Patient Advocacy: Healthcare on your side
by Martine G. Brousse,
Healthcare Specialist, Patient Advocate, Certified Mediator
The question never to ask a medical provider
You actually meant: "I have some kind of insurance. I trust and expect you to understand it, will deal with it and will get paid by it while I focus on my health with little further responsibility".
Here are the 3 mistakes you made:
A. Not knowing your basic insurance coverage
I understand, the alphabet soup and complex terms mean nothing to you, and you have neither inclination not time nor energy for it. But you should know which one of the 3 basic types of coverage your coverage falls under. Your card should indicate the letters or name you need. See "question of the day" below for details.
B. Blindly trusting the medical office staff
You assume and trust that the people who work for your doctor are: caring, trained, knowledgeable, and have taken care of all the necessary details. In a perfect world, and in many offices, this is the case. However, in these days of overworked, overwhelmed and oftentimes untrained personnel, consider this: no one wants to turn you away even though the office is not part of your insurance network, no one wants to tell the Dr a significant appointment spot was erroneously scheduled then wasted on a patient who was turned away, no one checked coverage beforehand, no one had your correct insurance info, no one bothered to get an authorization, there is no time to get an authorization now that you have provided insurance info, 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 you will be taken to the cleaners for.
It is your responsibility to make sure (1) the office has the correct insurance info (2) the necessary authorization is on file (3) the provider is contracted and "in network".
C. Not understanding that you probably do have some kind of financial responsibility.
Unless you have the extreme good fortune to have some type of coverage that covers you at 100%, the odds are that you will owe something to someone. Even Medicare patients have a yearly deductible. Knowing what to expect can help you plan better, lower your anxiety at unexpected "surprises", negotiate payment plans or look for financial assistance.
Patients are usually be responsible for:
- yearly Deductible: the amount the patient pays first before an insurance issues reimbursement
- Out of Pocket: after the deductible is met by you, 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 OOP has been met, then will your claims be paid at 100%.
- Office Copay: many plans impose a set amount per office visit, whether you see the Dr or not. This copay will be requested by and is owed to medical office at the time of your visit.
Note: if using non contracted providers ("Out of network"), your cost will likely skyrocket. Expect your Deductible and OOP to double, and your insurance reimbursement rate and payment to be much lower. You will also be responsible for any sum between the amount billed by the provider and the allowed amount by your insurance. Never use a non contracted provider unless absolutely necessary. If you must, NEVER receive services before negotiating the fees ahead of time.
In conclusion, these are the 3 major reasons why your conversation with your medical providerʻs office should run something like that:
" I have --- (name type of coverage like PPO or HMO) with ---- (name insurance)
Is Dr Smiley a contracted provider with this insurance and plan?
Is an authorization needed? If yes, do you already have it or should I get one? (ask who can issue it). If no, are you sure?
What kind of cost should I expect for the services?
Last piece of advice: record the name of the person, answers given to you and date in your files. You never know. And if the person you speak with seems evasive, uncaring or ignorant, trust your instinct and either ask for a supervisor or find another office.
©  Advimedpro.
©  Martine G. Brousse.
All rights reserved.
My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.
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