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

Referrals & PCP's

I prefer not to mention commercial insurance carriers by name, so it's going to make today's post a challenge.  Many insurance carriers require you to "declare" a primary care physician (PCP) and any time you need to be seen by a specialist you have to have your PCP refer you to the specialist.  That sounds simple enough, but it can get complicated really fast if you don't know your policy well, because as with any set of rules, there's always an exception to them.  Just because you have insurance coverage doesn't mean you can see any doctor you want either...well you can, but it will all go to your out of network benefits, and depending on what those are one trip to the doctor can become very costly. Another problem we run into is situations where a patient didn't realize that their insurance carrier required them to declare a PCP and then when they needed to see a specialist a referral couldn't be done.  



This picture has absolutely nothing to do with today's topic, it just made me laugh...

Questions? Comments?
deargabbyinsurance@yahoo.com

Part A & Part B

I prefer not to mention insurance carriers by name for various reasons, but as Medicare is a government funded program it's benefits are the same across the board for anyone...

If you have Medicare it's important to understand the difference between part A and part B.  Medicare part A covers medical expenses for hospital services, skilled nursing, and home health and part B covers expenses for medical services at doctor's offices, out patient services, DME, & some home health.  

On several occasions we have had patients that tell us they have Medicare coverage and no supplement and when they get to our office and we see the card we discover they only have part A.  This of course means they have to be considered a self pay patient.  

There are deductibles to meet for both part A and part B Medicare.

Deductible amounts for Medicare 2010:

Part A  $1100

Part B $155

Once the deductible amount is met it goes over to co insurance, which means 20% of the allowable charges is patient responsibility. For extended hospital stays it's a little different, you pay a certain amount per day after so many days. 

Helpful link about premiums and deductibles for Medicare patients:

https://questions.medicare.gov/app/answers/detail/a_id/2260/~/medicare-premiums-and-coinsurance-rates-for-2010


Questions? Comments?
deargabbyinsurance@yahoo.com

More on EOB's

It really is a good idea to at least glance over your EOB's when they come in the mail, even if you're pretty sure you know what's coming.  For example I once caught a filing error on one of my kiddos trips to the pediatrician.  

The insurance I carry uses a different ID number for each person on the policy. While the first digits remain the same on each person the suffix changes (ie: 123456-01, 123456-02, 123456-03 etc).  When I had my youngest child they were automatically added to my policy with the next suffix in line even though their name wasn't on the insurance card yet.  

When I filled out paperwork at the pediatrician's office I noted that on the paperwork that this kiddo would be 123456-03 and I even told them when they copied the card.  Several months later I got an EOB for this office visit and I noticed that payment had been denied because the patient didn't fit the age requirements for the services billed.  The code that was billed was correct, a check up for an infant, however, despite my best efforts to notify the pediatrician's office of the insurance ID number they filed the office visit under my ID number and date of birth.  Since I'm clearly not an infant my insurance carrier denied payment and my EOB showed that I may owe my provider the full amount of about $180.  I called the billing office for the pediatrician's office to let them know about the error, so they could refile the claim with the correct ID and date of birth. Thankfully someone had already caught the mistake and refiled everything and had even received payment from my insurance carrier already.  

With the holiday's approaching I probably won't post anything for several days, but that doesn't mean you can't still email me questions! :)  

deargabbyinsurance@yahoo.com

MRI Benefits

Every insurance plan is different and today I have the perfect example of just how different they can be...

Patient #1 has a commercial insurance carrier we will call A.  Patient #1 knew they would owe 20% of the allowable charges for their MRI, but had been told it was cheaper to have it done at Facility D than at Facility C where we had them scheduled.  After a phone call to insurance carrier A and to Facilities C & D I confirmed that patient #1 would in fact owe 20% of the allowable charges for the MRI.  I also learned that Facility D did bill less for the MRI as patient #1 had suspected, however the allowable charges were higher at Facility D than the allowable charges at Facility C. 

**Facility C bills more for an MRI than Facility D; however, 20% of Facility C's allowable charges was around $400 where as 20% of Facility D's allowable charges was $500.**

Patient #2 has a commercial insurance carrier we will call B. Patient #2 went for an MRI only to find out when they were there that they had to pay $4,900 out of pocket for medical services before insurance carrier B would pay anything.  This is what we would call a "major medical" policy.  Problem was patient #2 didn't realize they had a major medical policy and left without having the MRI done due to confusion about what the actual cost out of pocket would be.  After phone calls to insurance carrier B and Facility C I found out that with the insurance coverage patient #2 had they would owe the allowable charges of about $1400.  While $1400 is a lot to pay out of pocket, it sure beats the $3200 it would cost to pay out of pocket without insurance.


Questions? Comments?
deargabbyinsurance@yahoo.com 

Co Pays

Yes you really do owe your co pay at time of service. The co pay is the amount you agree to pay for office visits according to your contract with your insurance carrier. If you don't pay the co pay it's possible your insurance carrier will deny payment, which means you get stuck with the entire bill.

