1.5 Terminology
Planwatch uses terminology consistently across all areas of analysis and reporting. Use the following alphabetical index of terms to quickly locate the definition of a field, option, or value.
Index of Terms
Abbreviated or alternative forms are provided in parenthesis.
- # Claims ( # Claims )
- % (of Network)
- % (of Non-Network)
- % Discount
- % Paid ( Plan Paid Percentage )
- % Usage ( Percentage of Usage )
- % of Total Claimants
- Average Paid ( Avg Paid )
- COB Savings ( COB )
- Category
- Charge Count ( # Charges )
- Claimant Count ( # Claimants )
- Coinsurance ( Coins. )
- Copay
- Covered Population ( Member Population, Members )
- Current Enrolled ( # Current )
- Deductible ( Ded. )
- Discount ( Disc. )
- Enrolled Count ( # Enrolled )
- Facility ( Hospital )
- Ineligible
- Member ( Claimant )
- Member Paid
- Network
- Network Steerage ( Steerage )
- Non Discounted Claims
- Non-Network
- PEPM ( Employee/Month )
- Physician ( Doctor, Practioner )
- Plan Paid
- Plan Sponsor ( Sponsor, Employer )
- Provider
- Savings
- Savings Percentage ( % Savings, Disc. % )
- Total Charge ( Total Charges, Billed Charges )
# Claims
Total number of claims for each represented network and savings outlet used to monitor volume activity.
% (of Network)
Percentage of network claim activity between facility and physician.
% (of Non-Network)
Percentage of non-network claim activity between facility and physician.
% Discount
The "discount rate" (percentage of total charge reduction through savings).
% Paid
The percentage of original billed charges paid by the plan sponsor.
Plan Paid / Total Charge
% Usage
The percentage of total dollars paid by the Plan sponsor. This is a measure of how much of total plan payment went to a specific item and is a useful indicator of how plan dollars are distributed between network and non network.
This is a measure of how much of total plan payment went to a specific item and is a useful indicator of how plan dollars are distributed between multiple items.
% of Total Claimants
The percentage of claimants (members) whose plan expense fell within the corresponding expense band. This is calculated by dividing the number of Claimants by the total number of covered claimants.
Average Paid
The average amount paid by the plan sponsor per member.
COB Savings
Reporting of other insurance coverage.
Category
Customized benefit categories.
Charge Count
The number of charge lines processed (each claim may have multiple charge lines).
The number of charges is often useful to get a sense for the volume of claims that were processed.
Claimant Count
The number of individual members that incurred claims.
Coinsurance
Amount paid by member in coinsurance.
Coinsurance indicates how the plan sponsor and member share the costs of a bill that exceeds the member's deductible. The plan sponsor pays a fixed percentage of the billed amount until (1) the member reaches their out of pocket maximum, in which case the plan generally assumes 100% responsibility, or (2) the plan flips into stop loss, in which case a separate insurer assumes a portion of responsibility.
Copay
Amount paid by member in copayment.
Sometimes called "per charge deductible," the copayment (or copay) is a fixed dollar amount paid by the member each time certain types of care or service is provided.
Covered Population
The group of individuals receiving benefits from the plan, including employees, spouses, and other dependents.
Current Enrolled
The total number of members active on the last day of the time period.
This is a measure of enrollment at a single point in time as opposed to the Enrolled Count, which measures enrollment over a time period.
Deductible
Deductible amount paid by the member.
The deductible is a fixed amount that must be "met", that is, paid by the member, before the benefits of the plan can apply. Once the deductible is met, the plan begins to pay a percentage of billed charges (Coinsurance).
Discount
The amount of savings through the PPO network and other out of network savings outlets.
Prefered Provider Organization (PPO) and other types of provider networks apply a percentage based discount to claims incurred at contracted providers.
Enrolled Count
The number of members enrolled within the time period.
This is a measure of enrollment over the entire time period specified on the report. A member active for the entire time period is considered 1, a member active for exactly half of the time period is considered 0.5, a member active for three months of a 12 month plan year is considered 0.25, and so on. The enrollment count is the sum of each members fractional enrollment value, rounded to the closest integer value.
Facility
A hospital or other general medical facility (i.e., not a physician).
Planwatch typically uses the term "Facility" in cases where hospitals need to be distinguished from doctors and other physicans. Physicans and Facilities are collectively refered to as "Providers".
Ineligible
The total amount of ineligible charges due to non eligible participation, invalid submission, duplicate claims, etc.
Member
An individual that is eligible to receive benefits under the plan.
It is important to distinguish "Members" from "Employees" - the former includes each individual covered member including the plan participant (Employee), a spouse, and dependent children. The latter refers to the plan participant only.
Member Paid
Member's Responsibility for deductibles, copays, coinsurance and non-covered services.
The total amount paid by the member through Deductible, Copay, Coinsurance, and Ineligible dollars.
Network
In network (PPO) Plan Paid dollars broken out by facility and physician.
Network Steerage
Techniques for increasing network usage among the covered population.
Non Discounted Claims
Claims that are non medical paid expenses (Rx, Fees, etc.), COB or dublicate charges.
Non-Network
Plan Paid dollars broken out by non contracted facility and physician.
PEPM
The amount paid by the plan sponsor per employee, per month.
Physician
A doctor or other medical practioner (i.e., not a facility).
Typically includes professionals holding a Doctor of Medicine (M.D.), Doctor of Osteopathic Medicine (D.O.), Doctor of Chiropractic Medicine (D.C.), Naturopathic Medicine (N.D.), Doctor of Dental Surgery (DDS), etc. Also included are general practioners, family practitioners, and psychologists. Planwatch typically uses the term "Physician" in cases where practioners need to be distinguished from "Facilities", such as hospitals. Physicans and Facilities are collectively refered to as "Providers".
Plan Paid
Total amount paid by Plan Sponsor.
Plan Sponsor
The payer entity that is responsible for providing payment on benefits.
In employer-funded scenarios, the Plan Sponsor refers to the employer. In other scenarios, including fully-insured and health maintenance organizations (HMO), the Plan Sponsor may be a separate entity.
Provider
Any physician, facility, or product vendor that provides care services to the covered population.
Note that this definition is significantly more broad than the traditional use of the term in some medical circles to refer to certain types of medical professionals. Planwatch uses the term "Physician" to refer to individual practioners.
Savings
The total amount of savings due to primary network discounts, out of network programs or negotiations (Secondary Network), coordination of benefits (COB), and reasonable and customary (R&C)
Savings Percentage
The "discount rate" (percentage of total charge reduction through savings).
Total Charge
Original total amount billed by provider before any network or other claim payment consideration.
Original amount billed by the provider of care, product, or service. The total charge includes all other dollar figures, including ineligible moneys due to Duplicate and Denied dollars; savings from Network Discount, Coordination of Benefits (COB), and Regular and Customary (R&C); member payment from Deductible, Copay, Coinsurance, and Ineligible; and finally the amount paid by the plan sponsor.