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 can I do to help myself get better sleep?

What can I do to help myself get better sleep?

Keep in mind that you may need less sleep as you age. Some people need only 5 to 6 hours of sleep a night, but most people do better with 7 to 8 hours. Sleep usually occurs in 3-hour cycles, so it is important to get at least 3 uninterrupted hours of sleep.

These tips can help you develop better sleep habits:

  • Go to sleep only when you feel tired.
  • Avoid reading, watching TV or worrying in bed. These can cause your body and brain to associate your bed with these activities, rather than with sleep.
  • Develop a bedtime routine. Do the same thing every night before going to sleep. For example, take a warm bath and then read for 10 minutes every night before going to bed. Soon you’ll connect these activities with sleeping, and doing them will help make you sleepy.
  • Use the bedroom only for sleep and sexual activity.
  • If you can’t fall asleep after 15 minutes, go to another room and return to your bed only when you feel tired. You may repeat this as often as needed during the night.
  • Go to sleep and wake up at the same times each day, even on weekends. This helps your body develop a sleep schedule.
  • Avoid or limit napping, because it can disturb your normal sleep rhythm. If you must take a nap, only rest for 30 minutes and don’t nap after 3:00 p.m.
  • Avoid caffeine from coffee and soft drinks, and nicotine from cigarettes, especially late in the day.
  • Avoid eating large meals or drinking a lot of water in the evening.
  • Keep your bedroom at a comfortable temperature and as dark as possible.
  • Make sure your bedroom is quiet and dark. If noise is a problem, use a fan to mask the noise or use ear plugs. If you must sleep during the day, hang dark blinds over the windows or wear an eye mask.
  • Try eating a light snack before going to bed, but don’t eat too much right before bedtime. A glass of warm milk or some cheese and crackers may be all you need.
  • Exercise regularly, but don’t exercise within a few hours before going to bed.
  • Set aside some time to relax before going to bed. For example, spend 30 minutes after dinner writing down what’s worrying you and what you can do about it.

Another good way to relax is to focus on your breathing by taking slow, deep breaths while counting to 5. Then listen to the sound of your breath as you breathe out. You can also try to tighten and relax the muscle groups in your body, beginning at your feet and ending with your face muscles. A trained therapist can teach you other ways to relax. Relaxation CDs or tapes may also help you relax.

Source

Nonpharmacologic Management of Chronic Insomnia by Parul Harsora, MD and Jennifer Kessmann, MD (American Family Physician January 15, 2009, http://www.aafp.org/afp/20090115/125.html)

Prolia Medication Guide

This page is a handy resource for patients at Family Care who have started taking Prolia. Please use the links below to access patient education materials that are required to be given to our patients before beginning treatment on Prolia. If you have any questions, please call our office and ask to speak with our nurse, Melissa. Thank you!

Prolia Patient Brochure

Prolia Medication Guide

Prolia® is a prescription medicine used to:

  • Treat osteoporosis (thinning and weakening of bone) in women after menopause (“change of life”) who:
    • are at high risk for fracture (broken bone)
    • cannot use another osteoporosis medicine or other osteoporosis medicines did not work well
  • Increase bone mass in men with osteoporosis who are at high risk for fracture
  • Treat bone loss in men who are at high risk for fracture receiving certain treatments for prostate cancer that has not spread to other parts of the body
  • Treat bone loss in women who are at high risk for fracture receiving certain treatments for breast cancer that has not spread to other parts of the body

World Family Doctor Day is May 19!

The first World Family Doctor Day was declared by the World Organization of Family Doctors (WONCA) in 2010. It has gained momentum globally each year, with activities, meetings, and celebrations planned to:

  • Bring attention to the contributions of family doctors globally;
  • Recognize family doctors;
  • Increase the morale of family doctors, and;
  • Highlight important issues relating to family doctors and the work they perform in supporting health care for people around the world.

From globalfamilydoctor.com:

  • World Family Doctor Day (FDD) – 19th May – was first declared by WONCA in 2010 and it has become a day to highlight the role and contribution of family doctors in health care systems around the world. The event has gained momentum globally each year and it is a wonderful opportunity to acknowledge the central role of our specialty in the delivery of personal, comprehensive and continuing health care for all of our patients. It’s also a chance to celebrate the progress being made in family medicine and the special contributions of family doctors all around the world.
  • We’re very happy for Member Organizations to develop their own theme for FDD, depending on local priorities, but this year we’d especially like to highlight smoking cessation. Smoking is the activity most damaging to health in a whole range of ways, and part of our role as family doctors is to be able to encourage our patients to stop smoking and to provide resources and support to help them.

To help raise awareness for this year’s special topic of smoking cessation, check out this beautiful infographic that describes the short-term and long-term benefits of quitting immediately!

Stamp Out Hunger Food Drive on Saturday, May 14

Tomorrow, May 14, is probably the easiest day all year to donate food to the hungry because the post office will literally come to your house and pick your donation up for you! Every year on the second Saturday in May, the USPS partners with several different food banks across the country to host the “Stamp Out Hunger” Food Drive. Just leave a box of non-perishable food items next to your mailbox tomorrow to help out a family in need!

Here is the full write up from the USPS:

Every second Saturday in May, letter carriers in more than 10,000 cities and towns across America collect the goodness and compassion of their postal customers, who participate in the NALC Stamp Out Hunger National Food Drive — the largest one-day food drive in the nation.

Led by letter carriers represented by the National Association of Letter Carriers (AFL-CIO), with help from rural letter carriers, other postal employees and other volunteers, the drive has delivered more than one billion pounds of food the past 24 years.

Carriers collect non-perishable food donations left by mailboxes and in post offices and deliver them to local community food banks, pantries and shelters. Nearly 1,500 NALC branches in all 50 states, the District of Columbia, Puerto Rico, Guam and the Virgin Islands are involved.

