceable guidelines by which hospitals must make public the standard charges they have established. The regulation defines several types of standard charges, including gross charges (standard billed charges without any discount); discounted cash prices (the charge that applies to an individual who pays cash or cash equivalent for a hospital item or service); and charges negotiated between the hospital and third-party payers (e.g. insurance plans).
Insurance Formatted Bill
A copy of the medical bill formatted in a standard insurance claim format of UB-04 (facility) or CMS-1500 (professional). Providers submit bills to Medicare and other health plans in UB-04 or CMS-1500 formats.
Insurance Letter
A letter from the customer to the patient’s health insurance plan with questions or requests related to your dispute. An Insurance Letter is applicable only if the patient is using insurance for services under the medical bill, and the dispute includes issues related to health insurance benefits and protections. Patient Fairness will produce an Insurance Letter for the customer to approve, and Patient Fairness to send on his or her behalf.
Insurance Payment Only
The total the provider would be paid from the insurance payment alone, without any payment from you. Insurance Payment Only is the Insurance Price minus coinsurance, copayment and deductible amounts.
Insurance Price
The total the Provider would be paid by your insurance plan and your coinsurance, copayment and deductible amounts.
Laws and Regulations Issues
An issue in your dispute related to a federal or state law or regulation.
Letter of Dispute
Correspondence from the customer to the provider that challenges that the customer owes the medical bill. A Letter of Dispute incudes these key functions and notices.
· The customer formally disputes the medical bill.
· The customer presents his or her issues and concerns related to the dispute.
· The provider must resolve the customer’s concerns for him or her to withdraw the dispute.
· The customer will not pay the medical bill while it is under dispute.
Maximum Affordable Amount
An amount set by the customer that is the most he or can afford to pay towards settlement of the medical bill dispute.
Maximum Settlement Amount
An amount et by the customer that is the most you would be willing to pay to settle the medical bill dispute and consider the outcome fair to you.
Medicare Price
The price Medicare would pay for a service, if rendered by a participating provider to a Medicare beneficiary.
No Surprises Act (NSA)
Federal law under the Consolidated Appropriations Act of 2021 that gives consumers billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. The NSA also requires providers to issue in advance a good faith estimate of how much services will cost.
Nullifying Issues
An issue in your dispute that is a fundamental concern about the validity of the medical bill as a whole. A nullifying issue may warrant that the provider withdraws the medical bill, so the customer owes nothing to the provider.
Patient Cost Sharing
The sum of coinsurance, copayment and deductible amounts for a claim under insurance benefits.
Problem Medical Bill Assessment (PBMA)
The tool and questionnaire a customer completes to begin a medical bill dispute. Patient Fairness uses the PBMA to identify potential issues to raise in a dispute of the bill.
Profit Margin
The percentage of a payment that is Provider Profit.
Provider Cost
The estimated cost to a provider to deliver a service. Provider cost is derived from the Cost-to-Charge Ratio.
Provider Profit
The amount paid to a provider above the Provider Cost for a service.
(Price) Transparency
Requirements for providers to notify, publish and otherwise make available the expected costs of services and supplies to patients and the public. The federal Hospital Transparency Rule, and some state laws, require hospitals to provide clear, accessible pricing information online about the items and services they provide.
% of Medicare Price
The percentage derived from dividing the total payment amount by the Medicare Price.
