Everything you need to know about insurance, but you were afraid to ask
TO ALL PATIENTS:
We verify insurance coverage as a courtesy for our patients. We cannot guarantee the accuracy of the information we receive.
In the event of a discrepancy that may affect monies paid by the insurance companies or the insured, the responsibility is solely that of the patient/insured.
We recommend that you also contact your insurance companies to verify your benefits.
CHOOSING A HEALTH PLAN
DON’T CHOOSE A PLAN JUST BECAUSE IT IS LESS EXPENSIVE THAN OTHERS. SOME OF THESE “CHEAPER” PLANS HAVE A HIGH DEDUCTIBLE AND A HIGH CO-INSURANCE RESPONSIBILITY.
MAKE SURE YOUR DOCTORS AND SPECIALISTS PARTICIPATE WITH THE PLAN YOU CHOOSE.
CHECK ON THE “OUT OF POCKET” AMOUNT. SOME PLANS COVER THE BALANCE ONCE THE OUT OF POCKET IS MET.
FIND OUT THE PLAN’S DISENROLLMENT RATE. IF A LARGE NUMBER OF MEMBERS ARE LEAVING THE PLAN ANNUALLY, IT MIGHT INDICATE DISSATISFACTION WITH THE BENEFITS/CUSTOMER SERVICE.
ATTENTION ALL MEDICARE PATIENTS WHO HAVE SECONDARY INSURANCE
MANY OF THE SECONDARY INSURANCE COMPANIES DO NOT COVER THE BALANCE AFTER MEDICARE PAYS THEIR PORTION, WHICH IS 80%.
MANY OF THESE INSURANCE COMPANIES PAY $50 PER YEAR AND OTHERS WILL ONLY PAY IF MEDICARE PAYS LESS THAN THE SECONDARY WILL PAY. FOR EXAMPLE, IF YOUR SECONDARY SAYS THEY WILL PAY 80% OF THE BALANCE AND MEDICARE PAYS THEIR 80% FIRST, SOME SECONDARY INSURANCES WILL NOT PAY ANYTHING.
PLEASE CHECK WITH YOUR SECONDARY CARRIER
TO SEE WHAT YOUR BENEFITS ARE AND WHAT YOU ARE PAYING FOR. THIS IS FOR YOUR PROTECTION.
KNOW YOUR BENEFITS!!
COMMON HEALTHCARE LINGO
ACCEPTING ASSIGNMENT:
The practice in which physicians agree to be paid in full
for treating Medicare patients at the posted rates. Physicians who accept assignment bill Medicare directly.
CAP ON BENEFITS:
The maximum amount an insurance policy will pay over the life of that policy.
CAPITATION:
A set amount of money received or paid out, based on membership rather than on service delivered, usually based on members per month.
COBRA:
Consolidated Omnibus Reconciliation Act. A federal law requiring employers to allow former employees to continue their group health insurance for a specific amount of time as long as the former employee pays the full cost of the insurance.
COINSURANCE:
A percentage of the medical bill that the patient is responsible for.
COPAYMENT:
A preset amount that the patient is responsible for with each visit.
COORDINATION OF BENEFITS (COB);
An agreement that gives the order for what organization has primary responsibility for payment and what organization has secondary responsibility for payment; for example if both the husband and wife each have their own insurance.
DEDUCTIBLE:
The initial medical costs, paid for by the patient, before the insurance coverage kicks in.
EOB:
Explanation of benefits statement mailed to a member or doctor’s office explaining how and why a claim was paid or denied.
HCFA:
Health Care Financing Administration, a federal agency that oversees all aspects of health financing for Medicare. A HCFA is also the specific form that providers must use to file claims to the insurance company.
HMO:
Health Maintenance Organization which is a prepaid health plan that ensures that the members who use the HMO’s participating doctors will have all their bills paid in full or almost full. These HMOs generally offer the patient the LEAST freedom of choice.
MANAGED CARE:
This term describes many different strategies for cutting healthcare costs, usually by limiting the patient’s choice of doctors and hospital.
MEDICARE:
The Federal Health Insurance Program for the elderly and the disabled.
MEDIGAP:
Slang term for the health insurance sold to the elderly to pay for charges not covered by Medicare. (Covers the “gap” between insurances).
PPO:
Preferred Provider Organization, which is a network of independent physicians/specialists. The buyer of the PPO insurance gets full or close to full coverage as long as they use the participating provider.
PPO’s offer wider choices of physicians/specialists but not hospitals.
POS:
This is a Point Of Service plan that members do not have to choose how to receive services until they need them.
A common example is a simple PPO where members receive coverage at a greater level if they use preferred providers than if they choose not to do so.
TEFRA:
Tax Equity and Fiscal Responsibility Act that has a key provision that prohibits employers and health plans from requiring full time employees between the ages of 65 and 69 to use Medicare rather than the group health plan. (An excellent example of this is Walmart. Walmart has allegedly paid low wages to many of its employees so they would be Medicaid eligible. In that way all of us, not Walmart itself, pay for Walmart’s health benefits through increased taxes, by having a Benefits Manager actually assist the employees with the paperwork needed to get Medicaid coverage. The federal government knows that trick and has made such tactics illegal for Medicare patients.
