Let me just start by saying it is always the responsibility of the patient to know and understand his/her medical insurance policy! As the person who signed the contract, you should know exactly what it is you have purchased.
Secondly, individual doctor’s offices file your insurance for you only as a courtesy. They do not necessarily have to file for you and could, in fact, charge you up front and let you file on your own. It all depends on the office policy of that particular doctor and whether or not he/she has contracted with your insurance company. If they are, indeed, contracted, they will file for you. You should always ask when you make an appointment if the doctor is contracted with your insurance.
Now, to the meat of it all! There are many different types of insurance policies available but your main policies are PPO (Preferred Provider Organization) and HMO (Health Management Organization).
PPO insurance means you can go to the doctor of your choice. But there is a catch! Although you get to choose, if you choose a doctor who is not listed in your preferred provider directory, your policy will only pay at “Out of Network” rates. This is a reduced rate where you pay more of the percentage and co-pay for using a non-preferred provider. There is yet another catch. Your policy may not have out of network benefits. Here is one of those areas where it is up to you to read and understand your particular policy. If you do not have out of network benefits, you (the patient) are fully responsible for all the charges accrued for that visit and they are payable at the conclusion of your visit.
There are three parts to PPO insurance policies. (Not all policies have all three so you must read your contract)
1. Co-pay – This is the money you pay off the bat for your visit. There are three levels of co-pays.
A) Office Visit; which is for Primary Care Physicians (General Practitioners, Internal Medicine Doctors, Rheumatologists and Gynecologists). These are the doctors who handle your general health and well being.
B) Specialist Office Visit – This is the same as office visit except that the co-pay is higher and is for visits to Specialists (Any other type of doctor not listed previously)
C) Emergency Room Visit-This is usually the highest level of co-pay and is what you pay when you visit the E.R.
2. Deductible – Your deductible, just like in your auto insurance, is the amount you must pay out first before your insurance policy starts to pay out. The deductible sometimes applies to office visits as well, depending on individual policy but usually it applies to in-office procedures such as injectables and any bodily invasive surgical procedure. This can be cryotherapy, biopsy, use of a laser, excisions, etc.
3. Co-Insurance – This is the percentage that your insurance company will start to pay for in-office procedures after your deductible is met. The insurance company usually pays the higher percentage while the patient is responsible for the smaller amount.
All of these fees are due and payable at the conclusion of your visit. Let me put it this way; would you go to a grocery store, fill your cart with food and go to the checkout and tell the cashier to bill you later? Trust me when I tell you that it is perfectly legal to collect all these fees at the time of service and that the staff in that office have already called and confirmed your benefits with your insurance company before you were taken to the check out desk. It does you no good to argue about the amount with the receptionist because you already signed a financial policy agreement when you filled out your paperwork to see that doctor. Again, refer to my first statements that the physician’s office does not have to file your insurance first and wait to see what comes back. They already know what your portion is going to be.
HMO Insurance – An HMO has differences. You must pick and sign up for a particular physician listed in the Health Management Organization directory. You do not get the privilege of choosing just any doctor. This physician that you sign up for will direct all your care and will refer you to a Specialist within your HMO only when he/she deems it necessary. No matter what your current malady is, you must visit your PCP (Primary Care Physician) first and he/she will either attempt to treat or refer you to a specialist.
A referral is required to visit a specialist! It is YOUR responsibility (not the PCP”S office or the Specialist’s office) to make sure a referral was generated and sent to that specialist before you can be seen. You cannot be seen by specialty without a referral. These are rules written in stone with HMO’s.
Co-pay – When you visit your PCP or a Specialist, you will pay only your co-pay. This is the feature benefit of an HMO. You do not have a deductible or co-insurance portion. Your out of pocket expense is negligible. The trade off is not being able to pick who you see and having to go through the referral process.
There are other types of private medical insurances that function slightly differently but the principles are always the same. It is entirely up to the patient (policy holder) to read and understand his/her policy.
I have seen many patients in my thirteen years of working with health insurance pitch a fit at check out because they were being charged their full portion of the visit up front. There are times when they’d literally be screaming “but my other doctor files my insurance first”. Let me re-iterate that every physician’s office policy is different and they are perfectly within their right to collect your share up front. When you signed their office policy at the start of your visit, you agreed to pay up front! Read what you sign before you sign it! That way, there are no surprises!
Finally, when you are investigating insurance policies of any kind, be sure to ask crucial and pertinent questions like “What is my responsibility financially, when I visit a doctor with this policy?” or “If I have any procedures, how does this policy work?” “Do I have a deductible to meet first?”
Ask questions, investigate and understand your policy. Feel free to call the customer service number listed on your card with any questions about your benefits. A representative is always happy to assist you. It’s what you pay for!
Copyright- Michele Gwynn All rights reserved
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