By Martine G. Brousse
"The Medical Bill Whisperer... and insurance stuff too"
Patient Advocate, Certified Mediator
Watch the YouTube video:
June 20, 2013
"My Dr takes my insurance"
"I trust that the office staff knows"
"My insurance will/should pay for it".
If I had to list the 3 top misconceptions that lead patients to surprise medical bills, these would be "it".
And yet, these statements make sense.
So why point them out?
1. My Doctor "takes" my insurance
You made your due diligence. You asked someone at the office: "Do you take my insurance?". The answer was "yes".
But it turns out your plan does not include this Dr, or he/she is out of network, or your insurance does not cover the service at all or completely.
This belief is costing you money as, by asking this seemingly benign question, you, the patient, have placed your financial future into the office's hands.
They heard: "I, the patient, have some kind of insurance, here is my card, itʻs my responsibility to know what is covered, I accept that insurance may not pay it all or at all".
What you actually mean is: "I have some kind of insurance, and trust you to deal with it while I focus on my health".
"Taking" an insurance does not mean accepting an insurance payment as "payment in full", does not mean the provider has a contract with your plan, does not mean the services rendered to you are covered benefits, does not mean your financial responsibility is low or none.
Patient should understand "taking my insurance" as "taking a picture of my card".
The office may consider billing your insurance as a courtesy.
The office may consider it your job to deal with any insurance delay or hiccup.
The office may consider that they must be paid up front, and for you to get reimbursed as best you can.
Unless this office is contracted with your plan, you should expect that the office only took your insurance info/card as a piece of information, and not as the full responsibility of dealing with it.
2. I trust that the staff knows
This second belief is As caring, trained, supportive the staff is, Medical Billing is another beast. More and more, external services and automated systems are replacing the billing manager I was for 2 decades. Too many billers are overwhelmed and clueless, only sending out statements without filing appeals, fighting insurance companies or even knowing why a claim was processed incorrectly.
When you get to an appointment and open the front door, no one warned you the Dr is not in your insurance network, no one wants to tell the Dr an appointment spot was wasted on a patient who decided to leave, no one checked coverage beforehand, no one bothered to get an authorization, there is no time to get an authorization now, no one cares at the front desk as it will be the Billing departmentʻs problem down the line.
See where Iʻm going?
Chances are the office will still get paid (something), the difference is how much will come out of your pocket.
Before your appointment, you must make sure (1) the office has the correct insurance info (2) the provider is contracted and "in network" (3) any necessary authorization has been obtained (HMO plans especially)
3. My insurance should/will pay for it
Unless you have the exceptional luck to have some type of coverage that covers you at 100%, you will owe something to someone, especially early in the year. Even Medicare patients have a yearly deductible. Knowing what to expect can help you plan better, lower stress at unexpected "surprises", negotiate payment plans or apply for financial assistance.
Patients are usually responsible for:
- Yearly Deductible: the amount you must pay before your insurance issues its payment
- Out of Pocket (also called "co-insurance"): even after the deductible is met, the insurance rarely pays 100%. They will pay a % (indicated in your policy) and you will pay the difference up to a certain amount. After that thresh hold has been met, then claims will be paid at 100%. IF THEY ARE "IN NETWORK".
- Copays: many plans impose a set amount per office visit, or ER visit. This copay is owed to the providers at the time of your visit.
Note: if choosing to use non contracted providers ("Out Of Network") your cost will likely skyrocket. Expect separate and higher deductibles and Out of Pocket amounts and for the % paid by your insurance to be lower. You will also be responsible for any sum between the amount billed by the provider and the allowed amount by your insurance.
Although some State laws and the Federal No Surprise Act protect you, there are still many exceptions (not an emergency, services not provided at a hospital, etc).
As much as possible, prepare ahead of time:
Visit your online insurance portal to locate In Network providers
Check your yearly liability (deductible + co-insurance)
Confirm the office/ER CoPay amount you will owe (it's often on your insurance card)
Call your plan for the need for a re-authorization and to confirm the planned service is a covered benefit (always get the name of the person just in case)
Give the office your insurance info and request an estimate of your cost IN WRITING
These few steps, although a pain, could potentially save you much grief and money down the line.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2023