Glossary

B2B

Business-to-Business: e-commerce

Balance Billing

The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made. Under Medicare, the excess amount cannot be more than 15 percent above the approved charge.

Base Capitation

Specified amount per person per month to cover healthcare cost, usually excluding pharmacy and administrative costs as well as optional coverages such as mental health/substance abuse services.

Base Year Costs

In Medicare, the amount a hospital actually spent to render care in a previous time period. Depending on the hospital’s Medicare cost reporting period, the base year was the fiscal year ending on or after September 30, 1982 and before September 30, 1983 for hospitals in operation at that time.

Bed Days

Number of inpatient hospital days per 1,000 health plan members for a specified period, usually annual.

Behavioral Health

An umbrella term that includes mental health, psychiatric, marriage and family counseling, addictions treatment. Many states have “parity” laws that attempt to require that behavioral health insurance coverage be provided “on par” to physical health coverages.

Behavioral Offset

This is the change in the number and type of services that is projected to occur in response to a change in fees. A 50 percent behavioral offset suggests that 50 percent of the savings from fee reductions will be offset by increased volume and intensity of services

Benchmark

A goal to be attained. These goals are chosen by comparisons with other providers, by consulting statistical reports available or are drawn from the best practices within the organization or industry. Benchmarks are used in quality improvement programs to encourage improvement of care, efficiencies or services.

Beneficiary – Also eligible, enrollee, member

Individual who is either using or eligible to use insurance benefits, including health insurance benefits, under an insurance contract. Any person eligible as either a subscriber or a dependent for a managed care service in accordance with a contract. An individual who receives benefits from or is covered by an insurance policy or other health care financing program.

Beneficiary Liability

The amount beneficiaries must pay providers for Medicare-covered services. Liabilities include copayments, deductibles, and balance billing amounts. HCFA has very strict rules about health providers billing patients for their liabilities. Cost based facilities are not allowed to charge non-payment by beneficiaries to bad debt unless a clear history of collection activity is recorded.

Benefit Limitations

Any provision, other than an exclusion, which restricts coverage in the Evidence of Coverage, regardless of medical necessity

Benefit Package

Aggregate services specifically defined by an insurance policy or HMO that can be provided to patients. The services a payer offers to a group or individual.

Benefit Payment Schedule

List of amounts an insurance plan will pay for covered health care services.

Benefits

Benefits are specific areas of Plan coverage’s, i.e., outpatient visits, hospitalization and so forth, that make up the range of medical services that a payer markets to its subscribers. Also, a contractual agreement, specified in an Evidence of Coverage, determining covered services provided by insurers to members.

Billed Claims

Fees submitted by a health care provider for services rendered to a covered person.

Block Grant

Federal funds made to a state for the delivery of a specific group of related services, such as drug abuse related services.

Board Certified – Boarded, Diplomate

Describes a physician who has passed a written and oral examination given by a medical specialty board and who has been certified as a specialist in that area.

Board Eligible

Describes a physician who is eligible to take the specialty board examination by virtue of being graduated from an approved medical school, completing a specific type and length of training, and practicing for a specified amount of time. Some HMOs and other health facilities accept board eligibility as equivalent to board certification, significant in that many managed care companies restrict referrals to physicians without certification.

Bonus Payment

An additional amount paid by Medicare for services provided by physicians in Health Professional Shortage Areas. Currently, the bonus payment is 10 percent of Medicare’s share of allowed charges. This is not to be confused with other payments to hospitals, such as the disproportionate share payment or the settlement made to facilities at the end of a cost report year.

BPO

Business Processing Outsourcing

Broker

One who represents an insured in solicitation, negotiation, or procurement of contracts of insurance, and who may render services incidental to those functions. By law, the broker may also be an agent of the insurer for certain purposes such as delivery of the policy or collection of the premium.

Bundled Payment

A single comprehensive payment for a group of related services. Bundled payments have become the norm in recent years and unbundled services are investigated closely by HCFA and other payers. Unbundling service charges has been a common form of fraud as defined by HCFA.