If you have received a bill from your doctor you will need to know certain lingo to understand what and why you are being charged $$ for.
This a small amount (typically $10-$40) that your insurance wants you to pay upfront before you get seen by a doctor. This is designed to deter / discourage excessively frequent visits to doctors that insurance may have deemed unnecessary.
This is the amount of money that insurers want members to pay before insurance kicks in and takes over the payments. This is typically high when insurers are trying to offer low monthly premiums to people that are sure they won't be needing regular care and are ready to pay up when something unexpected happens that requires hospitalization or surgery (e.g. catastrophic coverage plans or high deductible plans).
This is the percentage of the entire cost that insurance wants you to pay. Co-insurance is typically between %5-%30 and is also designed by insurance to deter / discourage expensive elective procedure that you would not have bought if you did not have insurance.
Insurance Claim Is Denied:
Very often patients change jobs or get new card at the beginning of the years and forget to notify the physicians office.
Coordination Of Benefits
Your insurance believes that you have coverage elsewhere and they are not responsible for this claim. You will need to speak with your insurance company to tell them this isn't the case.
Wrong Insurance Billed
Make sure you have supplied both front and back of your insurance card as there is a "claims address" in the back that we may not be able to guess.
Provider Is Out-Of-Network
We are in-network with almost all insurances that we accept! Please call us if you get a denial for this reason and we should be able to resolve the issues.
Free Annual Physical Exam
Most plans want to know how you are doing and encourage preventive care by offering once a year free physical examination. During this exam doctor is supposed to provide preventive service and counselling only. Scope of preventive care here includes measurements of vitals, BMI, some basic screening labs and all age appropriate preventive tests like colonoscopy and mammograms. If you have received a bill after you went in for this free annual physical exam (aka wellness checkup) most likely one of the following happened:
During the visit you had scope of care that exceeded annual preventive care visit and fitted more into a acute new problem or exacerbated chronic problem category.
You have an unusual plan that does not cover preventive care
You have presented a wrong insurance card and physicians office was unable to contact you to obtain the updated one
You have more than one insurance and there is a confusion as to which one is supposed to pay for this service (primary insurance). In this case you will be asked to contact your insurers to provide them what is called a "coordination of benefits" statement.
This is one of the "barriers to care" designed to deter the use of expensive options of care and to encourage cheaper non-inferior alternatives. This is often the case for brand name vs. generic medications and imaging tests at hospital based facilities vs. outpatient diagnostic centers. So when your services prescribed or ordered require prior authorization, its your insurer's way of saying please consider a cheaper alternative and have your doctor call us with extensive paperwork (purposefully designed to be difficult) in case such cheaper non-inferior alternatives are not tolerated or have been tried without much success.