Insurance can be confusing and knowing what your responsibility is, and what your out of pocket costs are can be a challenge.
I had my own insurance nightmare with a chiropractor, and that's one of the reasons why I became one. A chiropractor I was seeing didn't submit my claims in a timely manner. I started seeing them in January, and didn't get any EOB's (explanation of benefits) until March! By that point, the insurance was saying she was out of network (whereas I was previously told they were in-network), and had racked up a $500 balance.
It took me a while to pay down my balance as I was buying my first house that spring, and eventually ended up being dismissed from care for not paying my balance. I felt they had lied to me about their "in-network" status, and I apparently didn't understand how insurance worked.
Insurance is an agreement between the patient and the company and ultimately the patient is responsible for knowing their benefits, and for paying for services insurance doesn't pay for. There are many different insurance plans, and many different terms to know.
What to know about your insurance
Many insurance companies have online sites where you can check your benefits. There is also a phone number on the back of your card that is useful to talk to a customer service representative with additional questions.
Where do you start? If you have a doctor you are seeing or wanting to see, look on your insurance carrier's website or call to make sure that doctor is in-network. Being in net-work may mean lower fees for you, but not always. Some doctors that are out of network may have lower fees, membership plans, concierge services, etc because they don't have to "deal" with insurance filing and paperwork.
Do you have a deductible that has to be met BEFORE your insurance will pay for care? Many insurance companies will have a deductible amount anywhere from $150 all the way to $11,000! That's a pretty wide gap to cover. You also want to know how much of your deductible has been met for the term of your policy. For many policies, the deductible "renews" every calendar year, but you might want to ask just to make sure.
1. What is my deductible?
2. How much of my deductible has been met?
3. When does my deductible renew?
Co-pays - some insurance companies will require you to pay a co-pay for appointments. Each time you see a doctor, you may be required to pay a co-pay. Some policies will "waive the deductible" for doctor's visits, meaning each time you see a doctor, you only pay your co-pay, and your deductible does not need to be met. Some policies will require you to meet your deductible first, before you only have to pay your co-pay. Some co-pays only apply to what we call E/M services (Evaluation and Management) where a person is getting examined and diagnosed, but not treated. Some co-pays will cover visits for treatment too, like chiropractic, physical therapy, etc. It's important to ask if the the co-pay only applies to certain services.
1. Do I have a co-pay? What is my co-pay amount?
2. Does my co-pay apply to office visits only, treatment, or both?
3. Is my deductible waived or do I have to meet my deductible first?
Co-insurance - some insurance companies won't have a co-pay, but a co-insurance percentage. This is where the patient is responsible for a percentage of the "contracted rate" for services. When a doctor is in-network, they have agreed to give a discount on services or to cap the cost of services, as determined by the insurance company. This is why many doctors offices don't like insurance - some of the discounts are very high. Every insurance company, will have different "contracted rates," and they may vary by region, state, or even policy. A co-insurance means a person pays a percentage of the contracted rate, like 10% or 20% and that may be before or after the deductible is met.
1. Do I have a co-insurance percent and what is it?
2. Is my deductible waived or do I have to meet my deductible first before my co-insurance applies?
Some insurance policies may have a combination of co-pay, and co-insurance. They may have a co-pay for office visits that entail an evaluation and management service, and a co-insurance for treatment, labs, diagnostic imaging, etc.
If you need help determining your coverage benefits, we are happy to do this prior to your appointment, which is also why when scheduling online, we ask for a picture of your insurance card. This way we can know what you benefits mostly likely will be when you come for your appointment. While all insurance companies state that determination of benefits and payment are made at the time a claim is submitted, we can sometimes find out information for patients before they accumulate high balances they were not expecting. You can always e-mail a picture of your insurance card, front and back, along with your date of birth, to firstname.lastname@example.org, and we can determine your benefits before your appointment.
Our goal is to not only provide meaningful and effective care for our patients, but to also care they can afford and trust. We offer care plans for individuals who may have financial difficulties, or high deductibles. Please let us know if you need assistance determining out of pocket costs, or a payment plan that works with your budget.