MEDICAL INSURANCE
In
discussing insurance, this discussion will only involve Preferred
Provider Organization(PPO), Point of Service(POS) and Indemnity
insurance plans that allows a patient to select the doctor of
their own choosing.
Before coming for
treatment at a doctor's office, the patient's insurance should
be verified by the doctor's office to determine insurance benefits
for the office visit, procedure benefits and coverage of optional
items such as custom shoe inserts. Besides your coverage,
any outstanding deductible amounts must be determined. The
deductible remaining on your insurance is based on the amount
the insurance company allied to your deductible, and this may
not be the same amount as you paid to a previous medical office.
As such, it is important to insure that the office you
are paying a deductible to actually is billing your insurance.
Once you have had
treatment by the doctor's office, a standard form is used to
electronically send the billing to the insurance company. The
fees charged are based on the medical industry standards that
been developed over the years in which each service has a specific
number assigned to the service that was billed to the insurance.
Typically, a month and a half passes before any payment
is received by the doctor's office. Patients have a lot
more clout in getting insurance companies to pay their bills
and a call to the insurance company can significantly speed up
the claims process. Most claims go very smooth and there
are no delays. Sometimes, the delay is not for any good
reason other then to delay the claim and in other cases the delay
is because the insurance company is contesting the billing. Usually,
a form is received by the doctor's office after about a month
stating the problem with the medical claim, and the doctor than
has to write a special report or document some other medical
justification for the reason the medical care was rendered. When
payment is finally received, the form that accompanies the payment
is called an EOB which stands for Explanation of Benefits.
Over the years,
patients have wondered why the doctor charges one fee and the
insurance company pays an entirely different amount. In
most cases, the doctor is a preferred provider for the insurance
company and the fee for the medical service that is provided
is set by the insurance company. For the patient, when
the Explanation of Benefits is examined, it appears that the
doctor's office over charged the insurance company when in fact
the amount paid to the doctor's office is the exact PPO rate.
Most doctors charge every insurance company the same fee
for the service provided and let the insurance company determine
what the PPO contracted rate is for that specific insurance company.
Unfortunately, even through there is no discount because the
amount going to be paid to the doctor never changes under the
PPO contract, the Explanation of Benefits states that a savings
occurred in reducing the doctor's original fee.
In processing medical
claims, insurance companies have many different reasons for disputing
the claim such as a pre-existing condition, the medical service
was unnecessary, the doctor is not a PPO provider or medical
records must be reviewed to justify payment of the claim. When
the disputed claim is received by the doctor's office and the
doctor sends back the requested information, another month can
pass before payment is received by the doctor's office. As
a patient, you can move the process along by calling the insurance
company to inquired why the dispute has not been resolved. In
many cases there is no reason for the extended delay in payment
other than the paperwork must move through a large bureaucracy
prior to payment or the paperwork is sitting in a stack on someone's
desk. Between the doctor's office and the patient working
together, claims can be paid in a timely manner.
When a procedure
is not paid for by the insurance company the doctor's office
can bill the patient for only those services that are not covered
by the insurance policy and this information will be listed on
the Explanation of Benefits when the medical claim is paid. Most
offices will inform the patient of the expectation that the medical
service will be not covered by the insurance company prior to
the service being rendered. For Medicare patients, there
is a pre-treatment form that lists which services Medicare does
not cover and the cost of each f these services.
|
