FAQs

General Information

What’s with all this terminology?

Premium = Essentially the cost of an insurance plan, typically broken up in monthly payments.

Deductible = Any additional out-of-pocket money paid by the patient, not covered by the insurance company.

Co-insurance = A newer term for additional out-of-pocket expenses not covered by insurance. This may be negotiable.

In-Network = A physician or other healthcare provider who has agreed to a negotiated rate from your insurance company. Payors and providers are constantly negotiating and renegotiating rates and hence network status.

Out-of-Network = A provider who has not agreed to the discounted ‘in-network’ rate. Typically, the patient needs ‘out-of-network benefits’ in their plan to see these providers.

Claim = Any time you see a provider or use a service that generates a bill which is referred to as a ‘claim’.

EOB (explanation of benefits) = Frequently your insurance company will send this statement explaining your benefits. It is frequently confused for a bill. It is not.

Payor = Generally speaking this is the insurance company. You are their customer and they are making payments on your behalf.

Provider = Any healthcare worker (doctors, nurses, physical therapists, chiropractors, massage, hospitals, etc).

Members = An insurance company will cover a certain number of people, ‘members’. This differs from subscribers because one subscriber may pay for several members (like in a family).

Subscribers = The individual who has subscribed to the insurance plan and pays the premium.

Know your rights:

The No Surprise Bill Act = Recent state level and federal level legislation that says, in the case of an emergency your insurance company needs to cover your expenses and you, the patient, are not responsible for billed charges.

Provider appeal = If providers are not paid fairly by insurance companies they have the right to appeal.

Patient appeal = If your insurance company is not covering the costs of your care fairly you have the right to appeal.