The new year has rolled in, and while you are working hard on keeping those new year’s resolutions, you may be overlooking one detail that can benefit you. Insurance! I know, it’s not exactly an exciting word, but the more you know about your particular insurance policy, the better off you’ll be.
My name is Cassandra, and I am the Office Manager at Etheridge Psychology. Part of my job is to help patients the best I can to use their health insurance benefits with us. Because your health insurance plan represents a contract between you and them (not us and them), it’s always best if you know your own benefits.
First, a disclaimer. We are not health insurance professionals at Etheridge Psychology, so we recommend that you read all materials that came with your plan and call your insurance company directly with any questions. We are, however, in-network with some health insurance plans and want you to be able to use your health insurance benefits with the maximum possible benefit and the least possible confusion. You should verify the information provided here with your own insurance company.
Here is some information that might help you. Let’s start by going over some insurance-related terms:
Benefit Period. The start and stop dates of your current plan. For many people, their benefit period runs from January 1 through December 31. Check your insurance card to be sure, as some plans start and stop on other dates during the year.
Covered Services (or Covered Benefits). A list of medical benefits/services, such as tests, drugs and treatments that insurance has agreed to cover at a certain cost based on your policy.
Allowed Amount. The dollar value for a service that the health insurance company and your provider have agreed upon. If your provider is in-network with your plan, the allowed amount is the most you are required to pay. For example, if our full fee is $200 for a particular service, and the allowed amount is $150, the maximum amount you pay is $150 and we discount the remaining $50 per our agreement with your plan.
Deductible. The amount you must pay for covered services each benefit period (for certain services or all services, depending on your plan) before your insurance kicks in. This means that you pay the full allowed amount for healthcare services until you have paid your full deductible amount. After the deductible is met, you may then have to pay coinsurance or nothing at all, depending on the details of your plan.
Co-Payment. A flat amount that you pay for a covered service, typically paid per office visit. Some plans do not have a co-payment and are deductible and/or coinsurance only.
Coinsurance. Your share of the cost of a covered service, expressed as a percent of the allowed amount. Coinsurance is often paid after the deductible is met, but not always. Not all plans include coinsurance.
Out-of-pocket limit/max. The most you’ll have to spend from your own pocket for covered services during the benefit period.
In-network. A specific provider contracted to cover services on your plan. You may still have to pay deductible, co-payment, and/or coinsurance directly to the provider.
Out-of-Network. A provider not covered under your plan. You pay that provider’s full fee, and your insurance may or may not include out-of-network benefits.
Preauthorization. If a service requires preauthorization, the provider must contact the insurance company (by telephone or by completing a form), typically after you have been seen for your initial visit with the provider. The provider must receive authorization from the insurance company prior to rendering that service to you, or the service will not be covered.
Knowing your benefits can help keep money in your pocket. You need to know five main pieces of information when you see a healthcare provider:
Is my specific provider considered to be in-network with my plan?
Is the service I will be getting a covered benefit under my plan?
Is the diagnosis I receive a covered diagnosis?
Is preauthorization required for this service? (If so, let us know before you get the service or it will not be covered!)
How much will I have to pay out of my own pocket to the provider for this service?
As you may have guessed, you may not know some of this information until AFTER you see the provider. Unfortunately, that is a risk of using health insurance. You cannot know what diagnosis the provider will render until the provider assesses you. You may not even know what service(s) the provider is going to recommend until you are assessed at your appointment. If you have any questions about the services to be provided, you can ask the provider for the service they recommend and then call your insurance company to find out if it is covered. The provider can even give you what’s known as a CPT code that identifies that service to the insurance company. Keep in mind that, even if a service is “covered,” you will likely still have some out-of-pocket costs such as a copayment, coinsurance, or deductible.
Many people assume that when they go see a provider or are referred to a provider, their services will be covered. While most provider’s offices try to check/verify benefits before a patient arrives for an appointment, this is done as a courtesy and may not always be the case. Every insurance policy is written differently. Blue Cross and Blue Shield (BCBS), for instance, has different plans available such as Blue Value, Blue Local, Blue Options, Blue Medicare, Anthem and so on. Your provider may be in-network with BCBS, but that does not mean that your provider is in-network with all the individual plans that BCBS offers. Each policy is written differently and can even be written differently between each type, especially if an employer or a self-insured has opted out of certain coverage/services. If you receive a service that is considered non-covered or see a provider that is out of network, the entirety of the bill falls on you. How do you know what is and is not covered? Read the materials that came with your plan or call your health insurance company directly.
The amount you must pay out of pocket is not always easy to determine, so calling your insurance company is usually the best bet. Even if your plan is deductible-only, you still save money by using an in-network provider and receiving covered services because you only have to pay the allowed amount.
Many people are unaware that their health insurance plan represents a contract between the health insurance company and the patient, not the health insurance company and the provider. This means that, if a service is not covered or gets denied, you are responsible for paying the provider for the service and must contact your health insurance company directly to dispute the result. Health insurance companies hold the patient responsible for understanding and abiding by the terms of the plan, even if those terms are confusing. The good news is that your insurance company wants you to know your rights and provides manuals and customer service numbers to get your questions answered. We are happy to call your insurance company for you in many cases, but we can only tell you what they told us and cannot guarantee a service will be covered.
So, to keep more money in your pocket, know your benefits. Call your insurance company, make sure your provider is in-network, that the service (and diagnosis, if available) is covered, and how much you will have to pay out of your own pocket for the service. Don’t be afraid to ask questions. We are always happy to help and do everything we can, but we are sometimes provided misinformation about benefits. You are the best defense to keep this from happening. When you call your insurance company, always write down the date and time of your call, the representative’s name, the reference number for the call, and what the representative told you during the call.
Why don’t we all add contacting our insurance company to our resolutions list this year and next and let the savings begin!