System of payment by insurance plans to providers based on their actual incurred costs.

Annual information document that all institutions and providers participating in the Medicare program must generate. It analyzes the direct and indirect costs of providing care to Medicare patients and the payments received during a certain period of time. The purpose is to make a proper determination of amounts payable under the Medicare program.

MEDICAL,USA: 1. Portion of payment of health expenses that the insured or beneficiary must pay including the deductible, copayment, coinsurance, and balance bill, thus sharing the costs with the insurance plan. 2. Under TRICARE, the portion of the allowable charge (20% or 25%) after the deductible has been met that the patient is responsible for. The most common types of cost sharing are coinsurance and copayment.
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A situation where covered persons pay a portion of the health costs such as deductibles. Coinsurance or copayment amounts.
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Refers to various ways in which an insurer passes costs on to the insured. This includes most types of out-of-pocket expenses such as deductibles, copayments, and coinsurance.

1. Practice of a provider to charge a higher fee to patients with private health insurance plans to make up for underpayment of fees for patients under Medicare, Medicaid, or managed care plans. 2. Practice of a provider charging a group of one managed care plan more than another for the same procedure. One reason this may occur is that one group may have large discounts from the provider or not adequately reimburse the provider for expenses. To make up for the shortage in revenue, the provider may charge another managed care group more.

Method in which a hospital facility is paid for outpatient services by Medicare based on the hospital’s last audited cost report.

Type of managed care organization (MCO) that will pay for all of the enrollees’ (members’) medical care costs in return for a monthly premium, plus any applicable deductible or copayment. The HMO will pay for all hospital costs (generally referred to as Part A ) and physician costs (generally referred to as Part B ) that it has arranged for and ordered. Like a health care prepayment plan (HCPP), except for out-of-area emergency services, if a Medicare member (enrollee) chooses to obtain services that have not been arranged by the HMO, he or she is liable for any applicable deductible and coinsurance amounts, with the balance to be paid by the regional Medicare fiscal intermediary and/or carrier.

Insurance payment that is based on the cost of health care services in which allowable costs are determined by the insurer. This method is used by some insurance plans or programs but is being replaced by prospective payment. Also called cost-related reimbursement.

Evaluation method that measures the insurance program’s economic benefits to the program’s medical care over a period of time expressed in dollar amounts. This is done to see if future health care costs can be reduced and earnings increased because of improved health of the members of a health plan.
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Procedure for comparing the costs of any proposal with the benefits of that proposal, in order to determine the proposal’s relative value.