Billing & Helpful terms

At OC Blood & Cancer Care we fully understand that a diagnosis of cancer is unexpected. At times, treatment and the road to recovery may seem financially overwhelming. We provide financial counseling to patients and their families to assist them. Our medical authorizations/financial staff evaluate every patient’s insurance benefits and can discuss their financial responsibilities and options with them. Typically, once a treatment plan has been recommended to you, our staff will provide you an estimate of your out-of-pocket expenses and review the covered benefits of your insurance plan.

Although you are responsible to pay any co-payments, deductibles or uncovered portion of the charges, if you need help with your bill, our staff can also assist you in obtaining financial assistance and accessing certain programs that may help with chemotherapy drug payment and other services. However, not all patients are candidates for such programs.

The aforementioned is meant to remove the financial burden as much as possible so as you and your loved ones can focus on the important issues, namely your medical treatment and getting better.

The following terms are included to help you better understand your health insurance:

Co-insurance: Involves the insurer and the insured sharing medical costs incurred after the deductible has been met. With traditional non-managed care plans, the percentage that the insured pays is based on provider charges, sometimes up to a maximum allowable amount per service. In managed care plans, the percentage the insured pays may be based upon provider contract rates.

Claim or Insurance Claim: Notification to an insurance company requesting payment of an amount due under the terms of the policy.

Co-payment: A flat fee paid out-of-pocket by the patient for medical services, usually at the time the service is rendered. This usually applies to physician office visits, prescriptions, and emergency or hospital services.

Deductible: The amount of medical expense a person must pay each year from his/her own pocket before the insurer or health plan will make payment.

Explanation of Benefit forms (EOB) or Medicare Summary Notice (MSN): Notification to patients from an insurance company or Medicare to provide necessary information about claim payment information and patient responsibility amounts.

Gatekeeper: A term used for a primary care physician that serves as a patient’s initial contact for medical care and referrals.

Health Maintenance Organizations (HMOs): HMOs are organized systems for providing health care within a geographic area. Each HMO plan offers a set of basic and supplemental preventative and treatment services. Members typically select primary care physicians who are responsible for making referrals to specialists when needed. HMOs offer no “out of network” benefits and have low out-of-pocket (co-pay) expenses.

Indemnity plans: In indemnity plans, the member chooses his or her own providers. Oversight of care by the health plan is minimal. The member’s out-of-pocket payments are generally a percentage of the provider’s usual and customary fee schedule.

Managed care: A broad term that describes programs designed to manage the cost and quality of health care. Ideally, managed care programs provide a comprehensive system for patients to receive the care they need, when they need it, including preventative care. The plans vary from restrictive provider panels and low out-of-pocket amounts to relatively open provider panels and high out-of-pocket amounts. Please click here for the Insurance & Managed Care List.

Medicaid: The government health insurance program for low-income, indigent and elderly individuals. Many states are introducing Medicaid HMOs for their citizens.

Medicare: The federal health insurance program for older Americans and eligible disabled individuals. Part A includes coverage for inpatient hospital or skilled nursing facility stays. Part B includes coverage for outpatient physician and nursing services, x-rays, laboratory and other diagnostic tests. Part C, often referred to as Medicare Advantage Plans, gives Medicare beneficiaries the option to receive their Medicare benefits through private health insurance plans. Part D includes coverage for drug benefits. Since neither Part A nor Part B pays for all of a covered person’s medical costs, some beneficiaries elect to purchase Medicare Supplemental Insurance often referred to as a Medigap plan to help pay for the out-of-pocket expenses such as deductibles and co-insurance.

Point of Service (POS): POS plans are similar to HMO plans. However, POS members have higher out-of-pocket (co-insurance) payments if they choose to directly seek specialists without referrals from their primary care physicians.

Preferred Provider Organization (PPO): PPOs generally provide “in-network” and “out-of-network” benefits and do not require a primary care physician referral to see a specialist. The member’s or insured’s portion of the payment is less when using an “in-network” provider.

Primary Care Physician (PCP): A primary care physician is a physician responsible for providing specific primary care services. These include the evaluation and treatment of a patient, including decisions regarding referrals for specialty care. Primary care physicians are generally found in family practice, general practice, general internal medicine, pediatrics, obstetrics or gynecology facilities. Under the HMO health plan model, the primary care physician may also be considered the gatekeeper.