Sometimes patients are bothered by the fact that their doctor's office collects the co pay before they see the doctor.  There are many reasons offices do this, it's easy to forget to collect it at check out, patient's are more likely not to skip out on paying their co pay if it's paid before seeing the doctor, but a friend of mine put it best...you wouldn't take our groceries home and use them without paying first.

 

Asking for discounts...

I read in a magazine article several years ago (I don't remember what magazine or the author) tips on how to negotiate a lower fee for medical services.  Most of the tips were legitimate; my only beef with the article was that it made it sound as though doctors were ripping off the public (keep in mind any money collected from patients and insurance carriers doesn't all go to the doctor, it helps pay the entire office staff too...I don't work for free).  

Many hospitals and doctor's offices do offer discounts to patients who are self pay (usually only if they pay the balance in full at time of service).  However, if you have insurance you're already getting a discount, so trying to negotiate a lower fee for services isn't allowed because that could be considered insurance fraud. 

Questions? Comments?

deargabbyinsurance@yahoo.com

Yes an injection really is a surgical procedure

After explaining this to several patients today it seemed like a good topic to cover.  :)

I know it seems silly, but the CPT codes used for an injection or an aspiration are considered surgical procedures by all insurance carriers.  Injection codes are sometimes referred to as "2" codes, because they all start with the number 2.  

    Example: 20610 for large joint injections like the shoulder or knee...the official description is "Arthrocentesis, aspiration and/or injection; major joint or bursa."

The "2" code is for the injection itself, not the medication.  Medications have a totally separate CPT, usually a "J" code. 

    Example: J0702 is Celestone a type of cortisone...the official description is "Injection, Bethamethasone Acetate and Bethamehasone Sodium Phosphate, per 3 MG." 

What does this mean to you? If you're outpatient surgical benefits all go toward your deductible or co insurance then it's possible that if you have an injection at your doctors office that it won't be covered by your co pay and that you could get a bill later. 

Questions? Comments?

deargabbyinsurance@yahoo.com

Got this question emailed to me shortly after posting the above information...

"Read the blog. A flu shot injection wouldn't be considered surgery would it?"

The short answer is no.  Immunizations are all "9" codes and aren't accompanied (to my knowledge) with an additional medication code like an injection.

   Example: The H1N1 vaccine code is 90470

The long answer is that it is still possible for a vaccine charge to go toward your deductible or co insurance.  Sometimes if an office visit code is accompanied with a vaccine code then the insurance carrier will consider it covered by the office visit co pay...but again every plan is different.  

More Health Insurance Vocabulary

Co pay:  The amount you pay up front to your doctor's office or hospital for services.  Often times co pays for specialists, MRI's, or CT's are higher.  Co pays do not always cover everything that is done at a doctor appointment or even a MRI or CT, so it is possible that you may get a bill later (keep an eye out for those EOB's so you are prepared for the bill  that may follow).  Every plan is different so if you're unsure about yours email me and we can take a look at it. 

Co Insurance:  Very similar to a co pay, in that it is paid by the patient, but it's typically a percentage of the allowable charges and not a flat fee like a co pay. 

     Example: 80/20 plan means the insurance pays 80% of the allowable charges and the patient pays 20% of the allowable charges.  So if the services billed totaled $500, but the allowable charges are $350 the insurance company would pay $280 and you would owe $70.  **Side note: sometimes you have to meet your deductible and then your co insurance, so that can get confusing.  If you're not sure email me and we can check it out.

Deductible:  This is the amount out of pocket a patient pays before the insurance carrier will pay anything. 

DME:  Durable Medical Equipment.  DME benefits cover things like knee braces, nebulizers, wheel chairs etc.  Often times you must meet your deductible before insurance will pay for DME, sometimes it goes toward your Co Insurance...but again every policy is different, so if you have a question about your DME benefits email me and we can discuss it.

Please email your questions regarding your health insurance policy to deargabbyinsurance@yahoo.com
 

Health Insurance Vocabulary

EOB:   Explanation of benefits. This is what you will get from your insurance carrier showing what they paid to your doctor's office, why they paid it, and an estimate of what you may owe your doctor.  It is not a bill.

Allowable fees or Contracted rate:   This is the amount your insurance carrier agrees to pay your doctor or hospital for medical services.  Just because they bill out $800 worth of services doesn't mean that's what they will get paid.  

ICD-9 codes:   These are diagnosis codes (ie. what's wrong with you) submitted on insurance claims.

    Example: 719.46 is knee pain

CPT codes:   These are procedure codes (ie. what the doctor did) submitted on insurance claims.

    Example: 99203 is a new patient office visit 30 minute appointment

Questions? Comments?
email me at deargabbyinsurance@yahoo.com