Know Your Insurance

Know Your Insurance

What do you know about your medical insurance? What services does your insurance cover? What does “patient’s responsibility” actually mean? How can you better understand your policy? Will medical offices check your benefits for you? T.O.P.S. is here to answer all these insurance questions and more!

We know that no one plans to get sick or hurt, but there comes a time that everyone needs medical care at some point. Health insurance and coverage seems to be a sensitive topic today, so we wanted to provide you all with a quick read that is important for all consumers to understand when getting medical services from ANY OFFICE! Consider this as a simple lesson on health insurance and medicine…

Do you know your plan?

Did you know… you can easily check online or make a phone call to the number on the back of your insurance card to learn more information about your specific plan??  Take the time to check what type of plan you have during open enrollment aka prior to committing to the insurance! Find out what type of policy you have, check to see if you have: premiums, deductibles, copays and in/out of network benefit details, and etc. (Here a quick breakdown of what that means:  Premium- the amount paid monthly for health insurance, Deductible- the money that is paid out of pocket before coverage starts, Coinsurance- the percentage you will need to pay after the deductible is met, Co-pay- a flat payment for medical services, In-Network- doctors and medical office that are covered in the insurance plan, Out- of-Network- Doctors/ medical office that are NOT covered)

Do medical offices verify your coverage?

At T.O.P.S. Physical Therapy, as a courtesy, we verify insurance benefits for physical therapy for all new and past patients. (NOT ALL MEDICAL OFFICES WILL DO THIS FOR YOU).

Regardless of whether offices check your insurance benefits for you or not, you should really know all parts of your plan to make sure that it can be used to it fullest. Knowing your plan allows you to see what you like/don’t like. If you don’t currently like something about your plan, keep that in mind when you go to back to open enrollment to choose your plan for 2019. You should pick a plan that best fits the needs of family/yourself.  If your someone with a pre-existing condition, you might want to consider a plan with a high premium and low-deductible. If you’re a healthy family/individual, then a low premium with a high-deductible. One thing to always keep in mind is that insurance is an investment and if you don’t know what your signing up for, how do you know if it can really help with your needs?

If you know your insurance plan start here!

For those of you who know your plan, you already know and dread this time of year because you know your plan has to RESET! Which means that when you visit TOPS Physical Therapy, or other medical offices, you are most likely going to have some out-of-pocket costs.

With that said, we saw an interesting post by, Dr. Ron Pavkovich. He gave a great summary of the fiasco that patients and offices go through when this reset happens. He wanted to share and give the point of view of a PT front office… It is a great read, for consumers, PT offices, and ANY medical office!

For those who don’t know, you, the patient, is ultimately responsible for knowing and understanding your benefits for medical care. The patient has the responsibility of knowing their plan, what is, and is not covered. As a courtesy, physical therapy and medical offices verify your benefits and explain them to you in a “language” that you can better understand. This courtesy of checking benefits is a relatively COST CONSUMING gesture on their part. It is also ALWAYS an estimate. With that said, it is your choice and responsibility to either check your own benefits or know your plan. If your insurance does not pay for the services or care you received, it is still your responsibility at the end of the day. This is why you sign your initial paperwork advising that you understand and agree to pay for the services provided, in the scenario that your insurance does not pay.

If you have had a service performed, it is not the PT or MD office’s fault that your insurance did not pay. Therefore, you cannot, and should not, expect that office to not collect for services rendered and treat you for free.

This is a simple education lesson on health insurance and medicine. Please do not blame your provider for you not knowing what your plan does and does not cover. Your provider’s office is simply the messenger and doing you a courtesy by trying to help you understand the type of coverage you have. At the end of the day, your provider does not make these insurance policies nor do they have a say in what is paid for. Also, please keep in mind that your provider is likely only getting reimbursed about 40% of what they bill your insurance carrier. Insurance carriers are killing medicine!

Another point made is that often the PT or MD offices are responsible for pre-certifications. If the office is “in-network”, the office is obligated to write off some procedures, which are oftentimes beneficial.
Furthermore, if you provide insurance information that has lapsed after the first of the month, that carrier isn’t liable for payment! Good luck collecting or getting backdated approval from whatever carrier, if any, succeeds the lapsed carrier. And TPA’s will not backdate authorizations until you can prove they were wrong with processing it the first time. So in other words, they can allow for their mistakes, but never yours.

This becomes particularly frustrating for small private practices. They bill everyone the same, yet they generally are not able to negotiate with insurance companies, as they have no leverage. Thus, they have to either take what they pay (usually around $0.40 of every $1 billed) or not participate as in-network. They then approve the full rate, but pass it to the patient as an out-of-network cost. Most small private practices will offer anyone who pays day of service, a discount (and if insurance paid day of service, they would get it too). So, anyone is welcome to see the prices, but insurances can change what they pay on a whim, so that is more difficult to keep up with.

This is an issue in our healthcare system that tends to be heated and followed with a lot controversy. Some responses we have had about this topic are:

  • Insurance anymore is only catastrophic Insurance at best. The deductibles are crazy and you’re 100% right about it killing medicine.
  • The mouse print on our patient delivery confirmation is extensive and has expanded to include all these points. Most folks have no clue how their insurance works. I have to explain regularly that office visits to their doctor and prescriptions don’t generally apply to deductibles.
  • I agree and fully understand your point. When will I be able to pay my doctors the same price for a service that they accept from insurance companies?
  • I agree the patient is ultimately responsible to know their benefits but we all live in the real world and that usually never happens. Protect yourselves and document, document and document some more!

If you do not like your coverage… Make a change for 2019!

Now is the time of year to start talking with your employer and see what other health insurance options exist for you. Do some research on your end and think about what medical services you will need for the upcoming year. Call around and see if your doctors offices take the various insurances your employer offers and which one gives you the most coverage at the offices you visit the most. Do your homework!