Debbie Miskell, RN Nurse Advocate
Angela Sain Health Benefits Supervisor
When you think of healthcare, you may imagine a complicated maze that includes insurance, a doctor or team who accept that insurance, affordable medications that actually work, and maybe complicated language and processes that are difficult to understand.
We use the term “Health Literacy” to describe the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. So, if we don’t have the ability to “find, understand, and use” the information given to us, then we can’t make informed health decisions. Ultimately, this affects our outcomes as patients. Unfortunately, when our doctors see that we’re not improving, they’re unlikely to ask if we understood their advice. Did we understand how to take our medications properly? Did we grasp the timeline of testing? Did we understand what our next steps are?
So how do we overcome this communication barrier? Here are some tips:
- Write down a list of questions before you go to each appointment so that nothing is forgotten
- Ask for clarification if something doesn’t make sense
- Patients learn in different ways – is there a different way the information can be explained? (i.e. drawings, pictures, etc.)
- Have a caregiver with you – two sets of eyes and ears are better than one
- If the doctor doesn’t speak your native language, bring a trusted friend or family member that can help interpret. Alternatively, ask the front desk staff if an interpreter can be provided (interpreter services are more available than ever)
- Ask how to interpret your lab results – what do they mean, what is considered the normal range, what should you be concerned about, etc.
- Ask if there are different treatment options that fall in line with what you value as a patient
- Ask if these treatments are covered by your insurance
- Ask if coupons are available to help offset costs for medications that are more expensive (Your Pharmacy Advocate can help!)
Using these strategies strengthens the bond between doctor and patient. Furthermore, it encourages self-advocacy, which is so desperately needed. Talking to our doctor and understanding what they need us to understand leads to better outcomes. As always, our Advocates are here to help. Our nurses can help explain doctors orders, and our benefit specialists can help you understand how your health plan works and what's covered. Contact us any time!
A health insurance claim is a bill for health care services that your health care provider turns in to the insurance company for payment. Your insurance carrier is responsible only for paying benefits that are covered under your policy, so you should do some research about what is covered and what is not to avoid being shocked when you settle up with your doctor or pharmacist. Don't hesitate to ask for clarification on anything you don't understand.
With many plans, like the YourChoice plan, when you go to the doctor and your bill is $100, you may pay a co-pay of $25 and your doctor bills your insurance carrier for the remaining $75. The insurance claims processing center gathers all relevant information from your doctor -- the patient information sheet, intake forms and the proper services documentation. If the service is covered by your insurance policy, your insurance carrier will submit payment for the remaining balance. If it is not covered, you are responsible for whatever balance is left after your co-pay.
For information about the precertification process for services like CT scan, MRI, Inpatient surgery, certain outpatient surgeries, etc., review this blog from the archives.
Denied Health Insurance Claims
Claims can be rejected because the plan doesn't cover the procedure, medication or supply, or because the insurance company deems it medically unnecessary or experimental. If you think you've taken all the measures to avoid a rejected claim -- like calling the insurance company before the visit or thoroughly reviewing your policy -- you can try and turn the denial to acceptance.
If a claim is denied for any reason, including administrative error on the part of the provider or the insurance company, a quick phone call could solve the problem. If this doesn't work, you can request a formal review by the insurance provider. You must resubmit your claim, which is reviewed by a health care professional who specializes in the field in which the procedure or medication belongs.
Understanding Important Terms and Definitions
This list defines many common healthcare terms you might not know. Knowing these terms can help you better understand how your insurance plan works and be able to anticipate your coverage and costs.
Allowed Amount - The highest amount we will cover (pay) for a service.
Benefit Period - When services are covered under your plan. It also defines the time when benefit maximums, deductibles and coinsurance limits build up. It has a start and end date. For the YourChoice Medical, Dental, and Vision Plans, it is one calendar year beginning January 1 and ending December 31.
Coinsurance - A certain percent you must pay each benefit period after you have paid your deductible. This payment is for covered services only. You may still have to pay a copay. Example: The YourChoice BEST Plan Level covers 80 percent of your medical bill. You will have to pay a $25 copay and the other 20 percent. The 20 percent is the coinsurance.
