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Billing Terms Glossary
Patient Financial Responsibility Terms: Definitions for Therapists and Psychiatrists
In this section
- 23 terms defined
- Written for psychotherapists and psychiatrists
- Source organization linked on every entry
Balance Billing
General (all payers)Also called: surprise balance bill; billing the difference
- Definition
- Billing a patient for the difference between the provider's charge and what the payer allowed, which is generally prohibited for participating providers and restricted by law in some other situations.
- Why it matters
- Improper balance billing can breach contracts and laws.
- Illustrative example
- An in-network provider cannot bill the patient for the contractual write-off.
Verify: rules differ by contract, state, and program.
Related terms Participating Provider (PAR)Contractual AdjustmentNo Surprises Act
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Patient Financial Responsibility TermsAudits & Compliance
Card on File
General (all payers)Also called: credit card on file; stored payment method
- Definition
- A patient's payment card securely stored, with written consent, for future charges such as copays and no-show fees.
- Why it matters
- Improves collections but requires consent and secure handling.
- Illustrative example
- A client signs an agreement allowing a copay to be charged after each session.
Related terms Payment PlanNo-Show Fee
Reference source HFMA
Categories Patient Financial Responsibility Terms
Coinsurance
General (all payers)Also called: patient coinsurance; percentage share
- Definition
- The percentage of the allowed amount a member pays for a covered service after meeting the deductible.
- Why it matters
- Practices must calculate it on the allowed amount, not the billed charge.
- Illustrative example
- A plan pays 80% and the member pays 20% coinsurance on the allowed amount.
Related terms CopayDeductibleOut-of-Pocket Maximum
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Patient Financial Responsibility TermsEligibility & Benefits
Collections
General (all payers)Also called: collection agency; patient collections
- Definition
- Efforts, sometimes through an outside agency, to recover unpaid patient balances.
- Why it matters
- Requires compliance with debt collection laws and privacy rules.
- Illustrative example
- A practice sends a past-due balance to an agency after notices.
Related terms Bad DebtPatient StatementDays in A/R
Reference source HFMA
Categories Patient Financial Responsibility TermsRevenue Cycle Metrics
Copay
General (all payers)Also called: copayment; flat fee copay
- Definition
- A fixed dollar amount a member pays for a covered service, often collected at the time of visit.
- Why it matters
- Collecting the correct copay at check-in improves revenue and patient experience.
- Illustrative example
- A member owes a $30 copay per therapy visit.
Related terms CoinsuranceDeductiblePatient Responsibility
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Patient Financial Responsibility TermsEligibility & Benefits
Copay Waiver
General (all payers)Also called: waiving copays; routine copay forgiveness
- Definition
- Routinely not collecting a patient's cost sharing, which can violate payer contracts and, for government programs, anti-kickback and false claims rules.
- Why it matters
- Waiving copays without a compliant hardship policy is a compliance risk.
- Illustrative example
- A practice forgives copays for all patients and a payer flags it in an audit.
Verify: confirm with counsel or a compliance officer.
Related terms Patient ResponsibilityFinancial Hardship PolicyAnti-Kickback Statute
Reference source HHS Office of Inspector General (OIG)
Categories Patient Financial Responsibility TermsAudits & Compliance
Deductible
General (all payers)Also called: annual deductible; plan deductible
- Definition
- The amount a member pays for covered services before the plan starts paying, for services that are subject to the deductible.
- Why it matters
- Explains why early-year visits often have higher patient balances.
- Illustrative example
- A patient with a $1,500 deductible pays the allowed amount until it is met.
Related terms CopayCoinsuranceOut-of-Pocket MaximumPlan Year
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Patient Financial Responsibility TermsEligibility & Benefits
Financial Hardship Policy
General (all payers)Also called: hardship policy; financial assistance policy
- Definition
- A written policy that lets a practice reduce or forgive patient balances based on documented financial need, applied consistently.
- Why it matters
- A documented policy is the safer way to reduce balances than ad hoc waivers.
- Illustrative example
- A practice reduces a balance under a written income-based policy.
Related terms Copay WaiverSliding ScaleCompliance Program
Reference source HFMA
Categories Patient Financial Responsibility TermsAudits & Compliance
FSA (Flexible Spending Account)
General (all payers)Also called: FSA; flexible spending account
- Definition
- An employer-sponsored account that lets employees set aside pre-tax dollars for qualified medical expenses.
