Helpful Information Regarding Your Insurance

The practice of medicine is just as much an art as it is a science and understanding the intricate workings of the human body takes skill, education, experience and understanding.  It may not be surprising then that understanding health insurance rises to almost the same degree of difficulty.  

There are a few things that come to mind regarding health insurance that should be understood in order to smooth the transaction between you the patient and your medical provider.  This article will attempt to address some of those matters and hopefully shed some light on what can be a mystifying trek.  

The first thing to take note of seems rather obvious, but the implications are important.  Your insurance is a contract between you and your insurance carrier.  Your medical provider is not involved in that contract nor does he or she know what the terms of that contract state.  What this means is your medical provider cannot know what your copay, co-insurance or deductible is, when that applies and to what extent.  But, these are important terms of your agreement that you should be familiar with.  For instance, with some policies an annual wellness check is covered at 100% with no out-of-pocket expense to the patient at the time of service.  What this means is that you would not be required to pay a copay, co-insurance or deductible payment  at your wellness visit even though you would normally need to do so for a regular “sick” visit.  If you aren’t aware of this provision in your policy (contract) then your medical provider may collect a copay or even a deductible payment when one was not owed.  Also, some policies do not cover certain types of procedures or visits.  Knowing what these terms are before coming to visit your doctor can save you frustration and money.

Another thing to think about before setting your appointment, or at least before seeing the doctor, is what type of visit you wish to have.  Not all visits are created equal.  It’s important to understand that what you report to the nurse as the reason for your visit when she checks you in is entered into your chart.  The doctor may also note your stated reason for your visit.  That coding  gets entered into your chart and ends up being processed by the billing department and sent to your insurance company as a claim.  After you receive your bill is not the right time to revisit the reason for your appointment.  Knowing what your insurance policy covers and what it does not as well as being sure on your reason to visit your doctor will save you money and frustration.

This is a good time to note that your visit can be a “mixed” visit.  If you schedule an annual wellness visit but also complain of a sore throat you will see different responses from your insurance company for different tests done at the same visit.  The screening labs your doctor ordered under your wellness visit might get paid 100% (if your policy provides for that coverage) while the strep culture may go to your deductible.  This is because the strep culture was part of a “sick” visit.  Also, your doctor can charge for his or her time during the visit that was used to discuss the sore throat apart from your wellness visit.  This can result in a bill for part of a visit you thought would be covered at 100%.

Here’s another good reason to know your coverage terms: your copay, co-insurance or deductible allowed amount is due at the time of service.  That means, when you check out at the end of your visit the staff at your doctor’s office is going to ask you to pay that amount.  If you’ve met your deductible for the year then you’ve saved yourself that amount.  If you don’t know whether you owe a copay or whether you’ve met your deductible then your provider will collect that amount.

After every claim filed on your behalf your insurance company sends you an Explanation of Benefits (EOB).  Your provider also gets this same document.  This document is extremely important to understand.  It shows what was paid, what was not, why those decision were made and how that will effect you.  Many people don’t bother to read their EOB’s because they state clearly, “This is Not a Bill”.  But, don’t make that mistake.  Insurance companies make mistakes and this is the first place those mistakes can be caught.  Most insurance companies require a “timely filing” in order to pay under the policy.  That means, they require that a “clean” claim be in their possession within a certain time period.  This period can run anywhere from 90 days to 6 months from the time of service.  If a claim is filed outside that time period, the claim will not be covered and the insured will be responsible for the entire bill.

This brings us to the last point of this article.  We understand it’s tiring to hear the same old refrain every time you show up at your doctor’s office: “May I see your insurance card, please?”  However, having the proper information to process your claim protects you as well as your doctor.  Something as simple as a misspelling of your name, a digit out of place in your birth date or the relationship marked wrongly between the insured and the patient can hold up a claim and result in a denial.  Insurance companies often change information on the card such as the group number or the copay information.  Your provider is being thorough when the staff asks again to check your insurance card.  This attention to detail holds costs down and moves your claim faster through the process.

Your insurance coverage is an agreement between you and your insurance provider.  Your medical provider is not a party to that agreement and needs your cooperation in order to efficiently submit your claim.  Know the terms of your agreement and stay up on what is going on with your claim.  Read your EOB when it arrives.  Understand your policy when setting your appointment and when discussing the reason for your visit with the nurse or doctor.  Hopefully, these tips will help you understand the mystery that is health insurance.