When it comes to your insurance, we want you to be informed. Below you will find helpful information from basic insurance terminology to suggestions on how best to deal with your insurance company, as well as how to find alternative insurance, if necessary. And as always, if you have any additional concerns, we are here to answer any and all of your questions. Contact us at firstname.lastname@example.org.
Talking to Your Insurance Company
Your medical insurance is a contract between you and the subscribers of the coverage. This includes your employer and the insurance company. Our office communicates with your insurance company when necessary and as a courtesy to our patients. However, it is ultimately your responsibility to understand the benefits and exclusions in your policy. We want to help you understand your coverage. Coverage and benefits are dependent on the type of policy you have. It is imperative that you understand the differences between the types of plans available when choosing insurance for you and your family.
When calling your insurance company, you should always record the date of the call and the name of the person helping you. The insurance company may log your call in its system and you should too. Insurance representatives can tell you what your benefits are, but often, they do not disclose contractual limitations. You should tell them why you are calling so they can give you all of the information available to them.
Contractual limitations or “exclusions” are items documented in the policy for which coverage is denied. For example, most medical policies deny coverage for dental procedures unless they are related to a specific instance, as stated in the policy. Some policies state that they do not cover treatment for congenital birth defects after the age of 19. Exclusions are not based on medical necessity. They are simply clauses stating exactly which treatments are not covered. It is possible to bypass an exclusion by changing your insurance plan or by petitioning your employer to override the particular exclusion. If coverage of a procedure is questionable, a “predetermination of benefits” may be necessary. This is a process of submitting all information regarding the patient’s health and proposed treatment to the insurance company for review prior to the service being rendered. The insurance company assesses the medical necessity of the case and evaluates contractual limitations that would prevent treatment from being covered. This can be a lengthy process but is a way of confirming your responsibility prior to initiation of treatment. “Pre-certification” may also be required before initiation of treatment. This is when the insurance company is notified that you are planning to undergo specific treatment. Insurance companies review certain cases prior to treatment to ensure medical necessity and coverage by the policy. If pre-certification is not obtained prior to treatment, the insurance company may penalize or deny reimbursement.
Our office usually obtains pre-certification for surgery. If we experience difficulties, we will contact you and request your assistance. Pre-certification is not a guarantee that the insurance company will pay the claim once services are rendered, but rather a stepping stone to help guide the process.
A “claim” refers to the charges for services rendered by a specific provider. Most claims from our office are submitted electronically. The insurance company often reviews claims for medical necessity, even if the surgery has been pre-certified. Additional information is often requested from both the provider and the patient. We supply all necessary information as soon as possible and expect the same response from the insured. Sometimes claims are delayed for unclear reasons and require frequent telephone calls to the insurance company to attain processing and payment of the claim.
Differences Between HMOs and PPOs
There are many types of medical insurance policies. These plans are defined by the type of coverage offered and how you obtain treatment. The basic types of plans are PPO, HMO, POS, and indemnity plans. PPO plans offer in-network as well as out-of-network levels of benefits. The patient can seek treatment from any provider. The insured is responsible for a co-payment for office visits and co-insurance for other treatment. An example of a PPO plan would be one that provides 90% coverage of the contracted rates as long as you stay within a given network of providers. This level of benefit may be immediate or may begin after a deductible is met. Then the insured is responsible for the 10% co-insurance up to the amount of their out-of-pocket expense which might be $1,250 including the deductible. The insured in this example would be responsible for $1,250 plus any procedures not covered by the policy. For the out-of-network benefit level, the same plan may decrease to 70% coverage of the usual and customary rates (UCR) after a $500 deductible, up to an out-of-pocket expense of $1,750. The insured in this instance would be responsible for their co-insurance of $1,750 as well as the difference between the billed charge amount by the provider and the UCR allowed amount by the insurance company for those charges.
HMO plans only offer in-network benefits. Therefore, the patient must stay within a network of providers to receive benefits. These plans require that the insured select a primary care physician (PCP) to coordinate treatment. If the patient wants to see a specialist, then they must contact their PCP for a referral. A referral is proper authorization to see the specialist and must be approved by the insurance company. In most cases, the specialist must be a contracted provider in order for the referral to be approved. The patient is usually responsible for a co-payment for office visits. All other treatment is covered at 100% with proper authorization.
POS plans combine the attributes of both PPO plans and HMO plans. Each insurance company that offers a POS plan has certain guidelines. An example of a POS plan is one in which the insured and family chooses a PCP. Referrals are suggested, but the patient has an out-of-network benefit in the event that the referral is not approved. The level of benefit is usually higher with the referral, regardless of whether the specialist is in-network or not.
Indemnity plans have no defined provider network. The benefits are based on a percentage of the allowed amount. Usually, these plans cover 80% of the usual and customary rates (UCR). The insurance company will simply pay 80% of what it considers reasonable for the service. The insured is responsible for their 20% co-insurance plus any difference between the UCR and the amount billed.
Alternative Forms of Insurance
Although our doctors treat patients from all over the world, we are only equipped to accommodate insurance coverage from the United States. Within the United States itself, there are many types of medical policies offered through private insurance companies, state and federal agencies, and public assistance programs. Our doctors are on a variety of insurance plans. It takes a constant effort to try to diversify their involvement to compensate for the ever‐changing insurance industry, patient demand, and the cost of providing care. As such, we accept various private medical insurance as well as some public assisted programs. Proper authorization, as dictated by the individual plans, must be obtained if required. Medical coverage on automobile insurance policies covers some medical expenses, but our office does not accept it. We also do not render treatment with the expectation of payment from a pending lawsuit. We must be able to cover the expenses of treatment. Neither automobile policies nor pending litigation fulfills that requirement. Our office does not accept workers’ compensation cases.