Insurance Education

Insurance Terminology 101: “Approvals” and “Authorizations”

Insurance Terminology 101: “Approvals” and “Authorizations”

One commonly misunderstood concept about insurance coverage is the term “approval.” It seems pretty simple, but many people think that having a service approved by their insurance plan means that they will not have to pay for the service. While that is possible depending on the situation, the most often result is that the patient is left surprised and confused when they ultimately receive a bill for an “approved” service. This post is part of a series to help patients clarify the terminology that your insurance company is using so they can better understand their coverage.

Approval / Authorizations

Approval by an insurance plan means that they will allow you to get something done and will at least consider paying for the test. This does not mean that your health insurance will pay for the test – it means they agree that the procedure will be subjected to the benefits listed on your insurance plan. Authorizations are essentially the same thing as approvals, but you’ll hear authorizations more often with prescription coverage details. Just like approvals, a prescription authorization only means your insurance benefits will be applied to the claim for your prescription and does not guarantee payment.

While you may still be paying for an approved service, your insurance company at least acknowledges that this test or medication is generally recommended for your particular medical situation and should be considered as part of your plan’s benefits. They are not saying they won’t pay yet, but they also aren’t saying they will pay, either. This is the first chance in the claims process for your insurance company to get out of paying for a service, so getting this approval is a good first step.

However, obtaining an approval does not mean you will not still owe up to 100% of the service you are approved to receive. Your benefits for an approved service could include deductibles, coinsurances, copayments, and additional out-of-pocket expenses that you will have to pay the service’s provider. If you have a high deductible that has not been met, for example, you will still incur a large out-of-pocket expense for approved services.

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Let me know what you think in the comments section below. If there are any other phrases or terms that you sometimes get confused, please send me a message and I’ll try to feature your question on a feature post. Thanks for reading!

What is a “grandfathered” health insurance plan?

What is a “grandfathered” health insurance plan? 

A grandfathered health insurance plan means that the plan does not have to follow the national healthcare reform guidelines implemented by our federal government as part of the Patient Protection and Affordable Care Act (ACA) in March 2010.

There are two types of grandfathered health insurance plans:

  • Job-based grandfathered plans. Job-based grandfathered plans can still maintain their grandfathered status if the plans haven’t been changed in ways that substantially cut benefits or increase costs for plan holders and notify plan holders that they have a grandfathered plan. To keep a job-based grandfathered plan, the employer must have continuously covered at least one person in the company since March 23, 2010.
  • Individual grandfathered plans. Individual grandfathered plans can’t newly enroll people after March 23, 2010, and have that new enrollment be considered a grandfathered policy. But insurance companies can continue to offer the grandfathered plans to people who were enrolled before that date. An insurance company can also decide to stop offering a grandfathered plan. If it does, it must provide notice 90 days before the plan ends and offer enrollees other available coverage options.

While the majority of stipulations in the ACA apply to all types of health insurance plans, grandfathered plans are allowed to maintain a lower standard of coverage as a political compromise towards meaningful reform. With their grandfathered status, these plans have a different set of requirements:

It is important to understand the reasoning behind the changes made with the ACA and why our government had to do something to fix a broken system before it was too late. Before the ACA took effect, health insurers had a completely disproportionate advantage on the patient/insurer relationship. These healthcare reforms have been long overdue and were actually set up to help patients regain control from health insurers, no matter what other motives you might hear on Fox News. It is named the “Patient Protection” act, after all. You may remember some of the many ways health insurers ripped people off before the ACA:

Do any of these ideas sound fair to you? Obviously not. I think we can all agree that putting a stop to these devious insurance practices is a good thing for the healthcare industry, overall.

