Assignment of Benefit (AOB)

This is a request sent to the insurance company, signed by the patient or member , requesting that the payment of their health benefit be sent to a person they designate to receive the payment of the health benefit. This request may or may not be honored and accepted by the insurance company depending on the patient’s or member’s health benefit contract or State Law. The patient or member’s health benefit contract may prohibit the assignment of the health benefit payment to anyone. State Law such as in Florida and Louisiana may require the insurance company to honor the Assignment request even if the contract prohibits it. If the Assignment is prohibited, the payment of the health benefit will be sent to the patient or member. The requires the provider to bill the patient or member. State Assignment of Benefit Laws can be referenced on the American College of Emergency Physician (ACEP) website: http://www.acep.org/advocacy.aspx?LinkIdentifier=id&id=29364&fid=1018&Mo =No

 Authorization 

Some patients, such as HMO patients may be required to obtain permission or authorization to receive certain services. Sometimes this is inpatient medical care which is when the patient is admitted to the hospital by their primary care provider or an emergency care provider or outpatient visits to an out of network provider.

Balance Bill 

This would be the amount of the debt that the patient owes the doctor after the patient’s commercial insurance company didn’t pay and is being billed for. Balance Billing can be regulated based on the type of health insurance such as Workers Compensation or Medicaid , State law or a provider contract. For example. If the patient has Medicaid and the provider is enrolled with Medicaid, the provider has agreed to accept the Medicaid payment as payment in full. California, Florida and other States have Laws prohibiting the balance billing of an HMO member if the insurance company accepts liability for the claim. In Florida, this law would be FS 641.3154. The contract that the provider has, may have language that states the contracted payment is accepted as payment in full with no patient balance billing.

Benefit

Healthcare services that an insurance company contracts to provide to a patient. Sometimes called a covered service. An example of a benefit could be emergency care. This means if emergency care is a benefit, and the patient (member) goes to the emergency room and it is determined that the medical condition is an emergency, the insurance company pays the benefit claim. How much is the cost of the benefit. That varies per patient or member policy (contract). The contract could require the benefit payment to be 100% of the member’s out of pocket medical expenses. It could also be based on a percentage of the insurance company’s usual and customary reimbursement amount. This could be 60%. The insurance company may allow $100 for usual and customary. Therefore, it would pay $60. The patient’s contract may require the patient to pay the other $40 plus the difference between the providers charge and the allowed amount. If the service is NOT a benefit or a covered service, it may be possible to have the patient pay for the service.

Catastrophic Cap

Catastrophic cap limits the amount of out-of-pocket expenses a patient will have to pay for TRICARE-covered medical services. The cap applies to all covered services—annual deductibles, pharmacy co-pays. Once the patient meets the catastrophic cap, there are no more out of pocket expenses. The claim is paid at 100% of the Tricare allowable.