With these uncertain times when it comes to health insurance, there are always questions about cost and coverage. We want to know: how much am I going to have to pay for a particular service? This is a very valid question. I have compiled popular questions (with answers) that I have had patients ask me in regards to their insurance. I hope these answers will help you!
- WHAT IS A DEDUCTIBLE? You’re deductible is the amount you have to pay before insurance will start paying their portion (I have seen deductibles range from $0 to $5,000 per person). Once you have accumulated your deductible, then usually your co-insurance kicks in.
- WHAT IS CO-INSURANCE? Co-insurance is the percentage that insurance will pay once your deductible has been met. The most common amounts I have seen are 80% insurance responsibility, 20% patient and 90% insurance responsibility and 10% patient.This of course varies insurance to insurance and plan to plan. Co-insurance usually does not apply once the out of pocket max has been met.
- WHAT IS OUT OF POCKET MAX? The out of pocket max, is the maximum amount that you pay for the plan year (usually January 1 to December 31). Once this is accumulated then insurances usually pay 100% of expenses as long as it is medically necessary. Usually the out of pocket includes the deductible amount and the co-insurance you have been paying.
- WHAT IS AN AUTHORIZATION? Some of our items do require, what is called an authorization. This is just letting the insurance know that a particular brace or product has been prescribed for you and that we (Bioworks) are going to be the providers. The insurance then just makes sure it is a covered benefit under your plan. Most insurances require us to obtain authorization prior to services being rendered. There are some instances that a brace is needed right away and we can try to obtain authorization after the fact.*Note that authorization does not guarantee payment, it just determines that it is a covered benefit; the claim still needs to go through medical review*
- MY INSURANCE SAID MY SERVICE WAS COVERED, WHY WAS MY CLAIM DENIED? Claims can be denied even if the item is a covered benefit because the insurance processes it under their medical review. For example you may be prescribed a custom ankle brace from your doctor and that particular code is covered under your plan, but after medical review, insurance may find that for your particular diagnosis, a custom ankle brace is not warranted.
- I HAD A PRESCRIPTION, WHY WAS MY CLAIM DENIED? Same reasoning as above, just because a physician prescribes a brace does not guarantee an insurance deems it medically necessary; it is all based on the plan stipulations.
- IS THE PRICE YOU BILL, THE PRICE I PAY? The price that is on your paperwork is not the price you pay. We have our costs based on all the different insurance allowables. This amount allows for any contractual write-offs we have with the insurance companies. Unfortunately every single insurance and plan are different, so we are unable to give you an exact amount but may be able to guess for you. Just know that is not the price you are paying. The price also includes any adjustments/office visits needed for that particular brace or product. Typically it is a one-time charge, unless anything extra is needed.
- ARE THERE DISCOUNTS FOR NON-COVERED SERVICES? We understand that not all of our services are covered under insurances. We have been able to pin point some insurances that we know do not cover particular services and yes we can give a self pay discount. This does vary based on product but we can always bill insurance, if you like, and see if they will cover; if not we can take a percentage off.
- DO I NEED A PRESCRIPTION? We legally need a prescription in order to bill insurance; this also gives us direction as to what your physician is wanting. But keep in mind that having the prescription does not dictate medical necessity/covered service, just gives us the right to bill insurance.
- WHAT CAN I DO IF MY CLAIM IS DENIED? You have the right to appeal any decision made by the insurance. We are here to assist in any way for the appeal.
Things to Remember!
Prior Authorization does not guarantee payment.
Covered benefits does not equal payment; always based on medical necessity.
Prescription is needed in order to bill insurance.
If claim is denied we can take a percentage off of your bill.
If claim is applied towards deductible/co-insurance we can not apply anymore discount.