Despite the obvious benefits of having an ACA compliant plan, it does make sense for some people to continue coverage under a grandfathered plan. However, 3 out of 4 people with employer-based health insurance have an ACA compliant plan, along with almost everyone who is insured through the individual marketplace, so having a grandfathered insurance plan means you are going to face challenges and issues that do not apply to most of the population anymore, thanks to the ACA. Here are a few closing points to consider:

  • The majority of the advertisements, articles, new stories, and policy discussions that you see in the media regarding healthcare do not apply to you.
  • Your out-of-pocket costs will most likely be significantly higher than someone with an ACA-compliant plan.
  • Your “preventive wellness exam” is not covered by your insurance. If you have a copay or deductible, those will still apply to this visit.
  • You do not have the right to appeal any decision by your insurer. This includes denials for prescriptions, imaging, and medical claims.

Patients Asked Thrice: Healthcare Insurance and Billing Q&A

This post is part of a series entitled “Patients Asked Thrice,” which is designed to answer questions I have received at least three times from our patients. The inspiration comes from the saying: “One’s an incident, two’s a coincidence, and three’s a pattern.” If three different people ask me the same thing, I can safely assume there is at least a fourth person out there who wants to know the answer.

If you have any other questions you would like me to address, or any follow up questions to this post, please include them in the comments section below. Thank you!

Finding In-Network Providers on the BCBSNC Website

There are a lot of things to consider when choosing a primary care provider, but one of the most important is ensuring that your provider is in your insurance’s network. One of the most frustrating things that happens to patients is finding out their provider is out-of-network with their health insurance when they show up for an appointment. They have had the same provider for years and have been very happy, but now their insurance is telling them they can’t see their preferred provider again without paying even more than they are already paying in premiums. This is not an ideal situation for either party, as the patient potentially loses their provider and the provider potentially loses a patient.

For many people with employer-sponsored health insurance plans, changing plans might be the only option available to you due to your employer’s necessary budget decisions. This post is for the rest of you on the individual marketplace for health insurance who have control over which plan you sign you and your family up for and need help finding in-network providers. Most of the frustration can be mitigated by checking with your insurance to determine your provider’s in-network status before changing insurances.

Most of Durham and the surrounding areas are insured by Blue Cross Blue Shield of North Carolina, so we’ll use the BCBSNC website for this example. The steps apply to almost any insurance, however, since most insurer websites offer a similar provider finder tool. If you have any specific questions, use the contact information on the website to call or email BCBS directly. 

1. Visit the bcbsnc.com website.

At the top right of the screen, you will see the “Find a Doctor” link. Click it.

Finding an In-Network Provider on BCBSNC.

2. Click “Find a Doctor or Facility” in the menu. 

Once you click this link, you will be able to search for a provider of any specialty type in your preferred location. On BCBSNC.com, our office is featured as “Family Care, PA” under most searches.

Finding an In-Network Provider

3. Select your plan type, or sign in to your member services account. 

If you are not sure which plan you are on, you can use your member services account to guide you. Otherwise, select your plan and proceed to the provider search page.

Finding an In-Network Provider - Select your insurance plan on BCBSNC.com

4. Fill in the search bar with the type of provider you are looking for. 

If you use the search bar once or have to refresh the page at all, be sure to re-select your chosen insurance plan before searching. Alternatively, you can follow the questions in the blue boxes in the middle of the page to determine which type of doctor is right for your current situation.

Finding an In-Network Provider on BCBSNC.com

5. If you do not know the name of the provider or facility you are looking for, select a category. 

There are also options on the right hand side of the page to sort by location, gender, and specialty. Our providers show up under most of the Primary Care designations, but the most accurate specialty would be “Family Medicine – Primary Care.”

Finding an In-Network Provider on BCBSNC.com

6. Select your provider. 

Depending on how far you narrow your search, there are potentially hundreds of options for you to choose from when finding in-network providers.

As a helpful hint, once you are on the 2nd page of any search, a new URL segment gets added to the page you are transferred to that can be changed to skip forward to a particular page. For example, in a basic search for a primary care provider, the URL for the 2nd page of the search is:

https://healthnav.bcbsnc.com/professional?network_id=3&geo_location=gps&radius=25&page=2&sort=Distance&ci=COMMERCIAL&search_specialty_id=1031

By changing the “page=2” segment to “page=#”, where # is the page you would like to visit, you can immediately skip through the alphabetical listings to your chosen letter.

