No matter if you are a provider confirming coverage or patient receiving an unexpected bill, knowing your insurance status is of utmost importance. There are a few methods of doing this.
Start with your health plan’s website or portal. Many offer network, provider and doctor search tools which allow for easier comparison shopping between plans.
Coverage Documents
Insurance verification is an integral process that helps verify the legitimacy, accuracy and sufficiency of an individual or business’s coverage. It serves an array of functions for business operations, risk management and compliance activities – ultimately helping meet regulatory or contractual requirements as well as maintain customer trust and keep clients or customers.
One of the key steps in the process is making sure you have all of the relevant paperwork, such as insurance policy documents. This may be a difficult feat when dealing with more complex coverage, like health plans that require specific documents like physician referrals, pre-authorizations and certificates of medical necessity for reimbursement of services. Furthermore, certain policies have an exhaustive list of exclusions or services not covered under their policy.
There are ways to streamline this process more efficiently. One option is using online insurance verification tools that allow you to input all relevant information and then generate a summary report automatically. Another is gaining direct access to payer portals or websites where there may be online tools that allow you to enter policy details and view coverage details quickly and efficiently.
Evidence of Coverage (EOC). This document, commonly found in plan booklets or coverage documents for individuals or businesses, can provide invaluable policy guidance. An EOC helps you to assess what coverage exists as well as any restrictions or limits of such coverage; such as copayments, coinsurance premiums or deductible payments you need to make or benefits available from an insurer for certain services provided.
If your policy has been terminated, the EOC can offer helpful guidance regarding what steps should be taken. In most instances, reinstating it requires submitting new application and proof of coverage documents; to avoid delays be sure to send these in right away once selecting your new plan.
CPT Codes
CPT codes are numerical designations used by physicians and healthcare providers to report medical procedures, tests and evaluations to insurance companies. The American Medical Association CPT Editorial Panel oversees their development with input from clinical and industry experts; any healthcare professional qualified enough can use CPT codes for billing and tracking purposes.
Coding systems are essential, since their effectiveness determines how much reimbursement a health insurance company pays for procedures performed by doctors and hospitals. Accuracy in documentation increases chances that full payment for services rendered will be granted; as a result, doctors and hospitals take great care to use appropriate codes; especially for procedures that bundle services together such as knee replacements or spinal cord injuries.
CPT codes consist of five characters that may be either numeric or alphanumeric in nature, with three representing injury/disease documented by healthcare provider while two identify which category the code falls into. There are multiple categories; most frequently I-V are used; with IV reserved for experimental procedures/procedures.
E&M (Evaluation and Management) codes offer physicians a quick way to document office visits by eliminating duplicate code pairs that must be deleted and resequenced when recording visits. They’re conveniently grouped at the front of the book for easy access.
The Centers for Medicare & Medicaid Services provides a free online Medicare Coverage Database which allows users to search national coverage determinations (NCDs) and local coverage determinations (LCDs), which outline which tests, items and services Medicare covers. Furthermore, you can search using keywords, location or Medicare contractor name as well as CPT/HCPCS codes.
In-Network Providers
One of the key determinants in healthcare costs is whether your doctor or healthcare provider belongs to your insurance network. A health insurance provider network refers to a collection of doctors from multiple specialties who have contracted with an insurer to accept pre-negotiated rates; these providers are known as in-network providers and their out-of-pocket costs will likely be significantly less when seen through one than when seen elsewhere.
Insurance companies typically offer websites where you can search their network of healthcare providers. But to get an accurate assessment, the best way is to call directly and ask. Doing this will provide more precise answers and protect you against an unexpected bill down the line.
Before scheduling an appointment, having all the appropriate information can help reduce unexpected surprises down the line. Being aware of which physicians and healthcare providers are participating will allow you to select those offering cost-effective health services.
An HIP provider could either be in or out of network due to numerous reasons, such as retirement or relocation to a different city, lack of acceptance for new patients or choosing not to remain part of your health insurance provider’s network.
Some plans require you to use providers within their network while others do not, however, it’s wise to select an in-network provider whenever possible to decrease out-of-pocket costs and help reach financial wellness goals more quickly. Otherwise, out-of-network healthcare providers could force you to pay the full charges associated with them which can become very costly over time. So it is always in your best interests to check before scheduling an appointment whether a provider is part of their insurance network, as this simple step may save a substantial sum over time!
Out-of-Network Providers
“Out-of-network” refers to doctors and facilities who do not comply with the pricing contracts of an insurance network, often charging full price for their services regardless of what your health plan covers; any balance billing that exceeds what was covered might count against your deductible and out-of-pocket maximums but will typically not count toward them.
However, you have an option available to you to try to negotiate an in-network rate with your provider. Start with a phone call, asking for their name, title, and direct telephone number so you can reach them directly. Be polite but firm in explaining that you would like services at in-network rates from them; ask them also to write a letter summarizing this conversation and your request to send to your health plan for review.
If your health plan refuses to cover out-of-network care that you need, an appeal may be available. The process varies depending on your plan and state laws; contact a consumer assistance program in your area for help in filing an appeal.
Health plans must cover emergency services provided by out-of-network providers; however, they are not obligated to cover cost sharing such as copayments, coinsurance or deductibles associated with these services. Your plan must calculate what amount it would pay an in-network provider before including this information in its explanation of benefits document.