UCR:
Usual, Customary and Reasonable are the maximum amounts an insurance company will pay for certain procedures.
WHAT ARE EOB’S AND EOR’S
An EOB is an explanation of benefits and an EOR is an explanation of review; they are both the same. They are a form that is sent with or without payment to the patient and the provider stating the charges incurred, the amount the insurance company will allow, the amount the insurance company pays and the amount the patient will be responsible for. It also will explain, usually by a code, the reason for any denials.
The first column is usually the date of service; the next column is the amount that was billed.
Next is either the allowed amount or amount not allowed, (The difference between the allowed amount and the billed amount is written off. The patient is NOT responsible for that difference unless the insurance company says so.)
Usually the next column has the deductible amount, if any; the next column has the patient’s liability; either a copay or a co-insurance amount.
The last column has the amount that was paid to the provider of service. This is where there may be some codes after the amount.
The codes are the reasons for either no payment or partial payment. Claims can be denied for various reasons; no authorization, too many modalities or type of treatment not covered.
Sometimes the claim just pays incorrectly due to a mistake on the part of the insurance company; they paid at 80% instead of 100% or they charged a copay when there is none, or a deductible that is not required.
That is where our billing department comes in. We find out the reasons for the non-payment, incorrect payment or charges, by calling the insurance companies and straightening out the problem. The insurance companies then have to reprocess the claims thereby taking even longer to pay them.
A lot of patients will get their EOB’s before we do and wonder why they are receiving bills. If you have secondary insurance, the primary has to pay first and then it goes to the secondary for payment. The EOB’s from the primary must accompany the claims to the secondary insurance company; this can take up to two months.
If you notice any discrepancies on your EOB’s, don’t be afraid to call your insurance company and ask them to explain it to you. If you are still not sure, you can always call our billing department and someone will be glad to help you.
CPT CODES, ICD9 CODES AND UNITS
Insurance companies require all of the above on all bills sent to them.
ICD9 codes are for the diagnosis, the reason you are being treated.
An example is 726.90, which is shoulder tendonitis.
CPT codes are for the procedure, the treatment you will be having.
An example is 97140, which is manual therapy.
UNITS are measurements of time.
According to Medicare’s guidelines, anything up to the eighth minute is considered one unit; one second later is now considered two units and so forth.
All of these elements must be on the insurance form that is sent to the insurance company. The universal form that is used is called a HCFA, which is pronounced HICKFA; those letters stand for HEALTH CARE FINANCING ADMINISTRATION.
All of your information; name, address, policy number, ICD9 and CPT codes go on this form to let the insurance company know what type of medical treatment you have received.
The insurance company then pays according to their particular fee schedule. Each individual patient has specific benefit coverage that the insurance companies use as a guideline to pay the claims.
INSURANCE LIMITATIONS
MANY INSURANCE COMPANIES HAVE LIMITATIONS FOR CERTAIN CATEGORIES. EXAMPLES ARE MATERNITY, EYE CARE, DENTAL, PHYSICAL THERAPY AND OCCUPATIONAL THERAPY.
UNFORTUNATELY, UNLESS THE PERSON SELECTING THE INSURANCE FOR AN EMPLOYER HAS HAD PHYSICAL THERAPY, AND/OR OCCUPATIONAL THERAPY, THEY WILL CHOOSE THE LEAST AMOUNT OF COVERAGE FOR IT; THAT IS WHY IT IS IMPORTANT TO KNOW WHAT RESTRICTIONS YOU HAVE FOR EACH CATEGORY.
PHYSICAL THERAPY AND/OR OCCUPATIONAL THERAPY MAY BE LIMITED TO 30 VISITS PER CALENDAR YEAR, 30 VISITS PER DIAGNOSIS OR 30 VISITS PER CONDITION PER LIFETIME; SOME COMPANIES ONLY ALLOW 20 VISITS AND SOME ALLOW AN UNLIMITED AMOUNT.
THIS IS ANOTHER REASON FOR THE CONSUMER TO KNOW WHAT THEIR BENEFITS ARE; DON’T BE SORRY LATER FOR WHAT YOU CAN FIX TODAY!
IF YOU FEEL YOUR TREATMENT IS NOT BEING FAIRLY CONSIDERED, YOU MIGHT WANT TO DISCUSS THE ISSUES WITH YOUR EMPLOYER’S BENEFIT MANAGER. THE BENEFIT MANAGER OR EMPLOYER MAY NOT BE AWARE OF ANY RESTRICTIONS THE PLAN MAY HAVE.
INSURANCE COMPANY COMPLAINTS
IF YOU HAVE A PROBLEM WITH YOUR INSURANCE COMPANY, YOU ARE ALWAYS ALLOWED TO DISPUTE OR APPEAL ANYTHING YOU ARE UNSURE OF OR HAVE A QUESTION ABOUT.
