Typical case that has an extraordinarily high or extremely low cost when compared with most discharges classified to the same diagnosis-related group (DRG).

Review by a professional review organization (PRO) for the necessity of a patient’s hospital admission and to determine whether all services rendered were medically necessary. Cost outlier cases are recognized only if the case is not eligible for day outlier status.

Average amount of money a company spends to acquire one new customer.

1. Health insurance funding in which the insurance carrier does not assume an underwriting risk. The group that is insured pays the costs of benefits (incurred claims), pays administrative costs, and contributes to the insurance carrier’s contingency reserve fund. 2. System of payment for inpatient hospitalization in which total operating costs and certain allowable capital costs are used in determining the per diem (per day) rate. When the amount of payment from a payer becomes insufficient or when uncompensated services are given, providers go to cost shifting and charge extra to the payers who do not exercise strict cost controls. This system is a typical means for providing uncompensated care to the uninsured.

Payment system in which providers receive payment based on their actual costs plus a profit. This system is usually seen in fee-for-service (FFS) plans.

Ratio of the cost (or outgo, expenditures, or disbursements) of the program on an incurred basis during a given year to the taxable payroll for the year. In this context, the outgo is defined to exclude benefit payments and administrative costs for those uninsured persons for whom payments are reimbursed from the general fund of the U.S. Treasury and for voluntary enrollees, who pay a premium to be enrolled.

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.