Approved!

Approved doesn't always = In Network

Example:

Let's say an out of town college student comes home for the holidays to have surgery in his/her hometown and then returns to school a few weeks later and plans to complete his/her physical therapy at a facility closer to campus.  Unfortunately the insurance policy his/her parents cover them under restricts in network facilities to a 50 mile radius of their hometown with no out of network benefits.  

Option 1: The patient could go to an out of network facility any way, but the insurance carrier would likely deny the claims and the physical therapy facility could balance bill them (ie. they owe the full billed amount with no contracted discounts.)

Option 2: The patient can request that the ordering physician's (the surgeon) office submit an authorization request along with a letter of medical necessity from the doctor to the insurance carrier requesting that they allow the patient to seek physical therapy at an out of network facility due to the fact that he/she attends school outside the 50 mile radius. 

    If approved the patient would be allowed to seek treatment at the out of town facility, but would be subject to their out of network benefits (probably a large deductible amount would need to be met before the insurance carrier would pay anything, but it would allow some discounts)

    If denied, there's still hope! 

         a. A patient has a right to appeal the decision of the insurance carrier, though it can become a long drawn out process, sometimes it's worth the fight.

         b. Sometimes health insurance plans will allow (or even request) a "peer to peer" with the requesting physician and the medical director (a doctor who works for the health plan that makes decisions regarding medical authorizations).  Often times this can be difficult to coordinate, but it can help if the requesting physician appeals directly to the medical director. 

So keep in mind "approved" doesn't always mean in network. 

Shopping around for your own private health insurance policy and feeling confused and overwhelmed? I can help you better understand what each policy offers and what it means to your pocket book now vs. later. 

Send your questions to:

deargabbyinsurance@yahoo.com

 

From Personal Experience...

I know it's been a while since I've posted anything, but when life happens  blogging goes by the wayside.  I wanted to share my own recent experience of being on the other side of healthcare...this time I was the patient. 

About a month ago I had (in network) outpatient surgery and got to put my medical insurance to the test.  About a week and a half before surgery I went to the hospital for my pre op and registration.  When I got to the registration desk they confirmed all of my information and took a copy of my insurance card and were about to send me on my way until I reminded them that I owed an outpatient surgery copay.  If you want to avoid getting unexpected bills later, know your policy! I paid my $250 copay and went on my way.  

The day of surgery was all business, no more payments, just surgery. 

Four weeks post surgery I went online to view my EOB (explination of benefits) and see how much my inusrance carrier reimbursed all the providers.  I was billed by my surgeon, the hospital, and anesthesia as expected.  The total amount billed for all of these was over $23,000 (keep in mind this is not what was paid, only what was billed) and all I owed was the $250 out patient surgery copay (that I'd already paid).   I was extremely pleased. 

Random tid-bit:
Anesthesia bills for every 15 minutes worth of "the good stuff."  I did a break down and it costs about $315 for 15 minutes worth of anesthesia.  Worth. Every. Penney. 


You can email any questions or comments to:
deargabbyinsurance@yahoo.com

Insurance in the NICU

This article appeared in the Waco Trib today...

PPO vs HMO

I was asked the other day what PPO & HMO mean...here's what the acronyms stand for...

PPO: Preferred Provider Organization

HMO: Health Maintenance Organization

What does this mean to you? Often times if you're on an HMO plan you need to "declare" a PCP with your insurance carrier and must have referrals to see a specialist.  If you have a PPO plan you likely don't need to have referrals to see specialists.  In either case you want to be certain that the doctor's you see are in network with your PPO or HMO plan. 

Another question was why doesn't our health care system work more like building contractors?  In other words why can't the hospital take one payment from the insurance carrier and patient and then divide it accordingly to the hospital, surgeon, and anesthesiologist when a patient has surgery?  I was intrigued by this question and plan to do some research into it.  I have a sneaky suspicion that there are some federal and state regulations out there that would keep something like this from working, but with a major overhaul to our health care system it could have potential. 

What are your thoughts?

deargabbyinsurance@yahoo.com

The New Year a New Card

Tis the season for remembering to bring your new insurance card to your next doctor's appointment.  Not doing so can be disastrous.  It's a huge waste of time an money for an office to file with the wrong insurance carrier or with incorrect insurance identification numbers.  January 1 usually marks the time that any updates to your insurance policy take effect and new cards get mailed out to patients.  Even if you think nothing has changed with your ID number it doesn't mean your benefits didn't change.  Copays, Coinsurance, and deductibles often vary from year to year with policies that are carried through an employer.  If you're not sure your policy changed or if you haven't gotten your new cards in the mail this week (first week of January), call your HR department or your insurance carrier and ask.


An interesting article on Medicare and how we pay into the system...

http://m.apnews.com/ap/db_16026/contentdetail.htm?contentguid=Ag8SIFWG

Questions? Comments? Complaints?
deargabbyinsurance@yahoo.com

Affordable Care Act

Got a call from a patient yesterday who had been dropped from his parents insurance policy because he was 25 years old.  I suggested he try and fight it because under the new health care laws (that went into effect March 2010) adult children can be covered through age 26.  His family did call and were told that they (the insurance carrier) had opted out of that provision for one year, something I was unaware of that was an option for insurance carriers to even do. So unfortunately for him he is going to have to find new insurance coverage.

http://www.healthcare.gov/law/provisions/youngadult/index.html?gclid=CI6tjKez-6UCFSVe7AodFD13ow#

There are a lot of new regulations on insurance carriers...see how they might effect your policy...

http://www.healthcare.gov/law/provisions/index.html

A Little Insurance Sarcasm

Yes patients really owe co pays at every visit...even for follow up visits. (I'm going to go out on a limb here and assume that unless you're a medical professional you don't know how to read your own MRI and that even if you had the written report from the radiologist it wouldn't mean much to you without your doctor explaining it to you...that's what the appointment is for, and that's what your copay pays for.)

No your old insurance carrier will not continue to pay for medical care on an injury that occurred while covered under that policy if your coverage termed during treatment (with the exception of COBRA coverage).  (This means if you schedule surgery it might be nice if you informed your surgeon's office of the change, rather than have them spend 30 minutes pre authorizing surgery with the insurance information they do have only to discover it isn't valid.)

Yes patients are responsible for providing accurate insurance information to their doctor's office.  While the billing and insurance staff are amazingly awesome people they are not capable of telepathy.  (See previous sarcastic comment...it applies here too.)

Yes patients are responsible for getting referrals from their PCP to a specialists office, not the other way around. (This can lead to angry phone calls from patients who got a huge doctor bill because their insurance carrier denied payment...not super fun.)

Yes doctor's offices really do need the policy holder's social security number in order to file the insurance claims, not just the last 4 digits. (The last 4 digits are worthless, you might as well draw a picture of <insert something you find funny here> because it would be just as useful.)

Yes it is the patients responsibility to provide correct mailing addresses for both the person who will get the bills and the person who carries the insurance policy, as mentioned previously billing and insurance staff are not telepathic. (Guessing usually leads to angry phone calls from divorced couples.)


Just Sayin'  :)



Questions? Comments?

deargabbyinsurance@yahoo.com