A Patient’s Guide to Understanding Health Insurance Coverage and Payment Practices
What is a health insurance policy?
A contract between you and your health insurance company.
Outlines services they will and will not cover. It is important for you to know which medical treatments your insurance plan covers.
Requires you to pay for certain out-of-pocket expenses (e.g., co-pays, co-insurance and/or deductible).
How is the doctor’s office paid?
Your insurance plan requires us to collect any amounts you owe at the time of service, such as co-pays, coinsurance, deductibles, and non-covered services.
We submit a claim to your insurance company seeking payment for your treatment.
Your insurance plan pays us at a contracted rate, minus your financial responsibility for the covered services provided.
You pay for any remaining balance, such as services not covered by the plan.
Doesn’t the doctor’s office determine ahead of time what my insurance covers?
We perform a “verification of eligibility” prior to your visit.
Your insurance company only provides limited information.
Typically, we can verify if the policy is current and what your financial responsibilities are, such as co-pay, coinsurance, and/or deductible.
You are responsible for paying amounts your health insurance plan has assigned as your financial responsibility.
What if my health insurance company does not pay, or pays only a portion of my bill?
You are responsible for paying amounts your health insurance plan does not cover.
You should receive an explanation of benefits (EOB) from your insurance company explaining how they determined what to pay.
As a courtesy to you, we may contact your health insurance company or re-send the claim with more information.
This typically happens when the health insurance company has not paid for a procedure even if your doctor has said it was medically necessary.
You may be required to call your insurer or employer to update some information, such as your physician choice or dependent information.
What are some common reasons a health insurance company may not pay for treatment?
In the course of a physical/well/preventive visit, you may be treated for a separate problem.
Dependent upon your benefits, your insurance plan may require that you pay additional charges for the added service rendered.
The particular medical treatment provided is not covered by your health insurance policy, or it was a pre-existing condition.
You did not provide the health insurance company with information or forms it requires.
A spouse or child is not covered by the health insurance plan, or was not added to the policy.
The doctor is “out of network,” which meanswe do not have a participation contract with your health insurance company.
A health insurance policy protocol was not followed, such as the responsibility to obtain a referral or prior authorization.
Are there times I might pay extra for my visit?
If during a physical/well exam the doctor treats a new or existing problem, your insurance plan may require an additional co-pay, coinsurance, or deductible payment.
Your insurance benefits may have a limit on the coverage of wellness benefits (e.g., physicals).
Your insurance plan may not cover physicals or wellness benefits (know your benefits!).
Your financial obligations may vary between types of services (well vs. sick visit).
You are responsible for paying for non-covered services and your financial portion as determined by your health insurance company.
What information should I bring to the doctor’s office?
Photo identification, such as a driver’s license.
Your current health insurance card.
Any changes in personal information such as name, address, phone number, or insurance.
Payment for your insurance plan’s cost share
Helpful tip: plans may change from one year to the next, so be sure to review your benefit coverage as well as changes in co-pays, coinsurance, or deductibles at the start of a new contract period.