Day 2: Educate Us On Something You Know A Lot About
There aren't many topics I know more about than most people. I
know quite a bit about health insurance benefits because it's my job. SO, I'll keep my word. I said I'd try my best to blog every day in
May. I won't be mad if you skip this post, but you MIGHT learn something.
For clarity purposes, I'll use the following example to help you better understand all the jargon:
Jane Doe is the patient and her husband is the policyholder. They
have two kids, Jack and Jill. Her PCM is Dr. White and he works at Black and
White Primary Care. She currently has a PPO plan with Happy Healthcare of SC. :-)
Glossary
of Insurance Jargon
Beneficiary = Jane Doe; the person receiving benefits
Sponsor or Subscriber = John Doe; the policyholder
Dependent = Jane, Jack, and Jill Doe; those with a relationship
to the sponsor/subscriber
HMO Plan = Health Maintenance Organization; a primary doctor within
the company’s network is chosen and he/she handles a large portion of the medical needs and must provide referrals to see a specialist.
The specialist must also be within the company’s network of doctors.
There are no deductibles (except when you see doctors out
of network & then a large deductible applies). The patient is
typically only responsible for a small co-payment.
PPO Plan = Preferred Provider Organization; you aren’t limited to
see only networked providers and you don’t need referrals to see specialists.
However, you have a greater cost-share/co-insurance when you see an
out-of-network provider. You also have a deductible to meet and usually the
patient responsibility is larger than it would be if you had an HMO plan.
Authorization
VS Referral = an authorization is a
pre-approval for a specific service; a referral usually comes from your primary
physician & basically notifies your insurance that he/she wants you
to see a specialist for a specific issue or problem
Example
of an Authorization: Happy Healthcare pre-approved Jane to undergo a tonsillectomy
Example
of a Referral: Dr. White submitted documentation to Happy Healthcare advising
them he referred Jane to an Ear, Nose, & Throat (ENT) specialist for
chronic tonsillitis
Deductible = the amount Jane is required to pay out-of-pocket
to the ENT before her insurance pays a cent (this is an amount require
yearly) if she had a PPO plan vs. an HMO plan
Catastrophic
Cap = the maximum amount Jane is required to pay out of pocket in a given year (calendar/fiscal)
Copayment = the amount Jane pays to the provider as her share of the
cost
Cost
Share/Coinsurance = similar to a
co-payment; Jane would have a cost-share if she had a PPO plan and had met her deductible for the year; this amount is usually a percentage of the
bill rather than a fixed amount (ex. 25% of the bill vs. $20 co-payment)
Allowed
Amount = the amount Happy Healthcare allows the
ENT to bill them for a specific procedure or service; (calculated using many
different factors… from the geographical location where services are rendered
to the level of education the person who performed the procedure/service has
obtained, etc.) In other words, this is the amount Happy Healthcare would pay
the ENT if they paid it at 100%.
Coordination
of Benefits = refers to the process
of determining/calculating the amount each health insurance policy is
responsible for when more than one health coverage exists
Explanation
of Benefits (EOB) = the statement Jane
receives from Happy Healthcare that details exactly what was billed to them,
what they paid, how much the ENT can bill her, etc.
Point of
Service (POS) = an option most
insurance policies offer that allows you to see a doctor outside of your
insurance company's network but you have a higher patient
responsibility when you do
Top
Reasons Medical Claims are Denied:
- The
beneficiary or the provider didn’t obtain the required authorization or
referral for the services rendered.
- The provider
did not submit the claim within timely filing guidelines (each insurance limit is different).
- The provider
submitted the claim with a wrong ID number or sent it to the wrong location.
(For instance, say you have BCBS of SC, you got sick while vacationing in NC,
and you went to the ER. Instead of submitting the claim to BCBS of SC, the
hospital sent it to BCBS of NC in error. These two companies are not one in the
same, and the claim denied because you don't have coverage with BCBS
of NC. This happens ALL THE TIME.
- The provider
submitted the claim with incorrect coding (non-covered diagnosis, insufficient
diagnosis, invalid bill type, etc.)
Tips –
Always save
the EOB’s sent to you from your insurance company. Compare it with the bill you
receive from your doctor to ensure the amount your EOB says you owe and the
about your provider billed you is the same. It isn’t uncommon for the doctor’s
office to send a bill to the patient for an amount the patient is not
responsible for paying.
If you ever
question whether you owe your provider an amount, call your insurance
company. Always.
Just make
sure before you call that you have your policy ID, the date of the visit, and
the amount the provider billed your insurance company (not the amount they are
billing you) ready. I can’t tell you how frustrating it is for me to take a
call and the beneficiary doesn’t have this information. It’s incredibly
difficult for them to help you if they can’t pinpoint a specific claim when
there are multiple claims on file.
And now that I've bored you to tears... G'night.
