Coinsurance is the percentage of the cost of a covered healthcare service that the patient is responsible for paying after they have met their deductible. For example, if the coinsurance is 20%, the patient pays 20% of the cost, and the insurance company pays the remaining 80%.
In an indemnity health insurance plan, the patient usually pays the healthcare provider upfront for the services received. The patient then files a claim with the insurance company to be reimbursed for the covered expenses.
In an HMO, providers are often paid through capitation, a fixed amount per patient per month, regardless of how many services the patient uses. This payment model incentivizes providers to focus on preventive care and efficient management of resources.
Underpayment occurs when the amount paid by the insurance company is less than what was billed by the provider. This often requires follow-up to ensure that the payment aligns with the contracted rates or to address any potential billing errors.
Health Maintenance Organization (HMO) plans typically require members to choose a primary care physician and get referrals to see specialists. This structure helps control costs and ensure coordinated care.
