We are here to help you navigate the
secrets of medical
insurance claims.
Understanding Your Policy
The first thing to know is: You are the insurance company’s client. Educating yourself about your specific policy and being able to advocate for yourself and your quest for care is the most important part.
The best resource for specific information about your policy is your insurance provider. Because insurance can be confusing and each policy’s benefits can vary, it is usually better explained in a phone call.
If you would like counseling on understanding the benefits and limits on your policy, you can reach out to us Monday – Friday between 8:00am – 4:00pm
Definitions of frequently used words & abbreviations
Deductible – a specified amount of money that the insured must pay before an insurance company will pay a claim.
Copays – an agreed upon set amount for a service made by the patient/policy holder in addition to the amount paid by the insurer.
Co-insurance – an agreed upon % paid for a service made by the patient/policy holder in addition to the amount paid by the insurer.
Patient Responsibility – Deductibles, copays and coinsurance all fall under this heading. The patient is responsible for paying this amount directly to the provider for the service they received.
Authorization – A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency.
Non Covered Service – This service is not covered nor paid for by the limits of the policy. For example, some policies do not cover chiropractic services. Some policies only cover certain diagnoses for nutrition therapy or do not cover this service at all. Every policy is different. Know your policy!
Denial – Your service was denied coverage. There are numerous reasons this could have happened. (ie. expired policy, non-covered service, out of network provider). The patient is the best person to resolve this issue with their insurance provider. The provider’s office is not their client and therefore not in the best position to inquire why a service was denied.
EOB – Explanation Of Benefits – A statement from your health insurance plan describing what costs it will cover for care you received. It is generated when your provider submits a claim for these services.
In-Network – A provider who participates and is contracted by a health insurance plan.
OON – Out of Network – A provider does not have a contract with your health insurance plan provider.
Why does in-network vs out-of-network matter?
The coverage your plan may or may not have in-network and out-of-network health care providers. The network your provider is in can impact how much you pay for care. Some health insurance plans only cover care in-network, while other health plans cover both in-network and out-of-network care. If your health plan covers out-of-network care, staying in-network often still reduces the amount you pay for health care.
Patient FAQs
Why is my insurance not covering my visit?
There are two reasons there is a balance owed for visits.
First, the actual service for which the claims was filed is not a covered service. Calling the insurance company to verify benefits and that the provider one wishes to see is in network for your policy prior to the visit can avoid this situation.
Second, there is a deductible or copay/coinsurance that is considered “patient responsibility”.
I paid my deductible last year, why am I being billed this amount again?
Deductibles reset every year.
Some reset on a “calendar year”, which means every January 1st.
Others may reset on a “policy year”, which could be the same time every year on the date the policy went active.
Why are the rates so high?
The government sets maximum billing rates in the state. These rates are billed across the entire state by every provider in that discipline. They are not arbitrary and providers are ethically bound to bill every insurance company this rate for every patient.
Cash Pay Discounts vs Insurance Claims
This is a decision every patient has a right to make. By understanding their policies, patients can make informed decisions about how they choose to use their insurance. Providers and billers can not advise patients on what choices to make. However, knowing how many visits are expected during a course of treatment, for instance, and the amount of their policy’s deductible can help one make an educated decision about these options.
TLC PMB 