Understanding Health Insurance Claims Process
Health Insurance Explained
The number one complaint I receive about health insurance is how confusing it is. Below are some tips to help explain the process. I will start with a brief explanation of some of the key terms.
CO-INSURANCE is often confused with co-payment. A co-payment is typically a fixed dollar amount, while the co-insurance is a percentage that you pay after the deductible has been met.
OUT OF POCKET MAXIMUM is the amount you pay before the carrier is responsible for 100% of your medical expenses. The out-of-pocket maximum is a combination of your deductible, co-pays, and co-insurance.
DEDUCTIBLE is a fixed amount you are responsible for before the carrier begins to pay their share. A higher deductible means lower health insurance premiums.
CO-PAYMENT is a fixed amount you are responsible for a particular service. Typically, a visit with the primary care physician has a lower co-pay than a visit with a specialist.
Tips to Filing a Claim
- Know Your Network.
You should have an idea before needing to use the coverage of who is in network vs out of network. While you can go out of network on a PPO plan, co-pays and deductibles are significantly higher for an out of network provider. HMO plans do not allow coverage for out of network providers. This means you are responsible for 100% of the charges.
You can keep this simple by sticking with the same medical group (i.e. Advocate, Duly Health, Northwestern Medicine, UIC, etc.).
*If treated for an emergency, ALL services are covered as in network regardless of the location*
- Know Your Plan Coverage Limits. While I do not expect you to know everything, having a general idea of your co-pays and deductible is helpful. This eliminates any surprises in the end and alleviates stress when something major occurs.
- Urgent Care vs Emergency Room. Pay attention to the location of the urgent care facilities in your area. The wait is much shorter than the emergency room AND the cost is much less. It is common to see a $1,000 copay for the emergency room vs a $40 copay for the urgent care.
- Wellness Visit vs Follow Up. While wellness visits are typically covered at no cost, if the doctor codes the visit as a follow-up, you will be responsible for the payment. The service itself is typically shorter and less involved if it treated as a wellness visit.
- Additional Charges. As a reminder, each service renders a separate bill. For example, if a service requires additional testing, it is common to receive a separate charge for each service (i.e. labs, x-rays, etc.). This is the same for hospitalization or surgery. You can expect to receive a bill for the location, the doctor’s time, and whatever additional testing was required at the time.
- Consult an agent with any questions or issues. Many assume we are alerted every time someone files a claim, but we are NOT. Your agent can help set expectations, obtain answers, and fight if need be. While we are not able to discuss your claim with the carrier (HIPAA requirement), we can help you through the process.