Condition - An injury, ailment, disease, illness or disorder.
Contract - The agreement between an insurance company and the policyholder.
Copayment (Copay) - The amount you pay to a healthcare provider at the time you receive services. You may have to pay a copay for each covered visit to your doctor, depending on your plan. Not all plans have a copay.
Covered Charges - Charges for covered services that your health plan paid for. There may be a limit on covered charges if you receive services from providers outside your plan's network of providers.
Covered Person - Any person covered under the plan.
Covered Service - A healthcare provider’s service or medical supplies covered by your health plan. Benefits will be given for these services based on your plan.
Deductible - The amount you pay for your healthcare services before your health insurer pays. Deductibles are based on your benefit period (typically a year at a time). Example: The YourChoice BETTER Plan Level has a $500 annual deductible - you will be expected to pay the first $500 toward your healthcare services. After you reach $500, the Health Plan will cover the rest of the costs, minus coinsurance and copays.
Dependent Coverage - Coverage for your dependents who qualify.
Emergency Medical Condition - A medical problem with sudden and severe symptoms that must be treated quickly. In an emergency, a person with no medical training and an average knowledge of health/medicine could reasonably expect the problem could:
- Put a person's health at serious risk.
- Put an unborn child's health at serious risk.
- Result in serious damage to the person's body and how his or her body works.
- Result in serious damage of a person's organ or any part of the person.
Experimental or Investigational Drug, Device, Medical Treatment or Procedure - These are not approved by the U.S. Food and Drug Administration (FDA) or are not considered the standard of care. FSA (Flexible Spending Account) - An FSA lets you set aside pre-tax money for common medical costs and dependent care. FSA funds must be used by the end of the term-year. It will be sent back to the employer if you don't use it. A few common FSA-qualified costs include:
- Copays for doctors’ visits, chiropractor and psychological sessions
- Hospital fees, medical tests and services (like X-rays and screenings)
- Physical rehabilitation
- Dental and orthodontic expenses (like cleaning, fillings and braces)
- Inpatient treatment for alcohol or drug addiction
- Vaccines (immunizations)
Inpatient Services - Services received when admitted to a hospital and a room and board charge is made.
Legal Guardian - The person who takes care of a child and makes healthcare decision for the child. This person is the natural parent or was made caretaker by a court of law.
Medical Care - Medical services received from a healthcare provider or facility to treat a condition.
Medically Necessary (or Medical Necessity) - Services, supplies or prescription drugs that are needed to diagnose or treat a medical condition. Also, an insurer must decide if this care is:
- Accepted as standard practice. It can't be experimental or investigational.
- Not just for your convenience or the convenience of a provider.
- The right amount or level of service that can be given to you.
Example: Inpatient care is medically necessary if your condition can't be treated properly as an outpatient service.
Medicare - A federal program for people age 65 or older that pays for certain healthcare expenses.
Network Provider/In-network Provider - A healthcare provider who is part of a plan’s network.
Non-covered Charges - Charges for services and supplies that are not covered under the health plan. Examples of non-covered charges may include things like acupuncture, weight loss surgery or marriage counseling. Consult your plan for more information.
Non-network Provider/Out-of-network Provider - A healthcare provider who is not part of a plan’s network. Costs associated with out-of-network providers may be higher or not covered by your plan. Consult your plan for more information.
Outpatient Services - Services that do not need an overnight stay in a hospital. These services are often provided in a doctor’s office, hospital or clinic.
Out-of-pocket Cost - Cost you must pay. Out-of-pocket costs vary by plan and each plan has a maximum out of pocket (MOOP) cost. Consult your plan for more information.
Prescription Drug - Any medicine that may not be given without a prescription because of federal or state law.
Premium - Payments you make to your insurance provider to keep your coverage. The payments are due at certain times.
Provider (Healthcare Provider) - A hospital, facility, physician or other licensed healthcare professional.
Urgent Care Provider - A provider of services for health problems that need medical help right away but are not emergency medical conditions.