Q-When do I verify the insurance benefits?
Before the first session. Everyone should be clear on the financial expectations of the care.
The member/patient/client is responsible for providing all insurance information and establishing the proper sequencing of primary and secondary coverage (coordination of benefits) at the time of registration. Copayments/Coshares are due when service is rendered.
Q- Who submits the claim to the insurance company?
If the provider is OUT of network with the member’s plan then submitting a claim is optional. You can submit a claim as courtesy or give the client/patient a statement/Invoice for purpose of reimbursement. Many insurance plans do NOT pay Out of network providers. They only reimburse the member.
If the provider is IN network with the member’s plan then the provider will send a claim to the primary insurance company within a few days or weeks of the appointment. The insurance is expected to pay the claim within 30 days. After the member’s visit, the member and the provider should receive an Explanation of Benefits (EOB) from the insurance company, stating how much the insurance company paid and how much is the member's responsibility.
Q- Is a benefits verification that is done online, by phone or by fax guaranteed to be correct?
NO. It’s only an estimation. The Insurance company reviews the plan details when a claim is received for processing. That is where the insurance company’s billing team can see the providers’ credentials, DX, coding etc.
Q- Who is responsible to understand the plan coverage and limitations?
The member is the only person that has the opportunity to see the full plan. When the member selected their plan he/she was given a contract with all the details. The members are responsible to understand the plan they selected. They should contact their member services if they have questions about their contract.
Q- I have multiple health insurance companies. How do I know who to bill?
Coordination of benefit rules apply. One plan will be primary and the other secondary. Contact your Insurance provider to help in determining the proper order for billing.
Q- (from Client/Patient) If my insurance doesn’t consider the provider IN network aka preferred provider, will the provider still bill my insurance?
Only if requested. Many insurance plans do NOT pay Out of network providers. They only reimburse the member.
Please contact your carrier to verify your coverage and/or benefits for IN and Out of network care.
Q-(from Client/Patient) What if the insurance company does not authorize or cover services?
The member will be responsible for charges their insurance company does not authorize or cover.
Q- Does the member/Client/Patient owe a balance if the insurance company has been paid some of the amount billed? "Balance Billing"
IN network providers must accept the contracted payment amount they agreed to. They should only be requesting money due for deductibles, co-pays and co-insurance for fees not covered by the insurance company.
Out of network can balance bill. They have signed no contract or agreed to accept anything less then their billed amount.
Q-What does usual and customary mean? How does this work?
The usual and customary fee schedule is set up so that non-contracted providers are reimbursed at a rate that the insurance company feels is a fair fee for the service in that geographical area. The patient is responsible for charges that exceed the usual and customary rate for OUT of network providers.
Q-What is the difference between an HMO and PPO?
HMO stands for Health Maintenance Organization. An HMO is a group that contracts with medical facilities, physicians, employers and occasionally individual patients to provide medical care to a group of individuals. IN network benefits only.
PPO stands for Preferred Provider Organization. As a rule, you must select a primary care physician (PCP) who is under contract with the PPO. If you choose a doctor not under contract, you pay more. Like an HMO, you usually pay a small amount known as a copay each time you visit your PCP or health-care facility. Unlike an HMO, if you choose to see a doctor who is not contracted with the PPO, the plan might pay a percentage of the medical bills (out-of-network benefits). However, your cost will probably be higher than if you choose a caregiver that is in the plan’s network.
Q- What is a co-payment?
This is usually the language for IN network care. A copayment is a set fee the member pays to providers at the time services are provided. Copays are applied to emergency room visits, hospital admissions, office visits, etc. The cost is usually minimal. The patient should be aware of the copayment amounts prior to services being rendered.
Q-What is co-insurance?
This is usually the language for OUT network care. Co-insurance is a form of cost sharing. After your deductible has been met, the plan will begin paying a percentage of your bills. The remaining amount, known as co-insurance, is the portion due by the patient/client/member.
Q- What is a deductible?
Deductibles are provisions that require the member to accumulate a specific amount of medical bills before benefits are provided. Deductibles renew yearly, usually starting in January but some start on the anniversary date of the plan.