By Medical Bill & Claim Resolution (MBCR) | Submitted On October 13, 2015
It's important to understand what kind of health insurance you have. The most common types include:
Exclusive Provider Organization (EPO)
A Health Maintenance Organization (HMO)
Point of Service (POS)
A Preferred Provider Organization (PPO)
An HMO limits coverage to treatment from doctors under contract to the HMO. Out-of-network care is usually not covered except for an emergency. The EPO is very similar.
Users pay less if doctors and hospitals are in the network with a POS plan but referrals are required from the primary care doctor to see a specialist.
A PPO is similar to a POS. User pay less with an in-network provider and can use providers outside the network without a referral but will pay more.
Medicare and Medicaid are government run programs. Medicare's polices operate the same in all states because policies are set at the federal level. Medicaid is for low-income Americans and it operates differently in each state.
There are also different type of catastrophic plans too.
Deductibles, Co-pays, Co-insurance and Out-of Network Know your deductible, co-insurance and co-pay structure because this directly relates to what you will pay.
Deductibles: Deductibles refer to the amount of money you pay each year before the insurance even kicks in to help pay your medical bills. It may be something like $2,500 for individuals and $5,000 for your family.
Co-pays: This is a flat fee paid to your provider on each visit usually after the deductible is met. It may be something like $25.00.
Co-insurance: The percentage of charges you will owe to your medical provider after the yearly deductible is met and the insurance has started paying on the claims. This is expressed in a percentage. For example: Your insurance will pay 80% of your doctor's bill while you owe 20%.
In-Network vs. Out-of-Network: You might pay more for out-of-network healthcare professionals. This means if you are treated in a facility, group practice or individual healthcare professional who does not hold a contract and or a participating provider with your specific plan, your benefits are reduced or services may not be covered at all.
If you will be having surgery or extensive medical treatment, obtain a list of anyone who could be involved in your treatment from the billing office and check with your provider to see if they are covered. If they are not and cannot be switched with another provider, know in advance what they will charge.
Be aware as well, your plan may have an in-network AND out-of-network deductible, co-pay, and co-insurance. It is the out-of-network bills that typically result in sticker shock to consumers. Arming yourself with your plan benefits ahead of medical treatment will save you money and frustration. Best practice is to become your own best advocate by initiating expected financial obligation discussions with your healthcare provider.
And remember, health insurance in general is complex. Everything differs from plan to plan and even from year to year.
MBCR understands the challenges in receiving a medical bill and successfully resolving a health insurance claim issue. Learn more at www.medicalbillandclaimresolution.com.