IF A CLAIM WAS PAID INCORRECTLY OR YOU THINK A MISTAKE WAS MADE, YOU CAN CALL THE MEMBER SERVICES NUMBER ON THE BACK OF YOUR INSURANCE CARD. IF THE REPRESENTATIVE THAT YOU SPEAK TO CAN’T OR WON’T HELP YOU, ASK FOR A SUPERVISOR, EVEN IF YOU HAVE TO INSIST; IT’S IS YOUR RIGHT AS A SUBSCRIBER. ALWAYS GET THE NAME OF THE PERSON YOU SPEAK TO; FIRST NAME AND THE LAST NAME OR INITIAL. ALWAYS ASK IF THERE IS A REFERENCE NUMBER FOR THE CONVERSATION. THEY ARE OBLIGATED TO EXPLAIN THE ENTIRE APPEALS PROCESS. MOST HEALTH PLANS HAVE AT LEAST THREE LEVELS OF APPEAL. ALL APPEALS MUST BE IN WRITING. IT WOULD ALSO BE TO YOUR BENEFIT TO SEND ANY APPEAL “RETURN RECEIPT” SO YOU HAVE PROOF THAT THE INSURER RECEIVED YOUR APPEAL.
MAKE SURE THAT YOU “FOLLOW UP” WITH THE INSURANCE COMPANY TO SEE THAT STATUS OF YOUR COMPLAINT.
YOUR FINAL OPTION IS TO SEND A COMPLAINT LETTER TO THE STATE DEPARTMENT OF BANKING AND INSURANCE.
FINAL THOUGHTS
From Janie, Suburban’s Billing Director
Most of us are paying a small fortune for our health insurance coverage; wouldn’t you like to know how that money is distributed? I know I do. With the high cost of health insurance, it is important to know exactly where your money is going. Suburban is trying to be an advocate for patient care, helping you know how your premium money is used.
The insurance companies, not the providers decide on how much the reimbursement for services should be. How much is fair? How much is someone’s time and experience worth? Who should decide all this? Obviously the ones deciding all this aren’t worried about their healthcare costs, but most of us have to.
I can only give a few examples of my experiences dealing with the insurance companies.
Where does our money go? The copays can range anywhere from $5.00 to $50.00 per visit. Some of you also have high deductibles that can be as high as $5000.00. Our premiums seem to go up every year but the medical offices’ reimbursements are going down. The amount of visits your doctor requests are being denied, or reduced by the insurance companies; they feel that everyone is basically the same and should take the same amount of treatment and should be improved by their time frame, not what is best for the patient. How can they know what’s best for me if they aren’t treating me and they haven’t seen me?
Another plan has now instituted a new payment plan. The previous plan DID NOT, pay for your Initial Evaluation. That evaluation, which is required by Physical and Occupational standards, is done to specifically determine your course of treatment. The Therapist that does the complete evaluation is a licensed professional, just like your orthopedist or primary care physician, with one exception; they get paid for their evaluations. That evaluation is approximately one hour of the Therapist’s time that is done without payment. We do not pass that charge on to our patients.
If that wasn’t bad enough, Horizon, Aetna and UnitedHealthcare are dropping reimbursement rates by a minimum of 40%, are your premiums dropping by 40%? I don’t think so. Where is that extra money going? Why are we paying more for less? Who doesn’t want to pay lower premiums?
This also leaves these questions; will my insurance rates go up, how will this affect me? Let’s face it, we all want to go to a top-notch place, but we also do not want to pay a fortune for it. In this day and age unfortunately, money is a big issue. Malpractice premiums have gone through the roof. Many doctors are going out of business because of the high cost of insurance and the low return. If we continue to let the insurance companies run our lives, pretty soon we will have no say whatsoever. They really are holding us hostage; we can either pay excessive amounts out of our pockets, (I don’t know about you, but my pockets are usually empty), or we can do as they dictate. I am tired of being a sheep, are you?
Suburban believes its patients and the public in general will become proactive to change this horrific trend of the health insurance reimbursement schemes. Go to Medicare Beneficiary Model Letter to Congress (.pdf), Medicare Beneficiary Model Letter to the Editor (.pdf), Therapy Cap Patient FAQs (.pdf), and Sample Letter to the Editor (.pdf) familiarize yourself with the bills we are highlighting for action (or have a family member or friend do it); then do one of the following: Call Peter for further explanation, make the call based on what you know, send an email, ask to sign one of our form letters with addressed stamped envelope, or do your own letter. Be involved, be one of those 20 percenters who do 80% of the work.
Let’s MAKE A DIFFERENCE while there’s still time.
We all want quality healthcare and of course it won’t come without any costs; however, if the providers are not being paid fairly and have to increase their patient load just to eke out a living and keep the lights on, who is going to suffer? The provider AND the patient will. I know what you are thinking; now the therapist will have less time to spend with me and my care will be compromised; not so! At Suburban, our therapists will continue to provide their usual high quality of care and as always, our patients come first and always have.
If you agree that the insurance companies are becoming more and more controlling and more expensive, there are complaint forms that con be sent to the State Health Insurance Commission, names and addresses of the CEO’s of several of the insurance companies and telephone numbers to call. I would be more than happy to give you any of this information at any time and I will try to answer any questions you may have on these issues.
So what do you say? Let’s make the insurance companies come clean about what they do with our money; after all they’re getting most of it?
