The Insurance Dilemma goes On… and On… and On!

During the last few years' we have seen a vast change of the choices now offered to patients. It is no wonder that patients seek our practice assistance in deciphering covered versus non-covered services. Where can a patient go for care? What kind of care is covered by my plan? What will my out-of-pocket fees total?

This brief article is written as a description of insurance terminology. It is not intended to sell or direct you, the patient, to choose one insurance company over another. Always read your plan documents carefully and get clarification by contacting your member service department for explanation and benefits.

Types of Insurance Coverage

Primary Insurance carriers are responsible for first payment on a submitted claim. Per Arizona Statute, any 'clean' claim (a claim submitted without any errors), sent by your physicians' office must be responded to within 30 days. During this time, your insurance can pay, deny the claim, or request additional information.

Secondary Insurance carriers or a supplemental insurance policy; is responsible for paying any remaining balance after the primary insurance carrier has responded to a claim. Some secondary insurance carry high deductibles and may not pay the remaining balance. A patient needs to have full knowledge of any out-of-pocket expenses.

The Birthday Rule is used in Arizona to determine whose insurance is primary between working spouses. The person's birthday that is the earliest date in a year becomes primary.

Medicare is a health insurance program administered by the United States government and cover people who are either age 65 and over, or who meet other special criteria. Medicare covers only allowed necessary medical expenses. Any routine care such as a routine eye examination without a medical diagnosis is not a covered benefit. For additional information on covered services, please visit Medicare's website.

Medicare Advantage Plans or assigned plans are insurance carriers who have a plan to allow Medicare eligible persons, to assign their government Medicare health insurance to a private health insurance carrier. Insurance carriers who offer these plans have numerous options with some covering routine care. In almost all advantage plans, the patient will need to obtain a referral from the primary care physician and will have out-of-pocket copays.

AHCCCS stands for Arizona Health Care Cost Containment System, and are plans in Arizona equivalent of Medicaid in other parts of the country. To be eligible for AHCCCS there are eligibility and qualifying requirements. As a general rule, routine medical care for anyone over the age of 18 is not covered. Most AHCCCS plans have a minimal or no out-of-pocket expense to the patient.

In addition to the above many insurance carriers, carry HMO's, PPO's, POS's, and HSA's.

Our professional staff is ready and educated to assist you in explaining the basics.

What will I pay?

There are many areas in your insurance plan that could cost you out-of-pocket monies. Besides your premiums (paid by the month, quarterly, semi-annual, or annual), you may also have one or all of the following:

Deductible is a set dollar amount specified by your insurance carrier that will be your responsibility. This amount must be paid by you before a claim for service is paid by the insurance company.
Example: Medicare during 2007 has a $131 annual deductible for Part B medical claims. Until this amount has been satisfied by the patient, no other benefits will be paid. The general reason for individual deductibles is to help lower the insured's monthly premiums. Usually the higher the deductible = the lower the premium.

Copay - A dollar amount the insured is expected to pay for a medical service at the time of visit. Copays usually range between $0-$50 per office visit.

Coinsurance - Sharing costs between what the insurance company and the patient will pay. Typically, a coinsurance of 80%/20% means the insurance company will pay 80% of the allowable charges and the patient will be responsible for paying 20%.

Refraction is primarily used for a patient requiring a new prescription for eyeglasses. However, it also assists the physician to determine if a change in your vision is due to a medical disease that needs further exploration. The fee for having a refraction may not be covered by your insurance carrier if you do not have routine covered benefits. Our staff is happy to assist you in determining if this is a covered service.

Other Terminology

Pre-Existing Conditions are a medical diagnosis or condition that was previously diagnosed prior to joining a healthcare plan. Under the new HIPAA regulations if you are insured 12 months or more prior to joining a new insurance plan then pre-existing conditions do not apply. If you have not been insured for the previous 12 months with another insurance before joining a new plan then the patient may have a waiting period of usually between 1-3 years before any payments will be made. Sometimes pre-existing conditions may never be covered; please check with your new insurance carrier for their specific regulations.

Assignment of Benefit(s) is if the patient requests the insurance carrier to make payment directly to the healthcare provider for service or supplies. The balance of any amounts not paid is your responsibility.

ABN, better known as an Advanced Beneficiary Notification is a form stating that the services to be performed may not be covered by Medicare. This form is informing the patient prior to having a service of the charges and expected cost to the patient.

I hope the information in this article has helped in understanding some of the primary elements of insurance. Please contact Terry at extension 107 or Amanda at extension 108 in the Tucson billing office for assistance with your insurance benefits, billing, or general questions.

- Robin Buscemi: Practice Administrator
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