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