I have been billing chiropractic claims for 4 years at Source Health Center. I am here to talk all about my knowledge with you so that you can understand your insurance just a bit better. As we all know, insurance can be frustrating and hard to understand. I am here to walk you through it so hopefully it makes a little bit more sense.
Let’s start with some basic verbiage that most insurance companies and physician offices use.
In-Network Provider: This means that the provider you are seeing for treatment has a signed contract with your insurance company. That contract states a set of rates that your provider can bill for treatment. And each provider you see for treatment can have a different contract with different rates from different insurance companies.
Out-Of-Network Provider: This means that the provider is not contracted with your insurance. They can still bill your insurance usually, but that means that your cost for treatment might go up. This is because the provider can bill you the full charge they bill every other insurance company, but they do not have a contract stating they can only bill x amount of dollars and therefore have to write off the rest of the charge.
Plan: This is the plan that you as an individual or your company allows you to pick from to choose your benefit level with a specific insurance company. This means you have to take a look at different plans offered to find what is best for you. If you have questions about this you can ask your HR department for clarification on which plan is best.
Member ID Number: This is a specific identification number associated with your name and information with your insurance. This is the primary number provided to your providers to verify your benefits.
Group Number: This is the specific group that your insurance plan is a part of. There are many different group numbers for different plans associated with insurance companies.
Patient Responsibility: This is the rate or total cost a patient must pay for their treatment. This rate or cost can change depending on the type of service you are getting treatment for.
Co-Payment (Co-pay): This is a set dollar amount that your insurance plan requires you, as the patient, to pay for your treatment.
Co-Insurance: This is a percentage rate that your insurance plan requires you, as the patient, to pay for your treatment.
Deductible: This is a set dollar amount for an individual, family, or both that has to be met before your insurance will provide coverage. Meaning you have to pay the amount stated as your deductible all out-of-pocket, from your own wallet, before your insurance will pay anything towards your treatment.
Annual Limit: This is a limit that your insurance plan can have on certain treatments you get. This could be a limit of visits for the year or a limit of a dollar amount.
Out-of-Pocket Max: This is a set value that your insurance says that if you pay x amount of dollars out of your own pocket expense, before your limit has been reached and before the end of your calendar year coverage, your insurance will pay 100% of your treatment costs.
Benefits: This is another word for coverage under your plan. This is the details of your co-pay, co-insurance, deductible, limits, and out-of-pocket max that is specific to your insurance plan.
HSA/HRA/FSA: These are cards that you can use that are provided to you, if you qualify for them, that help pay for your out-of-pocket medical costs. Each one is a little different and you can ask your HR department more questions about these cards.
EOB (Explanation of Benefits): This is a piece of paper that shows the full payment details from your insurance. It shows your patient responsibility, what your insurance paid, and what the provider must write off. *You as a patient will receive your own EOB with the explanation of coverage.
How billing insurance typically works:
When a patient comes in for treatment, the physician is providing adjustments and services. Those adjustments and services are then posted as a charge that is then billed to insurance. When a patient comes up to pay at the end of their visit, our system will calculate the patient responsibility required based on your own insurance coverage.
You would pay your patient responsibility amount and the remainder of the charged amount gets billed to your insurance. *Keep in mind that what we find out from your insurance is never a guarantee of payment. We bill your insurance and will let you know if there are any changes.
An average turn around from when we would hear from your insurance is about 2-4 weeks. We receive an EOB that shows us what was paid and what is your responsibility. If there are any differences from what we charged you when you were in for your treatment visit and what the EOB says, we will discuss it with you.
What if there are errors with billing?:
There can be errors that happen while billing. Some are easy fixes and others take more time to try and fix. Some examples of errors that can happen are:
- There was a mis-communication with your insurance company based on their records.
- We do not have the proper patient demographic information. This includes your legal name, mailing address, and date of birth.
- We have the incorrect insurance information. This could be the wrong member ID number or group number.
- If you have changed insurance companies without notifying us and we have billed the wrong insurance.
- We are missing diagnosis codes that correlate with your charges.
- We are missing code modifiers. These are additions to codes or charges that point to specific details about your treatment.
- Your insurance required a pre-authorization and one was not completed for you.
There are some errors we would have to contact you about, but most of the time, the errors are for the medical biller to handle with the provider to be able to re-bill your insurance with the proper codes.
When there are errors and we need to re-bill your insurance, it will take longer to hear back in regards to your patient responsibility and for us, as an office, to get paid. This is because it can take that average of 2-4 weeks to hear back after each re-bill that might need to happen.
Notes for patients:
- We encourage all our patients to understand their benefits before seeking treatment for a particular service. That way there are less surprises and you will feel like you have a better handle on your own care and treatment. There is a customer service number on the back of your insurance card that can help you talk with your insurance company.
- We understand that insurance is frustrating to understand at times, but we are doing our best to help you so you can use those benefits for services. So, sometimes patience with our billing staff is key in order to figure out a solution.
- There are some questions you may ask about your insurance that we ourselves may not know the answer to. Please allow us time to be able to find the correct answer to your question, even if it wasn’t the answer you were expecting.
Cheat Sheet for who to ask certain questions:
- Questions about your plan choice or HSA/FSA/HRA cards?
- Speak with your HR department at work.
- Questions about your benefits or other services covered under your plan?
- Speak with your insurance company.
- Questions about the cost of treatment you received or errors with billing at the same facility you sought treatment at?
- Speak with the billing department at the physician office you got treatment at.