We get many patients who inadvertly sign on to MEDICARE ADVANTAGE policies while filling out “information forms” at shopping mall booths, or on their neighborhood when some of the insurance place promotional kiosks.  Unfortunately for many of these patients who hold medicare, the representatives at most kiosks will promise many benefits so they will fill up the forms.  The insurance, though, will be a restricted network which might not provide benefits for doctors that the patient normally visited.

While we have to agree that there are many good MEDICARE ADVANTAGE policies, we have to advise our patients and any MEDICARE member to be watchful and ask questions so they do not get signed up in something they didn’t want.  Also, DO NOT fill out forms at the mall or at street kiosks. If anything, take the information home and ask MEDICARE (1800-Medicare) if they recognize these plans and how will their benefits be affected.

The main issue we have with this practice is when they refer to claims beyond their own timely filing deadlines.  Yes they will not pay a claim past 90 days of the date of service but they will ask for money beyond 18 months of the payment date. Sounds unfair, no?  We have asked the insurance and those that know about contracts how to counter act these requests and there is no particular recourse. There are obviously, legal means by which to deal with these if they are unfounded or unfair, but they are quite time consuming and cumbersome.

Many of these refunds requests are due to patient data not correctly set at the insurance end once the claim has been processed. Our office prides itself on obtaining as much detailed and up to date information on our patients policies, hence avoiding surprises for us and for our patients. None the less this is not enough for that 10 to 15% of the claims (probably less, but the work related to resolution feels like much more).  We have had the case where the policy has been terminated as of one date say January of 2008, but our patient came to us on July. Even on July at the time of service our staff has verified (obtaining reference numbers and or printouts from the insurance website) eligibility as active and now then the refund request comes to us indicating the policy terminated on January of the same year, that’s about 6 months worth of outdated information!

Now with such a lag on information updates from employers to insurance or from insurance group to another, who are we to trust for payment of our patent’s claims?  Now then, they make the provider responsible for this by requesting a refund.  As a matter of principle, the employers or even the insurance should own up to their belated actions and carry the financial responsibility of not keeping records up to date. That is just an opinion of course.  Without such, they have NO incentive whatsoever to keep their records straight.

The third party collection agencies use quite a bit of aggressive means to collect these funds. It doesn’t matter how cumbersome it is to deal with them, providers should be careful to investigate each case for its validity and deal with each appropriately.  If you have done your homework on those and believe the request is belated or unfounded, then use what resources you have to dispute it, including the information obtained while verifying the policies involved, or medical information if its related to “INCORRECT” processing. Don’t give in too easily.

Lately we have seen this shift on our BCBS patients.  Unfortunately most of our patients are vaguely aware of what their responsibilities are based on their policies and it becomes our job to explain to them how their claims are being processed in order to collect what their insurance is assigning as their responsibilities.  We ask our patients to learn more about their policies and how they work in order to get the best out of their existing benefits.

Once more, thanks!

What do those terms mean? First, lets discuss WAITING PERIODS.  These represent time spans defined by your insurance company in your policy during which any claim sent in might be or will be held back to investigate it.  What is the insurance looking for? They are looking for anything that might imply that you as a patient had a particular condition prior to starting the insurance policy.   Most insurance policies have a clause that will not cover any PRE-EXISTING CONDITIONS, hence the insurance will want to find those out before they pay anything within that WAITING PERIOD.  Pretty simple?

The problem with these investigations is not if or not the item in question will be paid, its the fact that the investigation itself takes a lengthy period of time to finalize.  This causes the doctor’s office to receive belated payments for services rendered. Aside from that, most patients will have a hard time reconciling with the fact that the particular insurance will not pay for treatment for such conditions declared PRE-EXISTING.

How do you work around this matter?  CERTIFICATE OF CREDITABLE COVERAGE (this certificate is a letter from your prior insurance company certifying that you were insured from X date to X date).  For those patients who have switched policies for whatever the reason, this is the workaround. Most states allow an insured to provide evidence of INSURANCE COVERAGE to the new insurance if the prior policy terminated less than sixty (60) days of the beginning of the new one.  This on itself waives the WAITING PERIOD CLAUSE of the policy. You might want to look into this matter if you have acquired a new policy within the past 12 months and have not visited a doctor.

MAKE SURE ITS DONE!

