Excel is Here to Help

Rapid changes in insurance plans and provider networks make it difficult to understand what your insurance covers. As a service to all of our patients we offer FREE insurance check ups to determine the type and amount of coverage under your health plan before starting treatment. If you have questions regarding your specific coverage, please contact us. We can review and explain what type of insurance plan you have and what your coverage includes.

One thing that we frequently hear from patients is that insurance can be very confusing. Our staff works with insurance companies every day and we are frequently amazed at how insurance companies and government insurance programs administer and process claims. Most insurance plans are well-run considering they process millions of claims per year. That doesn’t matter if you are the one who doesn’t understand your benefits or can’t get a claim processed correctly. Fortunately, we are here to help. So if you don’t understand the difference between co-pays and coinsurance or don’t know your deductible from your out-of-pocket max, we hope that you will find the following information helpful.

Common Insurance Terms

HMO – Health Maintenance Organization – An insurance plan where a primary care physician directly authorizes and directs most non-emergency care. Care is limited to one network of providers. Most HMO’s have limited coverage for services provided outside of the network unless special approval is made. Co-Pays for services vary by plan and by type of service.

PPO - Preferred Provider Option – Care is directed by the patient but “in-plan” benefits are limited to a specific network of providers. Coverage for services performed by providers that are not in the network varies with each insurance plan and may range from an approximate 10 – 40% increase in coinsurance for going out-of-plan. Many PPO plans have separate out-of-plan deductibles

POS – Point of Service – Patients can seek care from any provider in the approved network, but need approval for services provided outside of the network. Coinsurance and deductibles may be higher for out of plan services.

Deductible – the amount that the patient must pay before the insurance company pays for any service.

Co Insurance – A percentage of the bill which the patient is responsible to pay. This is based on the amount of the bill and the approved amount. If you are receiving treatment from a preferred provider, the co insurance should be based on the “approved amount” (the amount that is payable based on the contract between the insurance company and the provider) not the billed amount. A typical co-insurance is 20%.

Co-pay - A set dollar amount due at each visit (i.e. $ 20 copay per visit) that the patient is responsible to pay.

Out-of-Pocket Max- After the deductible is met, the insurance pays the insured amount (80% and the patient pays 20%) up to the out of pocket max. The out-of-pocket maximum is the total of the deductible and coinsurance that must be paid before the insurance covers 100 % of the charges. This does not include non covered or unapproved services, or usual and customary payment reductions. This may range from $ 500 to
$ 10,000, depending on the plan.

Usual and Customary – Insurance companies that do not have contracts with providers will often reduce payment for services based on “usual and customary” charges from the same geographical area. The insurance company only pays what it approves as below the “customary” charge for a particular procedure. The patient is responsible for all payment of charges not paid by the insurance companies. Many patients do not understand that they can sometimes appeal these reduced payments made because of “usual and customary” reductions.

Getting the Most Our of Your Insurance Coverage

We’d like to give some general recommendations to help you get the most out of your insurance coverage. We hope that this will help you as you review your statements from us as well as your other medical providers.

1. Know Your Coverage. As you review your medical bills from any hospital, doctor, chiropractor, therapist etc, make sure that your insurance company is paying the claim correctly. Don’t assume that the provider’s office is going to alert you to errors in coverage (in some cases they may not know). Frequently those extra costs will be passed onto you. Review your insurance plan book and try to understand your coverage. Your insurance plan book is like a contract between you and your insurance company. It tells you what the insurance is responsible for paying.

2. Check Your Medical Bills – Make sure that they are accurate. If you don’t understand them, contact the billing department in the office where you received care. The bigger your bill, the more you should look for errors. Hospitals, doctors and other providers may adjust your bill if you find an error or discrepancy.

3. Appeal Denied or Reduced Payments – You can also appeal to your insurance company if they have not paid appropriately. This is where it is important to understand your coverage.