Posts Tagged ‘insurance’
Being a doctor in a small office I’ve had the opportunity to work and learn numerous aspects of running things. Insurance is the primary aspect I hear questions about on a daily basis. It seems as though each day insurance policies are changing. Regardless if you have a brand new policy midyear, or have maintained your current policy, there are a handful of terms you should understand.
All medical offices have a fee schedule. A fee schedule is a list of services and the amount billed to an insurance company. These fee schedules are determined based on location and other aspects which as a patient you could care less about. On a very basic level, paying for insurance gives you the privilege of paying that companies rates.
Medical office rate for exam: $100
Blue Cross Blue Shield Rate for same exam: $80
If you have BCBS insurance, you can only pay up to $80 for that exam. You get the $20 discount.
Here are a list of other terms you should be familiar with.
Deductible: A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all plans require a deductible, but a handful do. It is important to note that some plans also have a family and/or individual deductible.
CoPay (Co-Payment): A specific charge that your health insurance plan may require that you pay for a specific medical service or supply. For example, for office visits (exams), or prescription drugs you may have a $20 Co-payment. That is the amount you are responsible for and your insurance pays the rest.
Co-Insurance: Coinsurance is the term used by health insurance companies to refer to the amount that you are required to pay for a medical claim, apart from any co-payments or deductible. For example, if your health insurance plan has a 20% coinsurance requirement (and does not have any additional co-payment or deductible requirements), then a $100 medical bill would cost you $20, and the insurance company would pay the remaining $80.
Over the last few years I have noticed an increasing number of variable insurances. This means that for each service provided, the patient has a different coverage. In a chiropractic office, an example would be:
Office Visit (exam): $20 Co-payment
Adjustment : 20% Coinsurance
Physical Therapy: $20 Co-payment
X-rays: 20% Coinsurance
In most cases, a service with a co-payment, will not require you to fulfill your deductible, but a service with coinsurance WILL require you to fulfill your deductible.
Here is an example to help explain. Patient X has a BCBS Plan with the following:
$500 Deductible (has met $0.00 of $500)
$20 Copay for Office Visits
20% Coinsurance for all other services
Patient X visits our chiropractic office for an exam, x-rays and adjustment. Blue Cross Blue Shield rates for those services are:
Exam (Office Visit): $100
Patient X Will Owe:
Exam (office visit): $20 Copay
X-rays: $100 (being billed towards deductible)
Adjustment: $40 (being billed towards deductible)
Patient Z visits our chiropractic office with the same coverage and same services EXCEPT Patient Z has met all $500 of his/her deductible.
Patient Z will owe:
Exam (office visit): $20 Copay
X-rays: $20 (20% coinsurance of $100)
Adjustment: $8.00 (20% coinsurance of $40)
Insurance can be a bit tricky and we recommend you get familiar with your plan and ask questions. As a service to all of our patients we pre-verify your coverage for any services offered at our office so you are aware of what the cost will be for you.
Feel free to post questions that I can answer, especially if you were unable to follow any of the examples! I hope you take away a few basic terms to help make the transition with insurance an easier one in 2017!
Health care fraud is a key driver of rising health care costs. About 3% of all health care spending — or $68 billion each year — is lost to health care fraud. There are a few types of health care fraud including:
- Medical Identity Theft. This is the misuse of a person’s medical identity to obtain health care goods, services or funds. This can include fraudulent prescriptions, billing for services that were never provided or referring patients for unnecessary services.
- Upcoding. This is when the provider bills for a service of higher complexity than the service that was provided or documented. For example, a supplier may bill for motorized scooters, but supply manual wheelchairs.
- Billing for Services not Furnished
- Others can be found here
Here are some things you can do to help prevent health care fraud and abuse.
- Review your health care charges. Look over your Explanation of Benefits from your insurer and receipts from your doctor or pharmacist to make sure the right dates of service are recorded, and that you are billed for the right services or medications. If you have questions regarding your treatment codes, contact your doctor to review.
- Protect your health information. Keep your insurance card and health care records in a safe place at all times.
- Monitor your medications. Count your pills each time that you pick up a prescription.
- Report suspected fraud and abuse as soon as possible
You have a right to all of your health care charges, including codes to verify information. Make sure to only share your insurance information with reputable medical facilities. It is normal for a medical facility to need your social security number for billing purposes.
If you have any questions regarding insurance, billing or coding, please do not hesitate to contact our office. Our doctors and staff are heavily trained in billing, coding and insurance procedures and would be happy to answer any questions.
The premium is the amount you (or your employer) pay for your health insurance plan whether you use medical services or not. In most cases, it’s paid monthly, but can be paid every 3 months or yearly.
A deductible is the amount you must pay before the health plan starts paying for your covered services. For example, if your deductible is $1,000, your plan won’t pay for some services until you’ve paid $1,000. In most cases, the higher your deductible, the lower your premium. The lower the deductible, the higher premium.
Coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible.
For example, let’s say it costs $100 to see your doctor. If your coinsurance is 20%, you must pay $20 and the insurance plan pays $80. If you haven’t met your deductible, you must pay the entire amount.
A copayment is a fixed dollar amount you may have to pay at the time you get care. In most cases, it’s a small amount, such as $20 for a doctor’s exam. You won’t always have to pay copayments. The amount you pay depends on your health plan and which doctor you see.
Also called OOPM, this is the most you have to pay out of your own pocket for expenses under your insurance plan during the year. Deductibles, coinsurance, copays and other expenses for in-network essential health benefits (EHBs) apply to the OOPM.
If you have questions regarding your insurance coverage, our office does free verification of beneifts to let you know what services may or may not be covered.
Knowing the differences between medical insurance plans will help you choose the one that’s right for your health care needs.
PPO stands for preferred provider organization
EPO stands for exclusive provider organization.
Both plans use a network of physicians, hospitals and other health care professionals. The difference between them is the way you interact with those networks.
PPO plans give you more flexibility. You don’t need a primary care physician and you can go to
any health care professional you want without a referral—inside or outside of your network.
Staying inside your network means smaller copays and full coverage. If you choose to go outside
your network, you’ll have higher out-of-pocket costs, and all services may not be covered.
EPO plans combine the flexibility of PPO plans with the cost-savings of HMO plans. While you
do not need to choose a primary care physician with your EPO plan and you don’t need referrals
to see a specialist, you will have a limited network of doctors and hospitals to choose from. EPO
plans will not cover care you get outside your network unless it’s an emergency.
If you want greater flexibility or if you see many specialists, a PPO plan might be what you’re
looking for. But, if you’re interested in saving money by using a smaller network of doctors and
hospitals, an EPO plan would work for you.