Health Insurance: Is It Covered?

As a private practice physician, I am asked several times a day by patients if a medication, procedure or imaging study is going to be "covered" by their insurance. 

First, while we have an obligation under our participating contract to help patients to preferrably utilize participating facilities and labs, it is the patient's responsibility to read and understand the details of coverage and limitations of their insurance. 

After all, you as the patient have one insurance policy, we in the doctor's office may participate with 50-100 policies or versions and derivations of insurance policies. 

While we do have people in our practice to keep up with the myriad of contracts, there is no way for us to be completely sure that we are aware of all recent changes to your coverage. 

We do utilize various internet resources from most insurances to verify insurance and benefits, but these systems do have limitations and frequently are outdated by days to a month or two.

When I tell a patient a test is covered, it means that there is an approved diagnosis (ICD 9 code) that would properly indicate the need for the recommended surgery, procedure, medication or blood test. 

The most common reason for denial of coverage is an incorrect code being used.  Our billing forms are limited to only four ICD 9 codes; therefore, the proper code sometimes can't be used to justify the claim. In these cases, a claim can be clarified or resubmitted.

Even if a charge is "covered" does not mean it will be paid. Patients must understand and track their deductibles and copays. This is critical for you to know and understand. If you have a $1,500 deductible, and you have had not received medical care that contract year, and then you go for surgery or an MRI or other medical expense, you may have to pay the first $1,500 for that care. 

You need to read your policy closely. Deductibles may or may not apply to certain preventive care. That care may be covered at 100 percent but then your deductible is not applied, meaning that subsequent care received during that contract year will likely need to be paid in full until the deductible is satisfied.

In modern medicine, under the current mixture of private and public (Medicare and Medicaid) payors it is difficult for a doctor's office to tell you how much a particular service will cost with your insurance. Our fees are dictated by fee schedules from health insurance companies. 

Additionally, when multiple services are rendered they may or may not be bundled together. So, while there may be a standard fee schedule that we use, there are typically modifications to how much is paid and what is paid. The final determination of how much a patient owes is determined by their insurance company.

As part of most insurance contracts as well as Medicare and Medicaid, we are obligated to collect from the patient any money that the payor says that the patient owes. This determination comes on a form called an EOB, Explanation of Benefits. If we don't collect that money we have violated our contract and accepted a lower fee schedule. An insurance company that pays 80 percent of a fee can come back, declare that our fees are actually 20 percent less than the fee schedule and request reimbursement of 20 percent of what we were paid. 

In the case of Medicare and Medicaid, this can constitute fraud and the doctor could face criminal charges.  In essence, by not collecting what we are supposed to be paid by the patient we are breaking the law. 

The Office of the Inspector General, when doing a practice audit, looks for errors that result in overbilling but they also look to see that we are collecting fees from patients as directed by Medicare. So, while we would like to help patients out who are having financial difficulties, we can be facing jail time if we do.

Another common misconception is Medicare supplemental insurance. It is true that these policies help the patient by covering various medical expenses or copays not covered by Medicare. It is not true that the doctor is paid a better fee.  In fact, when a patient has a supplemental policy, we now must often time bill twice, first to Medicare and then to the supplemental company. In fact, some Medicare replacement policies try to pay doctors a lower fee than Medicare. That is why doctors frequently do not accept these policies.

In the end, while your doctor's office will try to help you resolve billing problems due to errors in billing or to obtain prior authorizations when necessary, it is, in the end, the patient's responsibility to know and understand the coverage that they have from their particular insurance policy. 

Be sure to review your coverage and keep the list of participating providers and facilities readily available and learn how to check for updated lists via your insurance company's website. 

When we refer patients for consultation, testing or surgery, it is helpful if the patient has a list of approved providers for us to select from.