Understanding Your Insurance Policy

Does trying to understand your insurance policy frustrate you? Are you confused about what each insurance term means? Do you understand why you get a bill from a provider after you paid in the office?

Let me help you with your frustrations. Stop pulling your hair out, and sit back and relax while I go over some simple definitions and scenarios with you.

First, let’s start with understanding basic insurance policy terms and definitions:

1. Co-Insurance: Your co-insurance is the part that you pay after your insurance has paid its portion. For instance, if your policy pays 80% of the charges for a doctor’s visit, then you will owe 20% of those charges.

2. Deductible: If your policy comes with a deductible, you must meet your deductible before your insurance company will start to pay a percentage of your charges. Your deductible is the amount that you pay out of your wallet before you see your insurance pay anything.

3. Out-of-Pocket: Some Policies come with an out-of-pocket. After your deductible is met, your insurance pays at 80% and you pay 20%. That 20% goes to the out-of-pocket. Some policies have out-of-pockets of $2,000. Once you have paid up to $2,000 in co-insurance, your policy will typically pay at 100% of the allowed medical charges. So, your out-of-pocket is really the limit that you have to pay up to until your insurance will pay your charges at 100% .

5. Copay: Not all policies come with a copay, but if yours does this is the amount that is promised to your provider through a contract from your insurance company. The copay comes from you as a part of the insurance’s upfront payment to the provider. Providers love to get money upfront, and insurances love to have the patient pay out money instead of them paying money. Typically, an insurance pays your charges at 100% if you have a copay, so the deal really works out nicely for all parties involved.

5. Allowed Amounts: An allowed amount comes from a contract between the provider and the insurance company. A provider may submit a charge of $260 to your insurance company. Because there is a contract between the provider and the insurance company, the insurance company may say that they are only going to allow $175 of the $260 charge and of that $175 they are only going to pay at 70%. This part is very tricky for patients to understand, because insurances companies can change their allowed amounts at any time. The allowed amount affects the patient’s co-insurance that is owed.

Your insurance company could tell the provider’s font office staff that they only allow $175 for a certain charge and that you have a copay of $25.  So, in order for the office staff to collect your co-insurance and copay, they figure an amount of $52.50 of coins due on the charge plus a $25 copay. The total amount that they would have you pay is $77.50.

This amount can change if the insurance company changes their mind after they give out the information. When the insurance finally responds to the charges, they can say that they allow the full $260. This means that the patient is going to owe more money. 70% of $260 is $182. The $182 is what the insurance will pay. This is more than they quoted to the provider office staff. Now, here comes the part that patients often have a hard time understanding: because the insurance allowed the full charge of $260 the co-insurance amount of $52.50 went up to $78.00. The patient may have paid 52.50 co-insurance and a $25 copay, but they now have $25.50 remaining due to the rise of the allowed amount. Please be aware that a quote of benefits is never a guarantee of payment. This means that the insurance’s decision is not final until they respond to the provider. IT IS NOT THE FAULT OF THE PROVIDER’S OFFICE IF THE INSURANCE COMPANY DECIDES THAT YOU OWE MORE MONEY THAN WHAT YOU WERE ORIGINALLY TOLD.

6. Provider Insurance Adjustments: When an insurance company decides an allowed amount on a charge, there is an adjustment made on the part of the provider’s office. The provider can charge your insurance company $300, but only allow $250. Because of the provider’s contract with the insurance company to accept their allowed amounts, they are responsible to adjust off the $50 that the insurance did not allow. This adjustment is “eaten” by the provider. This is one reason that you want a provider to be contracted with your insurance company. This is a benefit to the you as the patient.

7. Explanation of Benefits (EOB): An Explanation of Benefits (EOB) is how the insurance company tells the provider and the patient what exactly they did to the charges. It explains what they allowed for each charge, what the patient owes, and what they paid to the provider. It can also relay a denial or need for more information.

8. Medical Necessity: This term refers to the insurance’s decision on whether or not they believe that they need to pay for the patient’s charges. If a patient continuously goes to a physical therapist, an insurance company may question the validity and medical need of these visits. They can begin to deny your claims and request medical records from the provider. Once this process begins it is a very long and hard road to receive paid claims from your insurance company.

9. Denial: This term is easy to explain. A denial is anything that your insurance will not pay. What is difficult about this term is that once a claim is denied, it can be a long process to get it paid. A provider may “stick” a patient with the bill until things are worked out with the insurance company.

10. Pre-certification/ Authorization: Some policies require that you notify them to receive medical attention. This term is the name of the process in which a provider will contact an insurance company to receive approval for you to attend their services.

11. In-Network: This is the term that is used to describe a provider who is contracted with your insurance company.

12. Out-of-Network: This term is to describe a provider who is not contracted with your insurance company. Typically, an insurance company will not pay for your claims if you receive services from an out-of-network provider.

It is very import to know the terms of your own policy. If a provider is quoted incorrect benefits from your insurance company and if the insurance company does not pay, it is the patient’s responsibility.  Appeals can be written, but it is never a guarantee that they will be won. Always know your benefits for each doctor and specialist that you see. It never hurts for both you and the office staff to contact your insurance company to verify your benefits.


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