- Why it matters
- Some patients pay copays with FSA cards and may need itemized receipts.
- Illustrative example
- A patient submits a superbill for FSA reimbursement.
Related terms HSA (Health Savings Account)Superbill
Reference source HHS (U.S. Department of Health and Human Services)
Categories Patient Financial Responsibility Terms
Good Faith Estimate (GFE)
General (all payers)Also called: GFE; good faith estimate requirement
- Definition
- A written estimate of expected charges that providers must give to uninsured or self-pay patients before scheduled services under the No Surprises Act.
- Why it matters
- Missing or wrong estimates can create compliance exposure.
- Illustrative example
- A therapist gives a self-pay client an estimate for the first month of sessions.
Verify: confirm current CMS guidance and dispute rules.
Related terms No Surprises ActSelf-Pay
Reference source CMS (Centers for Medicare & Medicaid Services) · CMS No Surprises Act
Categories Patient Financial Responsibility TermsAudits & Compliance
Guarantor
State law (varies by state)Also called: responsible party; financially responsible person; bill payer
- Definition
- A guarantor is the person who agrees to be financially responsible for a patient's charges, such as a parent for a child or an adult for their own account.
- Why it matters
- For a minor, the parent is usually the guarantor. Several states say a parent who did not consent to a minor's outpatient mental health care, or who was not informed, is not liable for its cost. Examples are Connecticut, Texas, Florida, and Illinois. Confirm who signs the financial agreement before you bill.
- Illustrative example
- A 13-year-old in Florida consents to an evaluation on their own, so the practice does not list the parent as guarantor.
Verify: Rules on parental liability differ by state. Confirm with counsel.
Related terms Age of Majority (Healthcare)SubscriberPatient ResponsibilitySelf-Pay
Reference source National Center for Youth Law, Minor Consent Compendium 2024: Connecticut · National Center for Youth Law, Minor Consent Compendium 2024: Texas · National Center for Youth Law, Minor Consent Compendium 2024: Florida · National Center for Youth Law, Minor Consent Compendium 2024: Illinois
Categories Patient Financial Responsibility TermsEligibility & Benefits
HDHP (High-Deductible Health Plan)
General (all payers)Also called: HDHP; high deductible plan
- Definition
- A health plan with a higher minimum deductible than traditional plans, often paired with an HSA.
- Why it matters
- Patients often pay more out of pocket early in the plan year, affecting collections.
- Illustrative example
- A patient with an HDHP pays the full allowed amount until the deductible is met.
Related terms DeductibleHSA (Health Savings Account)
Reference source HHS (U.S. Department of Health and Human Services)
Categories Patient Financial Responsibility TermsEligibility & Benefits
HSA (Health Savings Account)
General (all payers)Also called: HSA; health savings account
- Definition
- A tax-advantaged account paired with a high-deductible health plan that a patient can use to pay qualified medical expenses.
- Why it matters
- Patients may pay copays and balances with HSA cards.
- Illustrative example
- A patient pays a balance with an HSA debit card.
Related terms FSA (Flexible Spending Account)HDHP (High-Deductible Health Plan)Deductible
Reference source HHS (U.S. Department of Health and Human Services)
Categories Patient Financial Responsibility Terms
No-Show Fee
General (all payers)Also called: late cancellation fee; missed appointment fee
- Definition
- A fee a practice charges a patient for a missed or late-canceled appointment, which insurance typically does not pay.
- Why it matters
- Payer contracts may limit charging insured patients, so policies must be written and consistent.
- Illustrative example
- A client is charged a fee under a signed policy.
Verify: check contract and state rules.
Related terms Patient StatementCard on File
Reference source HFMA
Categories Patient Financial Responsibility Terms
Out-of-Pocket Maximum
General (all payers)Also called: OOP max; out-of-pocket limit
- Definition
- The most a member pays in a plan year for covered in-network services; after it is reached, the plan pays 100% of covered in-network costs.
- Why it matters
- Determines when patient responsibility stops for the year.
- Illustrative example
- A member meets the OOP max and the plan pays all remaining covered claims.
Related terms DeductibleCoinsuranceCopay
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Patient Financial Responsibility TermsEligibility & Benefits
Patient Refund
General (all payers)Also called: refund to patient
- Definition
- Returning money owed to a patient after an overpayment or duplicate charge.
