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    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

    1. 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*

     

    1. 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.

     

    1. 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.

     

    1. 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.

     

    1. 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.

     

    1. 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.

    What to Consider When Filing a Claim

    Whether we want to admit it or not, accidents do happen, and you should know what to do in the event of a claim. Many people react at the first site and immediately file the claim. Only to be aggravated later when the claim is not covered, or the claim does not outweigh the deductible. What you may not realize, once you file a claim (whether the carrier pays out or not), the claim will remain on your record for 5 years. While the impact is not huge for a $0 claim, it can affect your rate with a new carrier or the new carrier could deny coverage due to the number of $0 claims.

    1. Assess the damage.
    Home: Walk the property and take pictures of the damage.
    Auto: Walk around the car, be sure to look underneath the vehicle and take pictures. It is important to take pictures of both vehicles, the location of the accident, etc. Often the police will not come out for a minor accident. You need to have evidence to determine which driver is at fault.
    If the police do not indicate fault on a report, it is up to the insurance carrier to determine fault. This becomes your word against the other driver!

    2. Swap information *This is only related to an auto claim*
    Get the other driver’s name, phone number, and picture of their insurance card. This is helpful during the claims process. If the other driver is at fault, file the claim with their company. If you are not at fault and you file with your own, you will pay your deductible. You will get this back, however it can take MONTHS if the other driver has a substandard carrier.

    3. Know your deductible!! It only adds more time to your repair if you file the claim, wait for the adjuster to come out and obtain your assessment only to find out the damage is less than your deductible. It also means the claim will be on your record for 5 years.

    4. Contact service professionals for a bid to determine if the damage outweighs your deductible. Do your homework. If the claim is less than your deductible and the claim is filed with the carrier, it will be on your record for 5 years. I have had clients denied coverage by other carriers due to too many small claims.

    5. Mitigate the damage. Once pictures have been taken it is safe to clean up the area. You want to do this so the damage does not become worse.

    6. Consult your 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.

    *Please note, this is only for small claims. If it is a large claim (i.e. fire, major roof damage, etc.) call immediately to get the process started. The carrier will provide you immediate relief funds to stay somewhere safe!

    Questions
    Questions

    Feel free to email or call me with any questions or comments about my services or if you have any insurance related inquires.

    Contact
    Contact

    Phone: 708.444.0050
    Email: kelly@kellyburkeinsurance.com

    Availability
    Availability

    Monday - Friday: 10am - 5pm
    Evening and weekends
    available upon request