This is a quick 5 minute read that is important for all consumers to understand when getting medical services from an office! This is a simple lesson on health insurance and medicine…
Now that it’s the New Year, PT offices, and many other medical offices have to reset all of their insurance information. With that said, Ron Pavkovich gave a great summary of this fiasco, from the point of view of a PT front office…great read, not only for PT offices, but 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 CONSIMUING 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 you 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 health care 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 your 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!
