Today was calling our patients regarding outstanding balances; and I had some rather amusing conversations, or amusing for non-business reasons. Mostly, I talk to answering machines just leaving name and number and a request to call back. But today, I found more people at home than usual; although in between the quirky and the indifferent, I think I preferred the answering machines.
But in the course of these conversations, a woman asked me a question that made me realize that people might not understand some important basics regarding their medical insurance coverage. And so, I'm writing today with hopes of helping to alleviate some of the confusion.
The woman was surprised that I was calling on a relatively small coinsurance balance. And I wish I'd explained that we have to bill coinsurance and copayment balances, we are legally obligated to do so.
Your medical insurance policy is a contract between you and your insurance company. Under your policy, you may have deductibles, coinsurance, or copayment amounts that you agree to pay, and the insurance company pays their portion of the bill.
Participating doctors also have contracts with insurance companies, stating how much they will be paid for their services. This payment amount is called an allowance; and how much of this allowance your doctor receives depends on the terms of your coverage contract.
For instance, Medicare pays 80 percent of their allowance for medical services, the patient is responsible for the other 20 percent. So if the Medicare allowance is $100.00, if you've met your annual deductible, Medicare will pay $80.00, and you are responsible for the $20.00 coinsurance amount.
If you have commercial insurance, it may pay 90 percent or 70 percent, or you may have flat fee copayment amounts, such at $10.00 for each office visit. And these are your responsibility to pay.
It might not seem fair to have to pay these fees when you're paying rather high medical insurance premiums. But it is part of your contract agreement. And it's still better than having to pay the whole bill. Let's go back to the Medicare example above. Let's say the doctor's bill was $450.00 and he's participating with Medicare. The Medicare allowance is still $100.00, they still pay the $80.00, and you are still responsible for only $20.00. And your doctor will only bill you for this amount.
Your best bet for success in dealing with medical bills and insurance if to know your coverage. I know the insurance manual is a generally a great remedy for insomnia, but you've got to at least skim through it a bit so you'll know where to look for information you may need later.
At the very least, you need to know the basics:
- whether you need to have a primary care physician (PCP)
- your deductible, coinsurance, or copayment responsibilities for office visits and other services
- if, and when, referrals or authorizations may be required for medical services
- how benefits may differ for participating and non-participating providers
- specific coverage details for your particular health concerns, such as allergies or diabetes
It is also a good idea to know what's not covered by your policy, the exclusions; as well as the steps to be taken to appeal an insurance decision.
And you should consult the manual anytime you need to see a specialist, especially if you may need tests or surgery. Know if you need a referral or authorization; and if so, ask questions to confirm this gets done. And if you're not sure, ask! Ask your doctor. Call the insurance company. It's better to be a pain in the neck now, then to have a really big pain in the neck later if your claim gets denied.
Forewarned is forearmed, as they say. So learn the ins and outs of your plan, and make it work for you.
Whenever possible use participating providers. This is good for the insurance company, and the doctors; and of course, for you. Using non-participating doctors may result in more money out of your pocket.
However, there will be times when you have no choice and have to use a non-participating provider. There may be only one particular specialist in your area, for instance. Or if you are in the hospital and need an xray, the radiologist may be non-participating with your plan. Your insurance company will still pay these providers. In the first example, you will likely need a special referral or authorization.
In the second example, if there is a balance due after the insurance payment, you can contact your insurance company and explain you had no choice of a provider and ask them to reconsider the bill for additional payment. This is known as an "invisible" or a"blind" provider. They will likely expect payment in full from either your insurance company or you. So you need to know your policy and how to appeal a claim to get the most bang out of your insurance buck.
And just so you know, medica providers generally will work with the insurance companies to get the claim paid, and only contact you if there is a balance due; or if they need you to contact your insurance company with some required information. Once again, feel free to ask questions. If you think the deductible or copayment balance is incorrect, call your insurance company and ask more questions. If the claim was denied, check the manual, if you think it's an error, call and ask more questions. And if you get a second or third notice from your doctor, call the insurance company and ask about the status of your claim.
And if you have a deductible or coinsurance payment due, but can't pay it all at once; call the doctor's office. They can likely work out a payment arrangement for you.
You can eliminate most medical insurance hassles if you're informed and willing to work with your doctor's staff. Know your coverage; and know your rights, as well as your responsibilities.
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