The United States Postal Service, National Association of Letter Carriers, National Rural Letter Carriers’ Association, AFL-CIO, United Food and Commercial Workers International Union (UFCW), United Way, Valassis and Valpak Direct Marketing Systems are all supporting this year’s Stamp Out Hunger food drive.

To donate, just place a box or can of non-perishable food next to your mailbox before your letter carrier delivers mail on the second Saturday in May. The carrier will do the rest. The food is sorted, and delivered to an area food bank or pantry, where it is available for needy families.

With 49 million people facing hunger every day in America, including nearly 16 million children, this drive is one way you can help those in your own city or town who need help.

It’s Opening Day!

Family Care begins our first season in the RTP Softball league today! If you notice everyone wearing the same thing at our office today, its because we have Family Care jerseys now!

If you want to come out and support our team, we play the NCREN Bears at 5:45pm on RTP Field 3. This will also be the first ever softball game for a couple of our employees, so should be a fun time. We have a great mix of players from different teams that Ryan has played with in the past and think we have a decent chance at the championship!

Play Ball!

March 30 is National Doctor’s Day!

“There is no greater reward in our profession than the knowledge that God has entrusted us with the physical care of His people. The Almighty has reserved for Himself the power to create life, but He has assigned to a few of us the responsibility of keeping in good repair the bodies in which this life is sustained.”

~ Dr. Elmer Hess, former president of the American Medical Association.

Primary Care Providers in Durham, NC

Thank you to all three of our providers for working so hard to take great care of our patients every day!

If you are interested, here is the link to President George H. W. Bush’s speech where he designated March 30 to be National Doctor’s Day in 1991.

Family Care is In-Network with United Healthcare!

Family Care is in-network with United Healthcare!

As of February 10, 2016, Family Care is now considered an in-network provider with United Healthcare! For all United Healthcare patients at our office, this means…

  • Visits at our office will now be subject to your in-network benefits on your insurance plan. You will now have full access to the benefits on your plan for services at our office!
  • In-Network co-payments, co-insurances, and deductibles will apply to your visits. No more high out-of-network deductibles!
  • Annual preventive wellness exams (for non-grandfathered plans) are covered 100%! No more denials for preventive care services!

For an average patient that came in every three months as an out-of-network patient, this means out-of-pocket savings of anywhere from $150 (for high-deductible plans) to $400 (for regular co-payment plans)!

Why did we decide to re-join the UHC network? 

If you have recently signed up for health insurance on the individual marketplace, you may have noticed that there are far fewer options available to you than there have been in years past. For the 27713 zip code, and most of the surrounding zip codes, BCBS has limited their available products on the individual marketplace to their Blue Value and Blue Local plans only. Because the Value and Local plans are affiliated with the UNC and Duke healthcare systems (and our office is fully independent), many of our patients were left without an option that would be considered “in-network” at our office.

Now, after signing an in-network contract with UHC, patients who sign up for insurance on the individual marketplace have the option of selecting a United Healthcare plan to receive in-network insurance benefits for visits at our office. We hope this helps our patients save money and get the most out of their healthcare budget.

If you are a new patient to our office, Dr. Elaina Lee and Sarada Schossow, PA-C are currently accepting new United Healthcare patients.

Please contact our office to schedule an appointment today!

Acne Prevention

Almost everyone at some point in their lives will suffer from acne outbreaks. While it can be embarrassing or frustrating, there are many easy ways acne prevention can help reduce the occurrence of breakouts. We tend to think that only teenagers should be plagued with pimples, but unfortunately, acne can be present our whole lives.

Ways to help reduce acne outbreaks:

  • I would encourage a well-balanced diet and plenty of water to keep the skin nice and hydrated. Although some people will find they break out after eating certain foods, there is no evidence that fatty or greasy or sugary foods lead to more breakouts.
  • Make sure to wash your face with hands and not a washcloth as these may be abrasive to sensitive skin. Some acne washes contain Benzoyl Peroxide or Salicyclic acid, both of which can be very harsh to the skin. They may lead to peeling and redness, along with increased sensitivity to the sun.
  • If you try an OTC acne cream, be sure to test it on one spot first before applying to you whole face to minimize adverse reactions.
  • Keep your hands off your face to reduce spreading grease and other irritants onto your face. Temptation to squeeze pimples can be hard to resist, but it can actually lead to tissue damage, infection, and scarring. Try not to pick!
  • Makeup can irritate and clog pores as well. Make sure to always wash off your makeup at the end of the day. Products that are water-based or more natural tend to be easier on the skin, as well.

Products I love and have found to be effective in helping clear my own skin include:

  • Cetaphil face wash. This is an incredible, gentle skin cleanser. It is available at almost all drug and grocery stores and is relatively inexpensive.
  • Cetaphil moisturizer. Again, this brand is really gentle on the skin. There is a moisturizer with, and without, sunscreen. It goes on smooth and does not feel like you are wearing a thick layer of moisturizer. Sunscreen is always a good idea to help prevent skin damage.
  • Neutrogena products. There are many Neutrogena products, but the ones I think are the best include the Oil Free Acne Wash for the face and Clear Body Wash, for back and chest acne. These products tend to be less drying to the skin than some of the other available washes.
  • Neutrogena moisturizer. There are several moisturizers with sunscreen in them that go on smooth and do not leave an oily residue. There are also overnight moisturizers to help fight off any dry skin.

Finally, if the OTC and home remedies are not working, you should come see us to discuss topical therapies or other medications to help reduce acne flares!

Sarada Schossow, PA-C is a primary care provider at Family Care, PA in Durham, NC. She has special interests in women’s health, adolescent and young adult health, and dermatology, including acne prevention. For more articles from Sarada, click here.