- Why it matters
- Timely refunds prevent compliance issues.
- Illustrative example
- A practice refunds a duplicate copay.
Related terms Credit BalanceOverpayment
Reference source HFMA
Categories Patient Financial Responsibility Terms
Patient Responsibility
General (all payers)Also called: PR; patient balance; patient portion
- Definition
- The amount of a claim the patient owes, such as deductible, copay, or coinsurance, as shown by the payer.
- Why it matters
- The ERA shows it with group code PR, and it drives statements and collections.
- Illustrative example
- An ERA shows $30 PR for copay.
Related terms Group Code PRCopayDeductibleCoinsurance
Reference source X12
Categories Patient Financial Responsibility TermsPayment & Reimbursement
Patient Statement
General (all payers)Also called: billing statement; patient bill
- Definition
- A bill sent to a patient showing services, payments, adjustments, and balance due.
- Why it matters
- Clear statements improve collections and reduce disputes.
- Illustrative example
- A statement lists date, service, insurance payment, and patient balance.
Related terms Patient ResponsibilityCollectionsPayment Plan
Reference source HFMA
Categories Patient Financial Responsibility Terms
Payment Plan
General (all payers)Also called: patient payment plan; installment plan
- Definition
- An agreement letting a patient pay a balance over time.
- Why it matters
- Reduces bad debt when set up early with clear terms.
- Illustrative example
- A patient pays a $300 balance in three monthly payments.
Related terms Patient StatementBad DebtCard on File
Reference source HFMA
Categories Patient Financial Responsibility Terms
RevSpring
General (all payers)Also called: RevSpring patient payments
- Definition
- A vendor offering patient billing, payment, and communication solutions. Listed for reference; not an endorsement or partnership.
- Why it matters
- Some practices use similar tools for patient statements and payments.
- Illustrative example
- A health system sends patient statements through RevSpring.
Related terms Patient StatementPayment Platform
Reference source RevSpring
Categories Patient Financial Responsibility Terms
Self-Pay
General (all payers)Also called: private pay; cash pay; out-of-pocket pay
- Definition
- A patient who pays for services directly rather than through insurance.
- Why it matters
- Requires fee policies and, for many, a good faith estimate.
- Illustrative example
- A client chooses to pay $150 per session without using insurance.
Related terms Good Faith Estimate (GFE)Sliding ScaleSuperbill
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Patient Financial Responsibility Terms
Sliding Scale
General (all payers)Also called: sliding fee scale; income-based fee
- Definition
- A fee structure that adjusts what a patient pays based on ability to pay.
- Why it matters
- Must be applied consistently and not used to waive insured cost sharing without care.
- Illustrative example
- A therapist offers reduced private-pay fees by income tier.
Verify: check payer contract rules on discounts.
Related terms Self-PayCopay Waiver
Reference source HFMA
Categories Patient Financial Responsibility Terms
Superbill
General (all payers)Also called: itemized receipt; out-of-network receipt
- Definition
- An itemized statement with provider, diagnosis, CPT codes, dates, and charges that a patient can submit to their insurer for out-of-network reimbursement.
- Why it matters
- It is the standard tool for OON reimbursement and must include correct codes and provider details.
- Illustrative example
- A therapist gives a client a superbill for a month of sessions.
Related terms Non-Participating Provider (Non-PAR)Out-of-Network (OON)Self-Pay
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Patient Financial Responsibility TermsClaims Processing
More billing terms
- Credentialing & Enrollment 58
- Contracting & Network Management 22
- Claims Processing 172
- Eligibility & Benefits 75
- Payment & Reimbursement 61
- Denials & Appeals 46
- Audits & Compliance 115
- Behavioral Health Specific Terms 148
- CPT, E/M & HCPCS Code Entries 54
- Telehealth Terms 23
- Revenue Cycle Metrics 44
- EDI & Clearinghouse Terms 63
- BCBS, UHC & Commercial Payer Terms 54
- Medicare & Medicaid Terms 145
- Value-Based Care Terminology 23
- Prior Authorization Terminology 22
- Quality & Risk Adjustment Terms 34
- EHR & Healthcare Technology Terms 54
- Provider Data Management Terms 26
- AI & Healthcare Automation Terms 12
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