Who is the individual paid on a fee-for-service basis subscriber provider insured administrator?

Editorial team Published on

The individual paid on a fee-for-service basis in health insurance is the provider.

Key Terms Defined

  • Provider: A doctor, hospital, or medical professional who receives payment for each specific test, procedure, or service they deliver.
  • Insured: The person covered by the health insurance policy.
  • Subscriber: The person who signs up for the health plan and pays the periodic fee or premium.
  • Administrator: The person or organization that manages the daily operations or claims of an insurance plan.

You can review more health insurance concepts on Quizlet's Medical Expense Insurance Flashcards.

Who is paid on a fee-for-service basis?

Healthcare providers—such as doctors, surgeons, clinics, and hospitals—are paid on a fee-for-service basis.

How Fee-for-Service Works

  • Payment per service: Providers receive a specific payment for each individual test, procedure, consultation, or office visit they perform.
  • Volume-based: Revenue increases as more services and treatments are provided, regardless of the ultimate health outcome.
  • Separation from outcomes: Payment is tied directly to the execution of a service rather than whether the patient's condition improves.

Who is the employer of the subscriber of the insurance?

The employer of the subscriber is the company or organization where the subscriber works and receives their employer-sponsored health insurance benefits.

Key Details

  • The Subscriber: This is the employee who holds or signs up for the insurance plan through their job.
  • The Employer: This is the business that provides, sponsors, or helps pay for the insurance coverage as part of the employee's benefits package.
  • Finding the Employer: If you need to find the specific name of the employer, check your insurance card's group number, review your human resources (HR) documents, or contact your insurance provider's customer service.

What are the two major types of MCO's?

The two major types of managed care plans commonly associated with Managed Care Organizations (MCOs) are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).

Health Maintenance Organizations (HMOs)

  • Structure: Requires members to see a specific network of doctors and hospitals.
  • Primary Care Provider (PCP): Members must choose a primary care doctor who coordinates care and provides referrals to specialists.
  • Out-of-Network Care: Generally not covered, meaning the patient pays the full cost if they see an out-of-network provider.
  • Cost: Usually features lower monthly premiums and out-of-pocket costs.

Preferred Provider Organizations (PPOs)

  • Structure: Offers a larger network of preferred providers.
  • Primary Care Provider (PCP): Does not require a primary care doctor or referrals to see specialists.
  • Out-of-Network Care: Allowed, but at a higher out-of-pocket cost to the patient.
  • Cost: Usually features higher monthly premiums in exchange for greater flexibility.

(Note: In government programs like Medicaid, the two main systemic categories are often classified broadly as Risk-Based Managed Care Plans and Primary Care Case Management (PCCM).)

Under which of the following organizations are practicing providers compensated on a fee-for-service basis?

Practicing providers are compensated on a fee-for-service basis in a Preferred Provider Organization (PPO).

Key Details About PPOs and Fee-for-Service

  • Payment Model: Providers in a Preferred Provider Organization (PPO) receive payment for each specific service or treatment they deliver.
  • Comparison to HMOs: Unlike Health Maintenance Organizations (HMOs), which typically use a capitation or salaried model where providers are paid a set amount per patient or time period, PPO providers bill per service rendered (often at a pre-arranged discounted rate).

Fee For Service vs Prepaid Plans 2026 Insurance Exam Guide: Master This To Pass Now

9 related questions found

Who is the individual paid on a fee-for-service basis administrator insured subscriber provider?

The individual paid on a fee-for-service basis is the provider.

Understanding the Terms

  • Provider: A healthcare professional or facility (such as a doctor or hospital) that delivers medical services and is reimbursed for each specific service rendered.
  • Subscriber: The person who enrolls in the health plan and pays the premiums.
  • Insured: The person covered by the health insurance policy.
  • Administrator: The person or entity that manages the healthcare plan and its policies.

Is fee-for-service the same as PPO?

No, fee-for-service is not the same as a PPO, though they both offer flexibility in choosing medical or dental providers.

Key Differences

  • Fee-for-Service (FFS): This is a traditional payment model where a provider is paid separately for each distinct service or procedure performed. In a pure FFS model, there is no restricted network, and providers charge their full standard fees without being contractually bound to a discounted insurance fee schedule. Patients often pay upfront and file claims for reimbursement.
  • Preferred Provider Organization (PPO): This is a managed care insurance plan type. A PPO features a specific network of doctors or dentists who agree to accept discounted, pre-set fees for their services. While you can see out-of-network providers (often with higher out-of-pocket costs), in-network providers are bound by contract to the insurance company's fee limitations.

How They Intersect

Some insurance plans are structured as a Fee-for-Service plan with a PPO option, meaning the traditional indemnity model uses a preferred network to offer discounted rates if you stay in-network. However, a standard PPO operates on discounted network contracts, whereas a strict traditional FFS practice or plan operates without network fee restrictions.

Who is considered the subscriber of insurance?

An insurance subscriber is the primary account holder who owns or enrolls in the Insurance Plan/Policy and is responsible for maintaining the contract and paying the premiums.

Key Roles of a Subscriber

  • Primary Account Holder: The individual whose employment, personal application, or direct enrollment established the insurance policy.
  • Financial Responsibility: The person obligated to pay the monthly Premium to keep the plan active.
  • Policy Manager: The person who holds the authority to add or remove eligible dependents—such as a spouse or children—onto a family plan.

Subscriber vs. Insured vs. Patient

  • Subscriber: The person who contracts with the insurance company and pays the bill.
  • Insured (Member): Anyone covered by the benefits of the policy, which includes the subscriber and any enrolled dependents.
  • Patient: The specific individual receiving medical, dental, or clinical care during a visit.

Note: While the subscriber, insured, and patient can all be the exact same person (such as an individual on an individual plan), they are often different—for example, when an employee is the subscriber, their child is the patient, and both are part of the insured group.

What is it called when a company pays for your health insurance?

When a company provides and helps pay for your medical coverage, it is called employer-sponsored health insurance (ESI) or group health insurance.

How It Works

  • Cost Sharing: The company usually pays a large part of the monthly cost, called a premium, and you pay the rest through a deduction from your paycheck.
  • Group Plans: The company buys a plan for all workers as a single large group.
  • Alternative Options: Some companies use Health Reimbursement Arrangements (HRAs) to pay you back for individual health plans instead of offering a standard group plan.

What does subscribers' employer name mean?

A subscriber employer name is the name of the company or business that provides and sponsors a health insurance plan for its employees.

Key Breakdown of Terms

  • Subscriber: The main person linked to the insurance policy, usually the employee who gets the coverage through work.
  • Employer Name: The name of the company where the subscriber works.
  • What it means on a form: When a medical form or insurance screen asks for this, it wants the name of the company that employs the person holding the insurance plan.