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.


# Charges

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.

# Claimants

The number of individual members that incurred claims.

# 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.

Adverse

The amount of dollars that have been flagged as denied but have a significant chance of being resubmitted and paid.

Available Claim Span

The span of claim history for report generation

Average Paid

The average amount paid by the plan sponsor per member.

COB Savings

Reporting of other insurance coverage.

Category

Customized benefit categories.

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).

Disclosure Level

The spec dollar amount identified in the disclosure reporting. (Typically run as 50% of spec)

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.

Length of Stay(days)

The number of days in a facility.

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.

Number of Visits

The number of claims or visits for the plan year.

Outstanding

The amount of billed charges in Risk Analysis that have been billed but not paid.

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

The subscription based medical or dental care arrangements offered

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.

Relation

The relationship to the Employee. E=Employee, S=Spouse, D=Dependent.

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.