AZ Healthcare Financial Management Association - Home Page
Financially preparing for health careLet’s be honest – medical treatment and health insurance are both costly. Whether you are planning for a surgery, a long-term treatment plan, or even a simple diagnostic test, it is important to understand all related financial responsibilities. Asking a few questions before the service will help prevent unexpected medical bills and let you concentrate on your health instead of your dwindling bank account. Here are some tips for everyone in starting those conversations. It may work best if you call your provider ahead of time and ask the following questions: Are you in-network with my health plan? Most medical procedures will involve both a professional fee (for the physician) and a technical fee (for the facility, hospital or surgery center). Make sure both the provider and facility are in-network to receive the maximum benefit from your insurance company.What is my estimated cost after insurance?Write down the name of the person who answers this question. Also write down his or her answer; where he or she works; and the date. Do you offer payment options, such as payment plans or financial assistance? If the quote for your out-of-pocket expenses is more than you expected, take a deep breath and ask about a monthly payment plan or any reductions or discounts you may be eligible for. Many hospitals offer financial assistance in order to maintain a not-for-profit status. Has this procedure been authorized by my health plan?An authorization, or pre-certification, is approval from your health plan based on medical necessity. It means you have been found to need this procedure.What is the CPT code?The CPT code is the procedure code for the service you are having. Write it down, because you will need it when you call your insurance provider. Will any other providers be involved in my treatment?Each service provider will bill your health plan (and then you) separately. For example, if you have surgery, it will involve at least one surgeon, one anesthesiologist and the facility itself (a hospital or surgery center). Depending on the surgery, there might also be an assistant surgeon, such as another physician or a physician’s assistant. You may also need the services of a pathologist, radiologist or other specialist. You may not have a face-to-face encounter with all these providers, so I recommend you know who will be involved to avoid confusion down the road.It may work best if you also call your insurance company ahead of time too. You can get their phone number on the back of your insurance card typically. Here are some good questions to ask them: Is this service covered by my plan? Give the person you speak with the CPT code and explain why you’re having the procedure done. There could be many different types of the procedure you’re having, and maybe only a few of them will be allowed by your insurance. In addition, sometimes a covering diagnosis is required in order for a procedure to be covered. One good example of this is bariatric surgery: there are several different types, and your insurance may only cover a certain type. The surgery may also be covered only if you meet certain criteria, such as a body mass index over 35 or a diagnosis associated with obesity, such as diabetes or high blood pressure.Even if the service has been authorized, you still need to verify that it’s a covered benefit. Often the authorization department of an insurance company will be separate from the benefits department, and will not inform the provider if the service is covered by the plan. I agree this is about as clear as mud, but I always say it’s better to be safe than sorry. What is remaining in my out-of-pocket maximum?Your out-of-pocket maximum is the most amount of money you will pay towards your medical bills for allowed charges within a benefit year. If this number is significantly lower than what you were quoted by the provider, make a second call back to that provider and inquire about the difference. As long as all charges associated with the procedure are covered, you should not exceed your out-of-pocket maximum. Write down who you talked to, the date and time of call, and reference number. Any time you speak with your insurance company, write down this information along with notes from the phone call. Hopefully this little bit of preparation helps you manage your associated costs and helps you make informed choices. While this may be a simple refresher for most of us, remember not everyone is well versed at navigating their healthcare, as a leader and an expert let us all share this tips and help spread the knowledge! ................
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