What is the difference between claims and encounters in …

  • What is the difference between claims and encounters in health care terms?

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    Claims are 837 EDI submissions made by service providers to Insurance companies. Encounter 837 EDI data is what typically MEDICAID/MEDICARE exchange with Insurance payers(the Blues) that detail claims paid for services.


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    Centers for Medicare and Medicaid Services (CMS) defines encounter data as the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner. Encounter data are often referred to as claims data although in the Medicare Advantage program under capitated payment no claim for payment may actually be made.

    Fee for service -Claims Data

    Medicaid programs that operate a fee-for-service system pay providers directly for their services.The data from these claims create a snapshot of services provided to Medicaid beneficiaries from both inpatient and outpatient care, as well as other services including pharmacy and home health care.

    Managed Care – Encounter

    In a capitated payment system, unlike fee-for-service, the Medicaid program does not pay providers directly for services to beneficiaries. The Medicaid agency pays managed care organizations (MCOs) a monthly capitation payment for each beneficiary enrolled in each MCO. The MCOs then pay providers for services delivered to Medicaid enrollees. Depending on the terms of the contract between the MCO and the provider, a MCO may pay the provider for these services through fee-for-service or through capitation. In this type of payment system the MCO is responsible for providing the Medicaid agency with encounter data, which is comparable to claims data, that details the specific services provided to an enrollee by a provider

    Capitation -The payment of a fee or grant to a doctor, school, or other person or body providing services to a number of people, such that the amount paid is determined by the number of patients, students, or customers.

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    Am a retired doc, not a lawyer, so will try to do my best:

    -a claim can be laid if there has been some malpractice, somebody not doing what has been promised (you need to proof that!), or the treatment wasn’t according to the accepted norm in the profession in the country where it took place, for a certain payment in whatever form

    -an encounter is just that: somebody meeting somebody else, it can be for an introduction, for consultation, treatment etc. etc. This encounter if not satisfactory could lead to a claim.


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    Well it’s not just Democrats.

    Health care are the services provided to diagnose and treat your illness or injuries MRI’s. lab tests, doctor visits, nurses, operations, and medicines. Anything and everything related to diagnosis and treatment of the actual problem.

    Health insurance is an insurance policy you buy so that you can hopefully afford to pay for the treatment / health care services you need, when you need it. Like car insurance in case you get in accident, it helps you pay for something you may need later.

    Health care = medical services and or medicines

    Health Insurance = an insurance program to help you pay for medical services.


    Healthcare, like most of the rest of our social safety-net depends on membership in the National Insurance Scheme. Being a member here grants you full access to not only healthcare, but also things like unemployment-insurance, disability-insurance, retirement-benefits and so on.

    The full set of rules for who is considered a member are complicated, but for most people it’s enough to know that if you’re legally in Norway for a period of time longer than 12 months, then you’re a member. (you’re a member from day 1, it’s sufficient that the period is planned to be over 12 months)

    Practically speaking, this means that every legal inhabitant of Norway is a member. There are no membership-fees or other costs to membership, the National Insurance scheme is financed entirely with government-funds. You’re contributing towards it by way of paying taxes, but being a tax-payer is NOT a requirement for membership.

    The healthcare-coverage is both comprehensive and high-quality and includes among other things:

    • All doctors visits and hospital stays at zero co-payment for children under 16.
    • All reproductive services, including things like abortions, childbirth, pregnancy-related services and any and all complications that might arise out of these are included at zero co-payment.
    • Doctors visits, hospital stays and medicine for adults has co-payments, but the co-payments are capped at $200/year or 1% of your income, whichever is least.
    • No co-payments on treatments of infectious disease, including STDs.
    • Rehabilitation following accidents or disease
    • Necessary travel-costs associated with medical consultation or treatment.

    The main thing which should be included, but isn’t, is ordinary dental work for adults, ordinary checkups and maintenance like removal of plaque at the dentist is paid for entirely out of pocket. (although is included for children, and more major things that fall under “disease” are covered, depending on specifics) There’s no rational reason why teeth are treated differently from all other body-parts, it’s mostly a historical accident. (and one we should rectify if you ask me)

    The overall summary is that everyone is covered, and few worry about noticeable financial strain as a result of medical costs.

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    What is the difference between palliative care and hospice care?

    My answers are relevant to the US

    Hospice care can be brought in (and is paid for by Medicare and to a lesser degree other insurances) when a physician can sign off that they believe the person may only have 6 months or less to live based on the persons health, current and history, and that they have a condition that cannot be cured and for which treatment is no longer be effective nor offered. Hospice care is geared toward comfort and quality of life for what ever remaining time the patient has. Once accepted to hospice services they will be followed by a team that consists of a nurse, an aid, a social worker and a non denominational pastor. They may also have volunteers that can be utilized. A patient can choose to see all or only a selection of the team. Should a patient or family member choose to go to the hospital for any reason, hospice will discharge the patient upon admittance to the hospital.

