Blue Cross Blue Shield of Illinois PPO
Aetna HMO and PPO
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Understanding Your Insurance Policy
As a patient, you should be involved in your medical treatments and paying for your health care. This information will help you understand your health insurance policy and the health payment process.
Midwest Health Center's staff follows the rules of your health insurance policy. The office staff works hard to send bills on time to your health insurance company for payment so you will not have to pay for medical care covered by your health insurance. In some cases, the office staff may ask for your help when bills are sent to your health insurance company to make sure your bills are paid on time.
Frequently asked questions about health insurance and medical bills:
What is a health insurance policy?
Your health insurance policy is a contract between you and your health insurance company. It is an agreement that your insurance company will pay for covered medical care as long as your premium is paid. The health insurance company may not pay for every bill. This is why it is important for you to know which medical treatments the health insurance company will pay for and which expenses will not cover. You are responsible for paying any medical costs that the health insurance company does not pay for.
What are some common insurance terms I should know?
Be sure to check with your health insurance company to see how these terms apply to your health insurance coverage.
Co-payment or “co-pay” The part of your medical bill you must pay each time you visit the doctor. This is a pre-set fee determined by your health insurance policy.
Co-insurance The part of your bill, in addition to a co-pay, that you must pay. Co-insurance is usually a percentage of the total medical bill-- for example, 20%.
Deductible The cost you must pay for medical treatment before your health insurance company starts to pay – for example, $500 per individual or $1,500 per family. In most cases, a new deductible must be satisfied every calendar year.
Non-covered charges Costs for medical treatment that your health insurance company does not pay. You may wish to determine if your treatment is covered by your health insurance policy before you are billed for these charges by the doctor's office.
Out-of-pocket This is the cost one would pay out of their own pocket. An out of pocket expense can refer to how much the co-payment, co-insurance, or deductible is. Also, when the term annual out-of-pocket maximum is used, this is referring to how much the insured would have to pay for the whole year out of their pocket, excluding premiums.
Lifetime maximum This is the greatest amout of money the health insurance policy will pay for an entire life. Pay attention to individual lifetime maximums and family lifetime maximums as they can be different.
Exclusions The exclusions are the treatments that the insurance policy will not cover.
Pre-existing Condition This is a medical condition that someone had before obtaining the insurance policy. Some plans will cover the pre-existing conditions while others may completely exclude them, but some health insurance plans will cover pre-existing conditions after a certain time period.
Waiting Period This is the time one would have to wait until certain health insurance coverages are available.
Coordination of Benefits If the insured has available two or more sources that would cover payment for certain conditions, such as being under a spouses' insurance plan along with their own, the insurance companies would not pay double benefits. In this case the health insurance company would coordinate benefits to make sure each plan pays a portion of the service.
Grace Period This is the amount of time one has to pay their health insurance premium after the original due date and before insurance coverage would be canceled.
How is my doctor's office paid?
You should pay your co-payment and deductible, if required, during your visit to the doctor. While you are responsible for your medical treatment, your doctor's office will make every effort to seek payment from your health insurance company for the amount owed under your policy. The process by which the office seeks payment is very complicated, which is why the doctor's office needs correct information from you.
What information should I bring to the doctor's office?
Photo identification, such as a driver's license or passport
Your current health insurance card
Any change in personal information such as your name, address, and phone number
Why does the doctor's office need my personal and health insurance information to get paid?
The doctor's office staff uses this information to confirm your health insurance coverage and to send your health insurance company a request for payment of your medical bill. The health insurance company requires your personal and health insurance policy information before it will pay your bill. Be sure our staff has your current health insurance policy information, including the health insurance company name and address, policy number, group number, etc., so the health insurance can pay your medical bill on time. Much of this information may have changed since your last visit to the doctor. The services covered by your health insurer may also have changed. That is why many doctor's offices require you to provide this information at each visit.
What if the health insurance company does not pay or pays only a portion of my medical bill?
