It is hard to miss the pattern of selling carefully worded notions on glossy pamphlets while the truth lies hidden in pages of unfamiliar terms written in a font size of 6. Are you familiar with the terms; EOB, PPO, HMO, deductible, out of network service, copayment, co-insurance, preferred, nonpreferred, eligible, percentage of plan allowance, excluded service, spending account, prior authorization, gap-exception, HSA, FSA, required, pre-approved, preferred provider, in network, preventive care, and Coordination of Benefits to name a few? Each layer of complexity seems intended to hide additional fees that when added together can really add up to a lot of money.
Imagine if booking a trip with an airline used the same approach that health care takes?
So, when we attempt to estimate cost of a visit, it’s a multi-step process, a summary of which is as follows:
1. First we need to break up the service we provide and try to map them to payable codes representing “standard” services required by payers, which are complex, sometimes inapplicable, and often times out of date.
2. Then we map each individual code to both “service types” and directly to your insurance policy, and each policy will apply deductible, copay, co-insurance, authorization rules, prior-approval rules, diagnosis rules per provider type, etc, differently to each code and/or service type, depending on your specific policy.
3. Finally we calculate total charges and estimated insurance coverage the best we can.
The only way to truly overcome this insanity is to team up with our patients and achieve an understanding that the only guarantee is that the patient is responsible for the stated maximum (our normal charges) minus what the insurance covers.
We urge everyone to study the details of their plan before someone in your family gets hurt, because simply going where you are told to by your carrier can cost you in time and money.