Insurance 101

Please make sure whoever is bringing the patient has the most up-to-date insurance information with them!  Outdated insurance information result in claims not being submitted to the correct insurer or under the correct subscriber ID, which results in the charges being defaulted to the patient's responsibility if corrected information is not received within a certain amount of time after the date of service.

Health insurance companies have tremendously complicated the landscape of healthcare costs.  Oftentimes, due to this complexity, we face billing issues due to misunderstanding of what the insurer will cover, what they will pay for, and what they want the patient/member to pay for.  Here, we are going to attempt to summarize all the individual components.

Covered vs Noncovered Services

​​These services are specifically listed in the member's contract but the insurer may still choose to pass up to the entire adjusted charge of the service through to member responsibility

The insurer considers these as specifically excluded; oftentimes they will absolve the member of all financial responsibility associated with these services, and the office has to write off the cost involved in providing these services

It can sometimes be tricky to distinguish whether a service is completely not covered by your insurer or whether they pass on the entire cost to you.  Just because a service is covered doesn't mean that the insurer will pay the entire cost.  If you examine the EOB and find that the insurer has made some kind of adjustment to the initial charge, that usually means that it is covered but still considered the member's responsibility.

 

Even within the same Insurer, every member's specific plan can differ regarding whether specific services are covered.

Copay vs Deductible vs Coinsurance

  • A flat fee you pay whenever you receive healthcare services
  • Applies whether or not deductible has been reached
  • Specific to your plan
  • The amount of money you pay before the insurer starts covering the cost of medical expenses
  • Resets every year
  • The percentage of your medical costs that you actually have to pay
  • Only applies after you hit your deductible
  • Specific to your plan

In the case of divorced parents, we respectfully ask that the parent bringing the child be ready to pay the copay or whatever balance may be on the account at the time of the visit.  We understand that there may be different allocations as delineated by the custody agreement, but the time spent to track down the other parent to pay their allotted portion takes away from the time available for more vital tasks for running the office.  A receipt can be provided so that it can be submitted to the other parent's attorney for reimbursement. 

Primary vs Secondary Insurance

Applicable if the patient is covered under multiple insurance plans, such as each parent's, or if there the patient is covered by a commercial plan and a government-sponsored plan, such as Medicaid or Tricare

The claim for the medical services are initially sent to the primary insurance

 

"The Birthday Rule"

The policy of the parent whose birthday happens first in the year is the primary insurance for the child, regardless of which parent is older and which policy might have more coverage.  If the parents are divorced and only one parent has custody, that parent's policy is the primary insurance

Once your primary insurance has paid its share according to the specifics of that contract, the remaining bill goes to your secondary insurance

 

Medicaid and Tricare are always secondary insurances

Each plan still will only cover up to its plan limits.  After the secondary insurance has paid its share, you may still be responsible for any remaining amount that wasn't covered.  It is still possible to have leftover out-of-pocket medical costs even if a patient is covered under multiple policies. 

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© Renee L. Cevey, M.D., P.A.

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