By Laura Sherman, Director of Patient Financial Services, IPMR
Navigating through the world of health insurance can be confusing, but knowing what to ask before you see a provider can save you time with your bills after.
Whether you have a new health insurance policy obtained from an insurance exchange under the Affordable Health Care Act (Obamacare), or an existing plan through your employer, there are three specific things you should know before going to a medical provider.
Step 1. Choosing Your Health Insurance Provider
After you have chosen the best provider for your health issue, the main thing you probably want to know is what costs are associated with your visit.
In order to determine costs, you should be aware of what your insurance covers, and which providers are contracted with your insurance company.
Step 2. Scheduling an Appointment With a Physician
When you call to make an appointment, you may ask the doctor’s office “Do you take my insurance?” If you ask this question, you will likely be told yes. You may also get a surprise when you see your bill, showing you are responsible for amounts above what you thought your copay or coinsurance should be.
A better question to ask is, “Are you contracted with my insurance company?” If the medical office is not able to tell you, call your insurance company or get online with them and verify through a provider search that the medical provider you wish to see is an in-network contracted provider with your insurance.
Your network consists of providers and facilities that your health insurance has contracted with. Doctors and hospitals often “take” insurance from companies that they are out of network with. They will bill your insurance company, but then they will also bill you for amounts you were not aware you would be responsible for paying. The office should tell you they are not contracted with your insurance, so you can make an informed decision based on the costs. The last thing you need when having health issues is additional stress from unexpected bills.
Step 3. Paying Your Bill
If a provider bills you for the difference between their charge and the insurance allowed amount, this is called balance billing. A contracted provider is not allowed to balance bill you for covered services.
“What is my share of the costs of a covered health service?” Most insurance plans have a deductible. This is the amount you owe before your health insurance begins to pay. If your deductible is $2000, your plan doesn’t pay anything until you have met your $2000 deductible for services subject to the deductible.
“Will I owe a copay or coinsurance?” Most plans pay a percent of the allowed amount, and the remaining coinsurance is your share. If your insurance covers 80 percent of the allowed amount, then your share of the covered services is 20 percent.
Copays are a set amount that you pay for the covered service. The amount can vary by type of service. You may have a $20 copay for a visit to your primary care physician, but a specialist visit might be $40.
You may have a $25 per visit co-pay for physical therapy. Some insurance companies equate the evaluation on the first visit with an office visit and will charge you a different amount for it.
“What will I be billed for?” If you see a provider and have tests, X-rays, or a minor surgical procedure, you may end up with three or four bills when you thought you would get one with a copay of $25. Labs and X-rays are processed at other facilities, generating pathology and radiology bills for the professional component from another billing service.
Surgery may result in a charge for the use of the facility. Anesthesia may result in another professional bill. Any procedure performed may generate another one to three for you; and don’t forget to ask if the other providers and or facilities involved are in your insurance network too. If your insurance is only contracted with OSF, and your doctor sends your labs to Methodist, you need to be aware that they will be processed at out of network rates.
“Does this procedure need prior authorization?” As costs rise, insurance companies look to manage those costs by requiring an authorization process for certain procedures. If your MRI needs pre- certification or authorization, and the provider does not obtain it prior to you having the MRI, it likely will be denied. Most medical providers are aware that their procedures require authorization, but you should be aware in case an office attempts to bill you for something that was denied due to their failure to get authorization.
If you have a second insurance, be sure to ask if your doctor’s office sends your claims to the second insurance company. Many providers only bill secondary insurance when Medicare is primary, and if your claim isn’t paid within 30 days, they may bill you for the balance.
If you are having trouble paying your bill, please ask your doctor, hospital, or provider of medical services if they have any payment options available to you. Most providers would rather work with you if you are able to make a monthly payment than to send your bill to collections. Financial aid may also be available.
Your insurance company should be able to give you your policy information if you call them with any questions about what is covered or what you owe. Always make a note of whom you speak to at your insurance company, and ask for a reference number.
Remember that it is your right to choose whom you go to, and therefore it is your right to have all the facts laid out in a way in which you can understand them. Receiving care should not cause you more stress; choose wisely when picking a physician and make sure to ask the right questions.
IPMR advocates for patients in getting the best care possible and makes it their mission to answer any and all insurance and billing questions in a timely and professional way. For more information or to schedule an appointment, call 309-692-8670 or 800-957-IPMR(4767) or visit www.ipmr.org.
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