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Is this covered? |
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Depending on the specifics
of your insurance plan,
there isn’t always an easy answer to this question.
Some services are
covered only after a deductible has been met,
only with network providers,
or only if you pay a higher percentage of the cost.
There is also frequent misunderstanding about how services are
categorized by insurance carriers.
Because each plan is different, our office staff is unable to give
you an answer if you ask “Is this covered?” Your best bet is to
contact your insurance provider directly. |
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When contacting
your insurance company to verify coverage for any service, be sure
to ask: |
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Do I need to meet a deductible before this is covered? If
yes, find out how much your out-of-pocket cost will be.
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Do I need to go to a specific lab or location for this
service? If so, what will happen if I go to an out-of-network
provider?
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Is there any cost other than my co-pay for which I will be
responsible?
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Coverage
Variables: |
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The following services 1) may require higher co-pays, 2) may be
subject to deductibles,
or 3) may result in higher out-of-pocket costs. This is only a
partial list. Please check with your insurance company to verify
coverage. Just because a service is provided in your doctor’s
office does not mean your only responsibility is the co-pay. |
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Sutures, casts, and foreign body removals
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Parents consider the removal of a bean up their child’s nose a
relief. Insurance companies, however, consider it “foreign body
removal,” which is often classified as a surgical procedure along
with other services like wart removal. Be aware: you may be
responsible for additional costs beyond your co-pay, even when a
service is provided in a regular office setting by your primary care
physician (PCP). |
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Preventative vs. Diagnostic services |
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Your insurance may classify laboratory work, x-ray, MRI, and other
services as either preventative (routine) or diagnostic.
Preventative services typically have different co-pay and/or
deductible requirements than diagnostic services. Diagnostics
usually cost more. In some instances, what begins as preventative
care such as a colonoscopy, may become diagnostic care if a
polyp is found and removed during the procedure. In this type of
situation you
may find yourself responsible for more out-of-pocket
cost than initially discussed, and there is no way to make this
determination before the procedure is performed. There may also be
preauthorization requirements for these services.
(Note:
preauthorization
is not a guarantee of payment.) |
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Immunizations and Prescriptions
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Co-pays vary depending on the drug and how it is classified. Some
may require higher co-pays or cost more until a deductible is met,
including:
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Prescription drugs that are not “formulary.” (Formulary drugs
are those on a specific list provided by your insurance
company.)
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Prescription drugs for which there is not a generic
available.
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Immunizations
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Specialty and
Injectables medications
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Specialty and Surgical procedures |
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If you are planning any type of specialty or surgical procedure,
verify coverage with your insurance provider prior to
the date of service.
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Verify whether or not you need to go to a specific facility
(in network).
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Find out if your insurance covers only part or all of the
procedure.
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Ask how follow-up or after-care is covered.
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Preauthorization or pre-certification is often required.
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Common Terms |
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Co-Payment (co-pay).
Your co-pay is the specified amount you must pay for office visits,
prescriptions and other services. There may be additional or higher
co-pays for out-of-network, diagnostic, surgical, and emergency
services. Co-pays do not apply toward your deductible.
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Deductible.
The amount of money you must pay out-of-pocket before
your insurance will cover expenses. Some plans require a deductible
to be met:
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before
any services are covered
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only for specific procedures
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when services are
out-of-network
Some plans may also require a higher deductible for specific
services, or when services are out-of-network.
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Out-of-network.
Insurance companies negotiate rates with specific providers and
facilities, which are considered preferred or
in-network. If you choose to go to a provider who is
not in your network you may be required to pay a higher
percentage of cost, higher co-pay, or the entire cost. Generally,
the office staff can refer you to an approved in-network facility
for lab or diagnostic services, just let them know what facilities
your insurance prefers. |
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Coinsurance.
The portion you must pay towards the total cost of covered expenses.
For example, if your plan pays 80% and you pay 20% of costs, the 20%
you pay is called coinsurance. There is usually a maximum
coinsurance you pay per calendar year.
Coinsurance is usually in addition to any co-payments
and deductibles. |
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Pre-authorization & Pre-certification.
Approval by your insurance company for a specific procedure or
service prior to the date of service. Even for covered
procedures, insurance may deny payment if authorization was not made
prior to the date of service. Office staff can
assist with referrals, pre-authorizations and pre-certifications. |
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