Frequently Asked Insurance Questions

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!

  1. 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.
  2. 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.
  3. 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. 
  4. 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*
  5. 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.
  6. 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. 
  7. 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. 
  8. 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.
  9. 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. 
  10. 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.

Understand Health Insurance and Durable Medical Equipment

Understand Your Health Insurance Bioworks is eager to help you save time and money and make optimal use of your health insurance. However, with the complexity of health insurance policies today, and the constant changes made by insurers and employers, keeping up-to-date on every policy is difficult for us. When possible, we do let you know what we know about certain carriers or policies, even when a certain product or services is not covered.

So we are encouraging you to understand the limits and requirements of your health insurance. This is critically important when you are or a family member is referred to a durable medical equipment (DME) supplier.

How Health Insurance Deals with DME

Many DME referrals require prior authorization by your insurance company, which means that your insurance company may reject the cost of the merchandise provided to you, unless they have been notified and provide approval in advance. Many carriers no longer allow you to obtain the DME before notifying them and get authorization later. Many insurances are denying these “retroactive” authorizations.

Not only do virtually all insurance companies differ in their requirements and coverage, but their policies and procedures are constantly changing. We strive to contact all insurance companies prior to you receiving your item, that way we can have your claim processed properly and the best way for you. While we try our best to keep current with developments in health insurance, you are the only person who can know everything about your particular policy at any given time and with particular treatments are equipment.

How You can Avoid Health Insurance Issues

Please review your policy and become familiar with all its requirements. Call your insurance carrier whenever you are going to the doctor or you are anticipating needing to make a DME claim. Our insurance and billing staff will be available to you as you need services and DME from Bioworks.

Some Things to Remember about the Billing Process

  • Prior Authorization does not guarantee payment.
  • If insurance tells you an item is a covered benefit, that still does not guarantee payment; insurance companies must first determine medical necessity before paying the claim.
  • Claims are not submitted until item is received (that is your bill date).
  • We must have a prescription prior to billing insurance but that does not prove medical necessity; insurance companies have their own stipulations.
  • If you claim does get denied we can offer you percentage off of your bill.
  • We will also work with you and the insurance company for any appeals that need to be done for denied claims.
  • If your claim is applied towards your deductible or co-insurance, we can not take any additional amount off of your bill.

If you have any questions, call us at 513-793-7335. Thank you!

The BIoworks Staff

photo credit:, photographer Marcelo Moura