    Here is something that can be a key point: If the hospital does not admit, and the hospice was not notified of the transfer to the hospital, or they did not agree to the transfer prior to he patient being seen by hospice nursing to deal with whatever the issue was, the patient/family may be liable for the payment to the ambulance, and for the ER time.

    Palliative care is usually care and assistance with someone who has a chronic disease that may end up getting them hospitalized with some frequency (COPD, out of control diabetes, and many others) and the goal is to keep people OUT of the hospital and treated in place. Palliative services are also covered by insurance. You do not need to be dying (within 6 months) to receive palliative care.

    According to Arcadia Healthcare Solutions:

    health care (noun)

    Definition: a set of actions by a person or persons to maintain or improve the health of a patient/customer


    • I have developed a plan for my patient’s health care.
    • A heavier emphasis on preventive health care by patients and providers will improve health outcomes and quality of life.
    • The RNs in this practice provide the majority of the health care for their patients.
    • Special case: hyphenated adjectival form of “health care” Health-care services have become more expensive and more complex over the last 50 years. The health-care needs of the patients in this hospital wing are much higher than the needs of the average patient.

    healthcare (noun or adjective)

    Definition: a system, industry, or field that facilitates the logistics and delivery of health care for patients/consumers


    • Noun I hope to work in healthcare one day. Healthcare’s number and diversity of players grew significantly over the course of the twentieth century. Modern healthcare requires both skilled clinicians and savvy, experienced business professionals to be effective and successful.
    • Adjective The healthcare IT industry has been booming as a result of the strong demand for population analytics and effective electronic health record (EHR) systems. Healthcare reform has been a tough but important process to address many of the systematic failures of the healthcare system. Many former Wall Street professionals are moving into healthcare finance as a result of the industry’s massive growth.

    To put it more simply, Dr. Waldman writes:

    “Health care—two words—refers to provider actions.

    Healthcare—one word—is a system.

    We need the second in order to have the first.”

    I hope this helps more than it confuses. 🙂


    The Final Word: Healthcare vs. Health Care – Arcadia Healthcare Solutions

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    A good healthcare system must be non-discriminatory. Everyone from the president on down needs to be protected equally under the law of our land. The best way to offer reliable comprehensive coverage for everyone from cradle to grave while saving trillions of dollars is to unite everyone into one not-for-profit public plan. That would allow us to eliminate ridiculously expensive, insatiably greedy, profit-before-people, very unreliable middlemen…and utilize efficiencies of scale. One nation, one plan: with healthcare liberty and justice for all.


    A (or one of many) health care benefits is coverage for hospitalization. Under that term “hospital” there are many benefits paid under “Health Care” insurance. They include (per eligible diagnosis) office visits to a doctor (most if not all specialties), home nursing, vaccinations/immunizations, skilled nursing, medications, x-rays, durable medical equipment, medical supplies, anesthesiology. And those are just a few.

    Assuming you don’t want the USB connection (for whatever reason), you’ve got three choices: (1) over the internet, (2) over a local network, (3) bluetooth. There is nothing else available from your phone. The problem is that some of those are difficult to setup (especially between an apple device and a non-apple computer), and some are rather slow, usually the one or the other – seldom easy and fast.

    The internet connection is likely the simplest, however this means you’re using either your phone’s data package or your ISP internet connection data – or both (which is most usual). It’s also likely the slowest, though bluetooth may be slower depending on just what version. You do this by syncing the phone’s data to the iCloud (effectively copying everything onto Apple’s cloud server), then linking your PC to that same iCloud server and copying it off again – i.e. you’re both uploading and downloading the same data across one or two internet connections. Thus the speed is governed by just how fast those connections are – some are truly horrendously slow, while others are pretty decent, though none would be able to match USB-like speeds.

    But you may be asking yourself: “Why am I sending the data to some server across the world, just so I can download it again onto the machine just next to me?” I’d be asking the same thing myself!

    IMO the most efficient would be to just use a USB, and as second best a local network (i.e. both the PC and the phone connected to the same router over Ethernet or WiFi). There are some apps available which makes this process easier, e.g. search for something called AirMore on the app store – it’s intended for this exact purpose.

    Health care is the medical treatment you receive for medical problems. Health insurance is insurance that pays for some portion of your medical bills. The better your health insurance, the more of the medical bills they pay for. Medicaid, health insurance that is provided by the government for people without the money to pay for health insurance, posts for all health care needed, so long as you go to medical providers (doctor’s and hospitals, etc) that accept Medicaid.

    I have heard people who are covered by Medicaid refer to Medicaid as “my health care.” This is a rather loose way to refer to it. However for some people, it seems like Medicaid insurance is health care because without Medicaid insurance they can’t get health care services. It’s a colloquial use of the term, “my healthcare.”.

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