Insurance Explained by Chippewa Falls Chiropractors

The insurance game is a tricky one and unless you are a healthcare provider, an insurance agent, or a very informed patron you probably have some questions.  The best way to have your questions answered is to talk to whomever your insurance is through typically that means your employer or human resources rep, and the insurance company themselves.  Every insurance card comes with an 800 phone number on the back and if you call that you can typically get through to someone that can explain your plan and benefits.  Overall there are a few key concepts to know about:

1)    In and Out of Network – Some insurance companies use what is called a “provider network”.  This means that your insurance company or a third party that your insurance company has hired out has negotiated with certain providers to accept lower rates than what they bill for in exchange for the insurance company sending their clients to this certain provider.  This works sometimes because some insurances limit their number of providers so the provider actually ends up seeing more patients and staying busier because they are getting referrals from being “in network”.  Unfortunately, there is a very fine line to having a broad provider network to benefit the insured clients and give them options and having too many options so that the providers don’t get a real benefit from participating.  As in insured person this you want to have as many options as possible and not pay as much, but as a provider you want to have as many referrals as possible and get paid more.  Speaking from an insured perspective it is typically more beneficial to see a provider that is in network if you are concerned only with the financial aspect of your care.

2)    Deductibles – Most insurance companies including Medicare has something in place called a “deductible”.  This is a certain fee set in place that must be paid by the insured person before the insurance company has to pay anything out.  If you have ever had to use your home owners insurance, renters insurance, or auto insurance all of these policies have a “deductible” which works in the same fashion as health insurance. This is the way that insurance companies limit individuals from seeking emergency care for a simple cut.  Currently most plans are shifting towards the high deductible plan so that an individual has to pay out a few thousand dollars before the insurance company starts to pay.  This is good for people trying to save money on health insurance because the premiums are less and they still get coverage for major or severe emergent situations like terminal illness or significant trauma.  The only trouble with deductibles is that most people understand that once they pay their deductible that they get so called “free care” and since they paid their deductible now they want to make their insurance company pay for as much as possible, because in a sense they are spending someone else’s money.

3)    Time of Service Payment Discounts and High Deductible plans –  One of the things that is unknown by most consumers is that “CASH IS KING”.  In the medical world the rules don’t change in fact most private offices and businesses will offer a consumer or patient a discount for using cash.  In order to be compliant with insurance networks and regulations our office is allowed to offer our patient’s a discount for paying at the time they receive the service known as a “Time of Service Discount – TOS“.  Many people with high deductibles actually elect to utilize this option so that they don’t have to pay the full rate and deal with billing and submitting to their insurance.  Anyone is allowed to take advantage of our time of service discount however there are three additional forms that must be signed in that case.  Our TOS – Time of Service Payment Discount is 40% off of our standard rates.

4)    Copays and Co-Insurance – Another way for insurance companies to make sure that their books meet and that they are still making a profit is by adding a feature known as a Copay and/or Co-Insurance.

• A Copay is a certain fee that is required to be paid at every visit.  For instance, many individuals have to pay $20 every time they see a health care practitioner regardless of the charges or services.
• Co-Insurance is a different regulation that states that an insurance company will only cover a certain amount of every visit.  For instance, if you were to have an office visit that costed $100 and the insurance company has established a co-insurance plan where they will pay 80% ($80 in this case) of the total charges meaning the insured is responsible for the remaining 20% ($20 in this case).
• The last situation is the most common where an individual’s insurance plan has a Copay and Co-Insurance.  In this instance for a $100 office visit if the individual has a standard Copay of $20 every time they see a health care practitioner and then has Co-Insurance of 80% the individual would be responsible for $36.  $100 office visit – $20 standard copay + 20% of the remaining $80 = $36 of patient responisibility.  So in this instance the insurance company would pay $64.
• Finally remember that you can also have a situation where you see an in Network provider so even if his charges are $100 if he/she is in network they may be required to write off a certain amount.  Which then changes the total which typically doesn’t affect one’s copay but will affect the co-insurance amounts.  DON’T FORGET that if you have a deductible that hasn’t been met it doesn’t matter what your copay or co-insurance is because you are responsible for all of the charges until you meet that deductible amount, however you may still get a discounted rate if you see a provider that is in network and is required to write off a certain amount based on the provider’s agreement with your insurance company.

As you can see insurance can be very confusing and sometimes it is more beneficial to avoid using your insurance all together.  Every person and every insurance plan is different.  Even if you have the same insurance company as a friend you may have a totally different plan and benefits; this is very similar to the differences in Auto insurance companies and plans.  Remember that in the end you get to make the decisions and even if you have insurance you are not required to use it, even if the provider is in network if you can get a better rate and less stress without using your insurance it may be the right option.

At Reilly Chiropractic we are a PARTICIPATING PROVIDER and IN-Network with the following Insurance Companies as of 12/01/2014 :

NOTE: Whether your insurance company is listed below or not DOES NOT guarantee benefits. As described above every plan is different and we may be in-network with your company but you may have a plan that has no coverage.  We may be out-of network but your plan may have full coverage.  The only way to know for sure is to either bring your card into the office and one of our staff members will call on your benefits or call yourself.  Please be aware that sometimes what they tell you over the phone is different from what your benefits actually are, and it is best to have an insurance professional like our front office staff help walk you through this process.

• United Health Care
• Medica
• Security Health Plan (SHP)
• Anthem Blue Cross and Blue Shield (BCBS)
• Aetna and Select Care
• Multiplan
• Humana
• Medicare
• Medicaid / BadgerCare / Forward Health
• WEA
• WPS
• Cigna
• MMSI – Mayo Health Insurance
• Benefit Plan Administrators (BPA)

For Auto Insurance or Car Accident cases In and Out of Network benefits and limitations do not apply.

For Workers Compensation or Work Related Accident cases In and Out of Network benefits and limitations do not apply.

Billing

Please be aware that due to the complexity of billing insurance and understanding insurance companies the billing process may be just as complex.  It is common for 4 or 5 parties to be involved in one claim (Reilly Chiropractic, the insured patient, the primary insurance company, the insurance company’s third party network management company, the secondary insurance company).  Because of this complexity it is common for patient’s that have us bill their insurance to not receive an Explanation of their Benefits for 3 to 4 months after the date of service.  This also means that you may not receive a final bill for that service for 6 to 7 months following the date of service.  Please keep in mind that the best medicine is prevention, which in this case means understand:

• what your services are at every visit
• what your charges for every visit are
• prior to starting care what your insurance benefits are suppose to be (based on a phone verification of benefits)

At Reilly Chiropractic we recommend reviewing your benefits, services, and charges after every visit.  We also encourage patient’s to keep a detailed record of all this information including receipts for payments made.  If you would ever like a receipt for payment or a summary of the visit charges please do not hesitate to ask.  The more informed you are the less problems we will have later.