YOUR RESPONSIBILITIES AS AN INSURED PATIENT
We have been presented with the comment, “I am fully insured, why did i get a bill?” over and over again. This particular statement comes from not properly understanding an insurance policy and its related responsibilities.
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.