It is very important, as an insured party, to make sure your insurance does what they say they would.  If you send documents to anyone, please collect their contact information, request a reference number, etc… Always keep copies of all documents sent.  Aside from that, give the mail sufficient time (a week at least) before you call again to verify if the documents have been received and have been attached to your policy/account.  Even though its time consuming, following up on this matters will save you time and headaches in the future.  It will also save your doctors, all of them, time and efforts better spent on other matters.  If you do not provide the CERTIFICATE OF CREDITABLE COVERAGE (presuming you were insured and have it or have access to it), you run the risk of having even the simplest of diagnosis declared as PRE-EXISTING and therefore excluded from your covered services. Please, for your own good, make sure your insurance acknowledges receipt of this document and that your WAITING PERIOD has been waived.  At that point, once more, collect the representative’s contact information and request a reference number, if they can provide this confirmation in writing, even better.

CO-PAY is a fairly simple concept. Its a set amount to pay per visit to your doctor. This amount will vary per policy but is constant across a year. Your insurance will indicate your CO-PAY is $20.00 (for example) for every “visit” to the doctor. So whenever your doctor invoices a “visit” (visits are specific service codes, as opposed to sonograms or other procedures) to your insurance, the insurance will require that you pay the $20.00. Since its required, most doctor’s offices collect the copay at the time of the visit. As times have changed, and sometimes a “visit” code is not invoiced for, most insurance companies are requiring a copay per encounter with your doctor. This way, they pass part of the cost to the patient for any service they receive. In the past a sonogram would not require copays, nowadays even labwork requires a copay. Copay varies sometimes by service type and place of service. This, you should be diligent and check with your insurance policy so you understand how much you are required to pay per visit to your doctor or even laboratory or imaging center. CO-PAY amounts might change each year depending on your policy. CO-PAYS are usually raised year by year.

CO-INSURANCE, is a portion of the approved medical expense for which the patient or insured party needs to pay. This portion is usually a set percentage of the approved amounts. Commonly the insurance will pay 80% (eighty percent) of the approved service and the 20% (twenty percent) is to be paid by the patient or responsible party. CO-INSURANCE percentages vary by policy type. Indemnity policies, which normally are not based on contracts with the doctors, use coinsurance. PPO polices have them and so does HMO/POS policies.

CO-INSURANCE usually is applied after deductibles are met. Depending on the type of policy you might have a total OUT OF POCKET amount to meet for the year before the insurance would pay at 100% (one hundred percent) of the approved benefits. CO-INSURANCE assigns this patient responsibility, claim after claim until the total out of pocket amount is accumulated. This process resets itself either by calendar year or yearly on the date the policy started.

This explains the most basic patient responsibilities. There are further variations and nuances to look into, but these are written in specific policies and you as an insured party should look into them to better understand your benefits and your responsibilities.

Your deductible for a year can vary from $135.00 a year (like Medicare on 2008) to several thousand dollars. In basic terms this means, if your deductible is $500.00 (consider yourself fortunate) this amount has to be applied to your approved services before your insurance pays anything for your claims. If you have medical services earlier in the year you will very likely be paying the doctor for most of those services (if your policy has deductibles). Say your claim is for $200.00, of this your insurance “allows/approves” $150.00, if your deductible is $500.00 then your services for this date will be your responsibility to pay. In this case the whole $150.00 approved by your insurance. Since the deductible is a cumulative amount, now you will have $350.00 remaining to be assigned to future services for which you will be invoiced by your doctor. Once all approved services have amounted to the total deductible, the following services should be processed and paid either partially or in full according to the particular policy’s benefit scheme.

Note that deductibles are a way for the insurance to make the insured pay for the difference between the high premium plans and the lower premium plans. Lower premium plans normally carry higher deductibles and more restrictions.

Next we will be discussing CO-INSURANCE

As health care providers it is our duty to provide our patients with the care they need. This care unfortunately has some costs involved. These costs are ultimately the patient’s responsibility. Now then, Insurance policies exists to aleviate this burden. There is a contractual relationship between the patient and his/her insurance and sometimes it exists between the doctors and the insurance. We will try to discuss the CONTRACTED or PARTICIPATING insurance aspect in this article.

As a contracted provider to a particular insurance plan, the doctor is obligated to accept the allowance (maximum amount or contracted rate) indicated by the insurance for a particular service. In other words the doctor will be paid up to that amount for a service. As an example, if the doctor invoices service XX for $200.00 and the insurance indicates the ALLOWANCE (contract rate) is $150.00, that is all the doctor is, per contract, getting paid for that service. The $50.00 difference is a contract discount. In the best case scenario, our patient will be treated, the invoice is sent to the insurance and the doctor gets paid. That on itself is the basic process.

In an effort to reduce amounts paid for health care, insurance companies have established a few clauses in most policies in which they pass some of the costs to the patient. These patient portions are reflected in:

1-Deductibles
2-Coinsurance
3-Co-payments

Aside from that, they also reduce or deny payment for services related to pre-existing conditions. We will make an effort in explaining these further in future articles.

Please note that no personal information or data will be discussed or exchanged in these pages.