Understanding health insurance

Understanding health insurance

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Guest post from the Billing Department

Health insurance can be complicated and confusing. Here are some helpful definitions and tips to help you better understand your insurance and how it affects your costs for treatment of a shoulder or elbow injury.

It’s important that you bring your insurance card with you to every appointment. If you have two insurance plans, be sure to bring both cards. Having your insurance information is the first step in being able to help you with any questions about your coverage or what payment is due.

Primary versus secondary insurance

Some patients have multiple insurance plans that may cover different things. Typically, an employer-provided plan is the primary insurance. The secondary insurance may be through the spouse’s employer or could be for a young adult still on the parent’s health insurance. Claims will be filed with your primary insurance first, then any remaining portion is filed with your secondary insurance.

Worker’s compensation claims are different

If you’re being seen for an on-the-job injury, it’s most likely covered under a worker’s compensation claim and won’t be billed through your health insurance. Please notify the receptionist and Dr. Nolan if you’re being seen for an on-the-job injury. We’ll need to check your employer’s process for worker’s compensation claims before we begin treatment.

Deductibles

The deductible is the amount you pay for healthcare before your insurance begins to pay. Your deductible may be listed on your insurance card or included in the insurance enrollment paperwork from your employer. If your deductible is $1,500, that means you’ll pay the first $1,500 in medical expenses in the year, and then your insurance will pay a portion and you pay a portion for the remainder of the year.

Co-payments

A co-payment, more commonly referred to as a copay, is the amount that you pay at the time of service. Most plans have a designated amount for primary care visits and a different amount for specialist visits. Dr. Nolan, like all other orthopaedic surgeons, is a specialist, and the amount due at the time of visit will be determined by your plan’s specialist copay as well as your remaining deductible (see above).

Co-insurance

Once you have met your deductible, you will still share in a portion of the healthcare costs with your insurance company until you have met your maximum out of pocket contribution for the year as determined by your plan. Typically, the co-insurance is designated as a percentage of the total cost of treatment. For example, your co-insurance may be 20 percent of total cost while the insurance company pays 80 percent.

Medicare coverage

There are multiple types of Medicare coverage that apply to different types of treatment. Medicare Part A covers hospital costs, while Medicare Part B covers physicians, outpatient care (such as physician office visits), and medical supplies.

Medicare Part C, which is also referred to as a Medicare Replacement Advantage plan, is an alternative to the combination of Parts A and B. This plan is always administered by a private insurance company and functions more like a traditional insurance plan. Medicare Part D covers prescription costs.

For Medicare patients, it’s important to know what coverage you have and bring your Medicare card with you to each appointment. Not all patients on Medicare have all of these parts. Some patients may also have a “Medicare supplement plan,” which is a separate health insurance policy that picks up some of the costs not covered by Medicare.

Multiple bills

If you require surgery or have diagnostic tests done outside of our office, it’s important to note that you will receive multiple bills. In the case of surgery, you may receive a bill from the surgeon, the anesthesiologist, the radiologist (if imaging is done in conjunction with surgery), and the hospital. Each of these bills will apply to your deductible and co-insurance according to the specifics of your insurance plan.

If you have labs, a CT scan, or an MRI, for example, those are not performed by our office, and you will not receive a bill from us. However, you may still receive multiple bills, such as one from the imagining center where your MRI was done and one from the radiologist who interprets the study.

Have questions about a bill or what your insurance will cover for treatment at Oklahoma Shoulder Center? Call our office and ask to speak to the billing specialist. We’re happy to help answer your questions.