7. Confirm participation with your provider. 

While this step doesn’t have anything to do with the BCBS website, it is still just as important when finding in-network providers with your insurance. Because websites aren’t always 100% reliable and the BCBS listings take several months to update, it is always best to confirm participation with your provider, as well. You should check out the list of in-network insurances at our office or contact us to ask about a specific plan to be sure that you are receiving all possible benefits from your insurance plan.

Choosing a primary care provider is an important step in your healthcare, so take some time to be sure you are making the right selection. Thanks for reading! Good luck!

How To View Online EOBs

This is a basic description of what you’ll need to do in order to access your Explanation of Benefits (EOB) statements online. Since the majority of our patients are insured through Blue Cross Blue Shield of North Carolina, we will use their website and process as an example. Most insurers have something similar available on their own websites, so if you have a different insurance plan, you can try to take some of the concepts and adapt them to your own insurer. You can contact the individual insurer to find out how to view online EOBs for that specific insurer.

The first step, is to sign up for an online member account. For BCBSNC, you can do that by clicking here and completing the registration process. To sign up for an account, you will need your Subscriber ID Number (available on your insurance card), Date of Birth, and Zip Code on file for the primary subscriber on your plan. If you already have an account, you can click here to login.

Once you are in your account, your screen should look something like this:

health-insurance-enable-online-bcbs-screen-shot

From there:

  1. Click on “Claims” on the top bar. You are now at a screen that can show you all of the medical and pharmacy claims that have been filed by your providers.
  2. You can expand the line items by clicking the + sign and then download the individual PDF files for the individual claims, if you’d like.
  3. Click on the link to download the PDF of the EOB, or just review the plan details shown in the online tool.

This is just a brief overview of the process for checking your online Explanation of Benefits statements for BCBSNC members. The Blue Connect online account has a lot of other great features (eg. deductible status, billing statements, prescription history, network access, etc.) for patients who want to manage their health insurance plan and usage,  so it is definitely worth signing up for any online tool your insurer offers. The screens will obviously be different, but the concept of “logging in to your online account and clicking the claims tab” should be pretty consistent.

In the rest of the blog posts in this series, I will explain the specifics involved in your EOB, including detailed information on the following topics:

  1. What is an Explanation of Benefits Letter?
  2. Basic EOB Terminology
  3. Determining Patient Responsibility
  4. Determining Plan Details
  5. Accessing Online EOBs
  6. Understanding Denials and Denial Codes
  7. How To File an Appeal

If you have any specific questions or topics you would like us to discuss, please mention them in the comments below and we will address them in future posts. If you are a patient at Family Care and have any questions about EOBs you received for claims from our office, please let us know by filling out our contact form. Thank you!

Determining Plan Details

Determining Plan Details

One of the most common problems that people experience with their health insurance is the frustration of having to pay out-of-pocket for a service or prescription that they thought would be covered by their insurance plan. “I thought that was covered” is a common phrase with patients and most of the negative perceptions of health insurers stem from the general distrust that this reaction causes. People are skeptical about insurers covering certain things because they have been burned in the past and see insurers as being greedy whenever they end up owing more than just their premiums for their healthcare expenses. While insurers do sometimes make mistakes and deny things that should be rightly covered (which you have the right to appeal), your insurance is usually processing your plan’s benefits exactly how they said they would when you signed up for the plan. They probably even have your signature on a sheet of paper saying you agreed to their terms. Sneaky, I know.

The problem usually begins because patients misunderstand their coverage and get surprised when they see the differences in benefits from what they thought they would have to what they actually have. The new Farmers Insurance commercials are really a perfect example. Knowing your coverage could influence your decision on where and when to get treatment and help you reduce your overall out-of-pocket expenses. It will also keep you from being surprised with unexpected bills or regretting services that you wouldn’t have done if you knew the cost. You may even change plans entirely because you realize your coverage is terrible, or if you are paying too much to have coverage for services you don’t need.