As a courtesy to you, the doctor's office staff will contact the health insurance company to ask why the medical bill was not paid. The health insurance company may ask the doctor's staff to appeal or re-send the medical bill with more information. This typically happens when the health insurance company has not paid for a procedure or service listed on your bill even if your doctor said it was medically necessary. You may receive a copy of your doctor's appeal letter to your health insurance company.
The doctor would like your help to get the medical bill paid when your health insurance company does not pay. You may be asked to call your health insurance company or your employer to ask why your medical bill has not been paid.
What are some common reasons a health insurance company may not pay for medical treatment?
Services were provided for a pre-existing condition. Most health insurance companies will not cover treatment for medical conditions you had before obtaining coverage through the health insurance company. Your health insurance policy should discuss pre-existing conditions in more detail.
Medical treatment provided to you is not covered by your health insurance policy
A coordination of benefits form or other required health insurance forms were not completed by you
The health insurance premium has not been paid, either by you or by your employer
A spouse, child, and/or newborn is not covered by your health insurance, since he or she was not added to the policy
The doctor is “out-of-network,” which means your doctor does not have a contract or agreement with your health insurance company. If your doctor refers you to another doctor, be aware that if the referred doctor is “out-of-network” you may be responsible for a portion of the payment
Another health insurance policy requirement, such as obtaining prior approval for your medical treatment, was not followed.
Questions to ask your insurance provider:
Does the plan cover wellness visits? Some plans do not cover any well care visits or cover them only for specific ages. Plans may also have an annual or life time maximum amount that will be paid towards the well care visits.
Are there restrictions on vaccine coverage? Some plans only cover certain vaccines, for certain ages, or may have a maximum annual limit for vaccine coverage.
How often are wellness visits covered? Some plans require a full 365 days between each visit.
Does the plan cover (or limit) sick visits?
What co-pay, deductibles, and co-insurance amounts does the plan require for wellness visits and sick visits? Are deductibles per person or for the entire family?
What coverage does the plan have for in-office lab work? Not all in-office labs are covered 100% and/or may be applied towards your deductible and coinsurance.
What coverage does the plan provide for emergency and urgent care visits?
Does the plan require a referral to cover a visit with a specialist?
What hospitals are covered by the plan?
Annual Physicals and Sick Visits at the Same Time
An annual physical exam is when a healthy patient is seen to screen for various illnesses and diseases; this is considered to be preventative medicine.
A problem visit is one where the patient has a specific concern, symptom, or complaint.
We are required to submit claims based on services you receive. If we provide both a physical and a problem visit exam on the same day, then both services should be billed. Depending on your insurance coverage, some or all of the cost may have to be billed to the patient. Your insurance company may cover well and sick visits differently, and it is very important that you familiarize yourself with the details of your insurance coverage. Regardless of whether there is no charge for the well visit (some insurance companies cover the annual physical 100%), you will be responsible for any charges passed on to you for the sick visit portion. We recommend you contact your insurance carrier prior to each visit and enquire about the type of benefits you have. Once a claim has been submitted to your insurance carrier, the office will not change the coding in order to circumvent an insurance denial, as this may be considered insurance fraud.
Well Woman (Preventative) and Problem-Focused Exams at the Same Time
A well woman exam is when a healthy patient is seen to screen for various illnesses and diseases (including breast and pelvic exam, Pap smear and STD screening); this is considered preventative medicine. A problem visit is one where the patient has a specific concern, symptom, or complaint. We are required to submit claims based on the services you receive. If we provide both a well woman and a problem focused exam than both serviced may be billed. Depending on your insurance coverage, some or all of the cost may be billed to the patient. We recommend you contact your insurance carrier prior to each visit and inquire about the types of benefits you have. Once a claim has been submitted to your insurance carrier, the office will not change coding in order to circumvent an insurance denital as this may be considered insurance fraud.
Bills from Laboratories, Hospitals, and Other Healthcare Providers:
If your medical care requires a pap smear, blood work, a culture or biopsy, the specimen is generally sent to an outside laboratory for analysis. When this occurs you may receive a separate bill from that laboratory. Any questions relating to those bills cannot be answered by this office and will need to be directed to the billing entity.