Frequently Asked Health Insurance and Medical Billing Questions

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Important Terminology & FAQs

What Is A Copay?

A fixed dollar amount that a patient is responsible for paying upon visiting a doctor’s office or hospital. This amount goes toward the total cost of the visit, the rest of which is covered by the insurance company.

What Is A Deductible?

A set amount of expenses that the insured will pay out of pocket before the insurance company pays for covered services. This amount generally reflects a sum that must be met each year.

What Is Coinsurance?

A percentage of covered services that the insured is responsible for once the deductible has been met and the insurance policy is paying for covered services.

What Is A Flexible Spending Account?

An account set aside by the insured’s employer that holds funds which can be applied to medical expenses not covered by insurance. Employers may contribute to an employee’s flexible spending account or provide other incentives for contributing to it.

What Is A Second Surgical Opinion?

A request by an insurance carrier for a patient to obtain a second opinion in the instance that one surgeon has recommended surgery that has been deemed as elective or non-emergency. It may be necessary to complete this step before a surgery is paid for.

What Is A Preferred Provider Organization?

Sometimes referred to as a PPO, a Preferred Provider Organization is a type of policy that offers a network of available physicians from which a patient is free to choose.

What Is An Health Maintenance Organization?

Sometimes referred to as an HMO, a Health Maintenance Organization is a collection of healthcare providers that work together to provide more inclusive care. HMO’s may exist within a single group practice or a network of doctors. Generally, patients who carry HMO policies have a primary care physician (PCP) who is responsible for managing their overall care.

What Is A Pre-Admission Certificate?

An authorization given by the insurance company upon approval of non-emergency or elective procedures. This certificate greatly increases chances that services will be covered.

What Is A Utilization Review?

A cost management technique used by insurance companies to assess the standard of care as well as the necessity of any procedures being performed. In a utilization review, a contracted employee from the insurance company will interview and investigate the proceedings before, during, or after a procedure has been performed.

What Is A Maximum Plan Dollar Limit?

The maximum amount that any one policy will cover for a policyholder and their dependents over the course of their enrollment in a given health plan.

What is the Difference Between an Individual Plan and a Group Plan?

The main difference between an individual plan and a group plan is that a group plan is chosen by your employer and then provided to you. Because your insurer chooses your plan in conjunction with several other of its employees, the premiums on a group plan may be lower and you will likely only have one provider to chose from. Your employer may pay all or some of your premiums for a group plan.

An individual plan refers to plans that are not provided through an employer. Self employed individuals or others who do not receive health insurance through their workplace may opt for an individual plan. With the roll out of the Affordable Care Act, many individual plans are subsidized by the government and may be just as affordable as group insurance plans.

How Do I Chose A Health Insurance Plan?

The best way to chose a plan is to assess your medical needs, habits, and your ability to pay a monthly premium. If you are a person who seldom goes to the hospital and you cannot pay a very high premium, you may choose a plan with a high deductible and a low premium.

While this will lower your monthly costs, it will also mean that you are responsible for greater out of pocket costs in the event that you need medical care. If you go to the doctor often or have dependents, like children, who require frequent office visits, you will likely prefer a plan with a lower deductible and a small copay. If you have specific medical needs, you will also want to make sure that you choose a plan that covers the procedures or treatment that you need.

What is the Current State Of US Health Insurance?

The United States health care industry is current in a state of growth and flux as the Affordable Care Act has brought about provisions to make health insurance more accessible by lowering the cost of premiums to many consumers and by reducing the amount of reasons that coverage may denied.

Pre-existing conditions, for example, which were once a common reason for care to be denied, are no longer a legitimate reason for insurance carriers to deny coverage. United States health insurance companies have been working to create more individual plans, as many of them previously sold most of their policies in the form of group policies.

Because health insurance companies are experiencing such a shift in their business models as well as a dramatic influx of new policyholders, many companies are overwhelmed by calls and customer service questions, but they may be expected to adjust fairly quickly to new changes.

Health Insurance From A Patient’s Perspective

Why do I need health insurance?

Health insurance is incredibly important to both your financial and physical health. The number one cause of bankruptcy is currently unpaid medical bills and countless other individuals are facing financial ruin because of bills they are unable to pay. Health insurance provides a financial safeguard in the event that you have unexpected medical issues.

Having health insurance also greatly increases your odds of getting regular check ups and other preventative care, which may help prevent serious illness in the future. Even a very healthy person may have unexpected health issues, and many unexpected health problems can be very costly if an individual is required to pay for them out of pocket.