Because all plans are unique, it is impossible to make a single guide that covers everyone to determining your coverage. This post is designed to help you understand the thought processes and terminology behind determining your plan’s details so you can navigate through your own insurer’s information with a good idea of what you should be looking for.

Which health insurance plan do you have?

This is probably one of the first questions you’ll have to answer and is the starting point for all other questions you’ll be asked in every possible healthcare situation. When someone asks you what health insurance you have, what do you say?

bcbs_insurancecard
Example Insurance Card

There are two things your healthcare provider or pharmacist is always looking for when they ask this question.

  1. The name of your insurance provider. This is the most basic starting point and 100% necessary for your provider to determine your plan details. Examples include Blue Cross Blue Shield (BCBS), CIGNA, Aetna, United Healthcare, etc.
  2. The plan type and/or name of plan. This is the first subsection of the insurance provider and describes the plan option you chose when signing up with your insurer. Sometimes the plan has an actual name. Examples of BCBS plans include Blue Advantage, Blue Value, Blue Options, Blue Saver, State Employees Health Plan, etc. The plan could also only be described by letters, like PPO, HMO, POS, EPO, etc.

Depending on the situation, your provider might also need some additional information. Typically, you will be asked for the rest of this information if you are going to be receiving medical services or prescriptions, if you need a prior authorization for anything, or if you are being referred to another doctor.

  1. Your Subscriber Number. This is the first basic identifier on your insurance card. It may also be called your Member Number, Identification Number, or something else similar. This is the biggest and most important number on your card, so it is probably highlighted in some way. If you have dependents on your plan, the Subscriber Number includes the two digit suffixes assigned to each dependent. For example, Dad could be ABCD0000-01, Mom could be ABCD0000-02, and Daughter could be ABCD0000-03.
  2. Your Group Number. This is usually the second most featured number on your insurance card and allows your provider to see which pool of subscribers has a similar plan. This is usually unnecessary for most purposes, but is generally required if you need a prior authorization so it is good to have on file. The group number also helps providers figure out your plan details when you have private employer-based plans or some of the more obscure plans available that they might not see that often.
  3. The Payer ID # or the Billing Address. This is necessary for billing your insurance, but most providers already know the proper way to bill your insurance provider and don’t necessarily need it if you have a popular insurance plan. If your plan is based out-of-state or if you have a smaller, more obscure plan, you will probably be asked for this information. The Payer ID # is a 5 digit number on the back of your card and should be somewhere near the Billing Address.

That information will help your provider process your claims, send referrals, and obtain necessary prior authorizations. It will not allow your provider to tell you how much you will owe for a service or what types of benefits you have on your plan. Knowing your basic plan details only guides your provider so they can use the proper channels to correctly process your insurance benefits – it will not help them predict what those benefits will be, or even if there are benefits allowed for a service, at all.

Because plan details can vary on an individual basis, it is impossible for your provider to predict your benefits with complete certainty. We process the claims at the time of service with every piece of verifiable information we have available, but there are always surprises.

For example, you may pay a $20 copay for your visit. Then, after your plan processes the claim and says you are not covered for that service, you find out that you are required to pay 100%, instead. This is why it is important for you to know your own coverage – you are the person that is impacted by how your claims are processed and are ultimately responsible for any surprises that happen with your plan, so it is best to avoid them!

What are my benefits for this service?

The primary thing everyone wants to know – how much do I have to pay for this? There are several methods you can use to figure out your plan’s details for a particular service and the types of benefits you can expect to receive.

