Insurance and Billing
Few things about health care are more daunting than the bill. One of the more common points of confusion is receiving two bills from different sources for one test. This occurs because a service (like an X-ray) is broken down into two components:
- A facility fee to pay for the equipment and technologist to perform the test
- A professional fee for the doctor's interpretation of the test
In some settings, the facility and the doctor are separate business entities. In others, the facility is owned by the physician so there may be one comprehensive bill. It becomes more complicated if you come to the hospital for a surgery.
The figure below highlights a typical hospital bill for a surgery.
Fig. 1. Find out if your insurance carrier participates with each of these entities and how payment for the services will be covered under your policy. Do not be afraid to ask the provider and your insurance carrier in advance of a procedure. Ask your doctor to identify all professional services that might be required to assist with your care so that there are no surprises afterwards. One common scenario is one where your surgeon and hospital are covered by your insurance company, but the anesthesiologist may not be.
Deductibles, Co-pays and Provider Participation
Another point of confusion is understanding insurance coverage. Knowing your policy's coverage in advance of a procedure will help you to anticipate what portion of a bill you will be responsible for, if any. Do not hesitate to speak with your doctor's billing staff to better understand the costs you might incur for the procedure. Not every doctor (and in some cases the hospital) participates with all insurance plans. This is because the fee the insurance plan is willing to pay for certain procedures or services is less than the doctor or hospital is willing to accept. When your provider participates or "pars" with your insurance carrier your insurance coverage for the cost of the service will be greater, and you will have to pay less. Some policies require you to pay an annual deductible. Most policies require payment of a co-pay depending upon the type of service. Even if your doctor does not participate in your insurance you may still have some coverage available but you must contact the insurance carrier in advance to understand the details. When a provider does not participate in an insurance plan, typically the cost to the patient and the family is greater. The key point here is that you are ultimately responsible for the bill and must contact your insurance to verify in advance (and in writing) that they will pay for the services. Be prepared to provide them with a procedure code so that they can identify the exact procedure to be performed. The surgeon's billing office can provide this to you.
This is critically important to understand. Many insurance companies will tell you in their plan that they pay for certain services. However, they will only pay for it if they agree in advance to do so. This means that the service will need to undergo preauthorization. Typically, your doctor's office will notify your insurance company to provide them with justification for the procedure and get the authorization. However, it is ultimately your responsibility to double check that this has occurred before the procedure is done to avoid any misunderstandings.
- Review your policy to familiarize yourself with the details of your plan.
- Call member services or visit the web site of your insurance company to obtain participating providers and hospitals.
- Each of our services contains links listing participating insurance carriers you may use as a guide.
- Call your insurance carrier for coverage details to be absolutely certain about your policy coverage and get their word in writing particularly for procedures and non-routine imaging such as MRI and CT scans.