Insurance Tips Part II (Or how I am a really carefree person)
Real talk: I hate talking about money. I have a lot of anxiety tied up in how much things cost and how much I can spend. My least favorite thing is to go into a store that doesn't have prices clearly marked on every item. I typically avoid going to restaurants if prices aren't listed on their online menu. I also struggle with talking on the phone. I love meeting and connecting with people, but I feel like I can't fulfill all of my people-pleasing tendencies if I can't see how my comments are hitting. So you can imagine that talking to insurance companies and hospital billing departments on the phone ranks right up there with getting a root canal on my list of things I want to do in a day.
Just in case I'm not alone in this, here is the script I used to get the information I needed from the insurance company
Me: Hi, My name is Krystyna and I am looking for some information regarding my insurance policy.
Them: What is your policy number? Who is the account holder? What is his or her date of birth?
The policy number is also your "ID number" that is on your insurance card. They will use the information you give them to look up your policy.
Them: How can I help you?
Me: I need to have a pelvic MRI with contrast, CPT code 72196. Is that covered by my insurance?
Them: It is covered at a 20% coinsurance after a $500 deductible.**
This means that after I pay $500, I have to pay 20% of the contracted rate of the MRI.
The insurance company could also say, "It is covered at 80%" which means the same thing - they pay 80% of the contracted rate, leaving me to pay the remaining 20%.
Me: How much is remaining on my deductible?
The deductible is how much of the $500 dollars I have left to pay before the coinsurance kicks in.
Them: $500
Me: What is my out of pocket max?
Them: $6,350, and after that services are covered at 100%
This means that throughout the plan year, after I spend $6,350, care will be free (covered at 100%)
Me: Do I need a referral or pre-authorization?***
Them: No
In the case of an MRI you will pretty much always have a referral - it's a note from a physician ordering the procedure. If you want something like physical therapy, for example, you need to know if you need a referral because it will tell you if your insurance company will pay for services without you needing to make an extra appointment to see an MD first.
Pre-authorization (or pre-auth) can be required from insurance companies, basically telling them exactly what is going to happen and the insurance company allotting money for it ahead of time. If you need pre-auth and don't get it, your insurance company can deny payment, which is why you have to ask.
Here is part I of the Insurance Tips Series with more explanation of some of these terms.
**Your insurance company only knows what is remaining on your deductible when it gets billed through. So if you have had recent care and paid any amount of money for it, they may not know what you've spent because of the delay in processing time. With that said, it is possible to overpay an insurance company, and it is a real pain to get money back from them.
***Pre-auth is performed by the provider/billing department performing the procedure, so you might wonder why you need to know. Medical billing is performed by people - people wanting to get paid and people who want to pay as little as possible, and regardless of which camp they fall into, mistakes get made all. the. time. It is easiest to avoid mistakes being made at your expense if you speak the same language and know the code.
Recap:
Getting Information From Your Insurance Company About Your Policy Steps:
Gather Relevant Information
You need your name, your policy number or ID number, the name and date of birth of the account holder, and the procedure or service you are looking to get information about - Physical Therapy, MRI, Surgery, etc.
Ask if the service is covered
Find out how much is remaining on your deductible and out of pocket max
They should give you or you should ask about a deductible, Coinsurance, Copay, and Out of Pocket Max
Ask if you have any out of network benefits
This will allow you to be more flexible with choosing your provider
Ask if you need a prescription or referral, or if you need pre-authorization