  1. Look at your insurance card. This is a “snapshot” of your coverage and usually shows the most pertinent details of your plan. The problem with relying on this is the lack of detail and explanation for your coverage for specific services, or the types of exclusions or exceptions that may be active on the plan. With most plans, this shows what you’ll need for the majority of the services you’ll receive.
  2. Reference your enrollment paperwork and benefits package. Whenever you sign up for a new insurance plan, your insurance provider is obligated to send you a detailed package that includes your plan’s coverage benefits. This is usually sent within a couple weeks of your enrollment and may be updated each year with a new packet of information. Usually, there is a table of information included with three columns – the service type, the plan’s in-network benefits for that service, and the plan’s out-of-network benefits for that service. Whenever you visit a provider or facility, reference their section on this table to help predict what your benefits will be for that visit.
  3. Contact your insurance provider. On the back of your insurance card, there should be a customer service number that you can use to ask any questions you may have about your plan. They will always give you a standard “this call does not guarantee payment of services and benefits will be subject to the plan’s details at the time of service” spiel to make sure they aren’t promising coverage they can’t provide, but they should be able to tell you what your copayments or deductibles are and how they apply to certain types of providers and services. Most plans have online portals with customer service emails or live chats, as well, but the process is the same. You’ll want to contact your provider for the CPT Code they will use for the service and ask your provider specifically about your benefits for that code.
  4. Look at how previous visits processed under the same plan. Past coverage is a good predictor of future coverage, but only if the plan’s details have not been changed. If you had a $25 copayment for a sinus infection six months ago, and your plan has not changed since then, you will probably owe a $25 copayment for a sinus infection today. This could be a little problematic because it refers to your benefits at a previous date, rather than your benefits today, so make sure your plan details have not been modified since the service you are using as a reference.
  5. Just hope something is covered and deal with it later. This is probably the worst option, but it is usually the one most people end up choosing because they are either intimidated or frustrated or confused with the process for actually understanding their benefits. Because this experience just ends up perpetuating the “patient-versus-insurance” mindset, when the two should be working together towards the mutually beneficial goal of reducing the cost of healthcare, I hope this post helps people avoid this option!

This was a basic summary of ways you can determine the details on your insurance plan.  This is the fourth post in a series on understanding the insurance claim process. In the rest of the blog posts in this series, I will explain the specifics involved in your EOB, including detailed information on the following topics:

  1. What is an Explanation of Benefits Letter?
  2. Basic EOB Terminology
  3. Determining Patient Responsibility
  4. Determining Plan Details
  5. Accessing Online EOBs
  6. Understanding Denials and Denial Codes
  7. How To File an Appeal

If you have any specific questions or topics you would like us to discuss, please mention them in the comments below and we will address them in future posts. If you are a patient at Family Care and have any questions about EOBs you received for claims from our office, please let us know by filling out our contact form. Thank you!

Determining Patient Responsibility

This is the third in a series of posts about the insurance claim filing process. The process can be daunting and seem confusing, but the basic components are fairly easy to understand if you break them down individually. The goal is to help our patients, and everyone else, understand what is actually happening “behind the scenes” when you use your health insurance. You can read the rest of the series by clicking on the link headers at the bottom of the post.

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Basic EOB Terminology

This is a breakdown of the major sections contained in the Explanation of Benefits letter you receive after a medical provider files a claim to your health insurer for medical services provided. More in depth breakdowns of specific terms will be included in future posts on this topic as we finish out the series (outline below).

  1. Subscriber Information:

This is basic identification information, including the name of the policy holder, type of plan, and member identification number of your insurance policy.

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What is an Explanation of Benefits letter?

This is the first article in a series about the Explanation of Benefits summaries that the patient receives after their provider files a medical claim. To read the rest of the series, please check out the links below.

What is an Explanation of Benefits letter?

Whenever you receive medical services and your provider files a claim with your health insurance, you will receive an Explanation of Benefits (EOB) letter in the mail from your insurer a few weeks after your appointment. If you are enrolled in an online membership account with your insurer, you may receive your EOBs electronically, instead. The EOB is an itemized statement of the claim filed on your behalf by your provider and gives a detailed summary of the amounts that are required to be paid by the patient. This summary includes all negotiated discounts and reflects the amount still outstanding after the insurer has processed the claim and assigned whatever insurance policy benefits the patient has through their insurance plan. This letter is meant to make sure that the patient is aware of the charges that have been filed on their behalf, thereby decreasing medical fraud and making patients aware of the true costs of their medical care.

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