Even a very short stay in the hospital or emergency room can result in very high bills, and can send an otherwise financially solvent person into major debt. Medical debt can be very dangerous to your credit score and can even prevent you from things like securing employment. Health insurance is simply an indispensable protection.

What medical bills does my insurance cover?

The bills covered by your health insurance will vary depending on your policy, and you should always make sure you have a full understanding of what types of coverage your policy offers before choosing it. There are some things that are covered by almost all policies, including regular office visits and trips to the emergency room.This is now required under the terms of the Affordable Care Act.

The categories of care that must be covered are: ambulatory care, emergency care, hospitalization, maternity (including prenatal and postnatal care), mental health and substance abuse, prescription drugs, rehabilitation services and habilitative devices (services or devices necessary to help heal from a major injury or mental health incident, and devices to help with a handicap or other major physical issue), laboratory services, preventive and wellness services (including chronic disease management), and pediatric care.

It is important to note that while all policies cover these categories to some degree, the amount compensated for each service varies with each policy, so you should research a policy well and make sure that it aligns with your medical needs.

Why are some medical bills not covered?

The main reason that a bill may not be covered by your health insurance policy is that the treatment you received was not part of the plan that you carry. This may be because you visited a doctor who was not part of your insurance network or because a step was missed prior to you receiving care. In many cases, your insurance may require that you receive authorization before undergoing certain procedures.

Does my insurance cover mental health treatment or rehab bill?

Yes. Under the provisions of the Affordable Care Act, there are ten categories that all insurance policies must cover to some degree. One of these categories is mental health and substance abuse treatment. If you require mental health treatment, make sure that you choose a doctor or treatment center in your network.

Health Insurance From A Physician Or Treatment Center Perspective

How do I bill patients without insurance?

If you have a patient who does not have insurance, you will bill them directly. Make sure that you or your office staff has been as clear as possible about the costs associated with the patient’s care and that if a patient communicates an inability to pay, you offer options like payment plans or referrals to grants or other programs that can help with bills.

How will the new ICD-10 medical billing codes affect my practice?

The new ICD-10 codes are much more comprehensive than the codes in its previous version, ICD-9. This means that your office will require some training in order to adapt to new codes and software, but ultimately you will likely experience higher levels of reimbursement because of the fact that you will be able to bill with more precision.

How to I handle medical billing disputes?

If a patient disputes a bill, it is likely that the dispute includes their health insurance company. Make sure that the patient is communicating with their health insurance provider and that they have confirmed that the amount paid by their insurance company is correct. Also double check charts and notes from the patient’s visit and make sure that there has, in fact, not been an error in billing or coding. If a dispute continues, be prepared to show all documentation regarding their visit and your rates.

Should I outsource my medical billing and coding?

Most healthcare providers agree that it is a wise decision to outsource medical billing and coding. The reality is that billing and coding are time consuming processes that can present a major drain to your practices’s resources. Communicating with health insurance companies can be an especially long process while health insurance companies adjust to the changes of the Affordable Care Act and may be experiencing very high call volume.

Contacting patients about past due bills can also take quite a bit of time and effort. Outsourcing billing and coding helps greatly increase the amount of time you and your staff have to devote to patient care and the matters that are occurring from day to day in your office.

What are the best practices to avoid medical billing problems & disputes?

The best way to avoid billing problems and disputes is to exercise good communication and clarity when it comes to how much a patient can expect to pay out of pocket. Making a diligent effort to make sure patients understand costs prior to undergoing treatment helps eliminate instances in which a patient is shocked or surprised by the amount of their bill.

If a patient expresses that they will not be able to pay a bill, offer solutions. Be willing to set up payment plans or take other steps to make care more affordable. Outsourcing billing and coding is a good way to eliminate or reduce instances of error. When office staff is juggling billing duties with matters of office management, they are more likely to make billing errors.

Future Of Health Insurance Coverage & Medical Billing

It seems that the Affordable Care Act will have quite an impact on the health insurance industry. Once insurance companies have properly adjusted to the increase in policyholders, they may be in a position to offer a number of comprehensive plans at low rates.

Ideally, as this happens, health insurance companies will be able to set up online portals with information about different policies as well as readily accessible customer service agents who can answer questions about coverage and various policies before a patient undergoes a non-emergency treatment or service.

This should lead to more manageable bills for patients and far fewer billing disputes or delinquent bills. The changes that are occurring in the medical billing should be highly beneficial for doctors, hospitals, health insurance companies, and patients.