Commonly Used Insurance Terms

An agreement between doctor and patient where the patient transfers to the doctor the right to receive future insurance payments that are owed the patient by an insurance carrier.

Capitation: 
A set dollar amount that a third party payer pays to a doctor regardless of the number of services provided.

Carrier: 
A third party that carries (or assumes) certain risks for a policyholder.

Claim: 
A request for payment of a loss by a policyholder that may or may not come under the terms of an insurance contract.

Co-pay: 
An amount paid by the insured for losses covered by a policy after the deductible amount has been met.

Deductible: 
An out-of-pocket expense that a policyholder pays directly to the doctor before insurance cover any treatment costs.

Deposition: 
A statement made under oath to obtain evidence in a legal matter.

Diagnosis: 
A clinical description of a patient's condition using terms that are accepted by the chiropractic profession and most other health care providers. 

Disability: 
The partial or total loss of mental or physical abilities caused by an injury or disease that prevents an insured from engaging in some or all of the duties of his or her usual occupation.

Exacerbation: 
An increase in the severity of a condition(s) or the patient's symptoms. 

Fee for service: 
The traditional method of payment for health care services where payment is made by the patient for specific services delivered by a doctor.

Gatekeeper: 
An individual, often a medical doctor, who controls patient access to healthcare services for members of a specific group. Referrals from this "gatekeeper" are necessary to see a specialist.

HMO: 
Health Maintenance Organization. Generally, a prepaid plan (not insurance) that offers certain health care services for a fixed monthly fee.

Impairment: 
A loss, alteration or abnormality of psychological, physiological or anatomical structure or function that does not take into account the activities and job functions of an individual. (See disability.)

IME: 
Independent Medical Examination. An examination arranged by a third party payer that is theoretically designed to "impartially" evaluate a patient's disability or another doctor's diagnosis or treatment plan.

Insurance: 
An agreement by which one party (the insurer) assumes the risk of the payment of health care treatment faced by another party in return for a premium payment.

Lien: 
A creditor's claim against assets to secure a debt.

Managed Care: 
A program that imposes controls on the utilization of health care services or the providers who offer such care.

Maximum Medical Improvement: 
A point at which the patient's care has reached his or her pre-incident condition, often ending the insurance carrier's obligations.

Medical Necessity: 
Health care services and supplies provided by chiropractors (DCs) that are appropriate for the evaluation and treatment of a disease, condition, illness, or injury.

No fault: 
Generally a form of insurance in which a person's losses from an automobile accident are paid by his or her own insurer, regardless of who was at fault.

Out-of-network: 
A provision for reimbursement of services by a provider who is not a member of the patient's managed care organization that usually involves a higher co-pay or a reduction in reimbursement.

Persoal Injury Protection (PIP): 
A type of coverage in an automobile policy that pays for medical costs in case of an accident. Also known as Medical Payments coverage or "Med Pay."

PPO: 
Preferred Provider Organization. A network of doctors and hospitals that contract with an insurance company or employer to provide employees with services at competitive rates.

Personal Injury: 
Usually associated with injuries sustained from an automobile accident, slip or fall incident, or harm caused by the negligence of others.

Pre-authorization: 
The prior approval required by some third party payers before benefit payments are granted.

Provider: 
Those persons who provide health care services, such as hospitals, physicians, chiropractors, nurse practitioners and others.

Reimbursement: 
The payment of the expenses incurred after an accident or sickness, up to any limit specified in the policy.

Third-party payer: 
Any payer other than the patient, for health care services, such as an insurance company, HMO, PPO or the government.

Treatment Plan: 
A practitioner's plan for treating a patient, over a period of time, for a specific condition. 

Uninsured Motorist Coverage: 
An insurance provision that pays for bodily injury to the insured, a family member or others in the insured's care when the injury is caused by an uninsured, underinsured or hit-and-run driver.

Unusual, customary and reasonable fee: 
A term that describes the amount that the doctor will charge for a particular service in a geographical area.

Wellness/Maintenance care: 
Health care that is not prompted by sickness or injury but by an attempt to achieve or promote an optimum state of physical, mental and social well-being.

Worker's Compensation: 
A type of insurance that covers employee illnesses, injuries and disabilities occurring in the course of their employment.