Business Insight Presented by Arlington Dermatology Important Questions Every field, home market, car dealership, and hundreds of others, have several crucial 'must know' questions. The same applies to the medical insurance industry. Yet, we see patients every day who do not know much about that little card in their wallet. You can look up Aetna or Cigna on-line and you find nothing useful unless you enter this very particular plan and member site. This year only, my billing staff counted over one hundred sixty different insurance plans among our patients. Hardly any of the patients knew what is inside their policy. Here are some important questions you should know: Q1.What is covered under my policy? Some insurance plans, especially those purchased in the open market, have only limited catastrophic coverage. All outpatient services are paid out of pocket. Q2.Is this plan an actual insurance or is it just allowance to use discounted network? We have seen it so many times. The ID cards say nothing different than the regular insurance. But when you call the benefit line, you find out there are no claims paid from the plan. The plan allows to discount services according to a common fee schedule but pays nothing. Q3.Can I keep my insurance if I lose my job? This is very important and, in most cases, a negative answer. Most insurance plans are tied to the employers. If you lose your job, you are sometimes entitled to take an extended coverage called COBRA, but you must pay 100% of the premium, which can run into heavy dollars. Q4.What is my responsibility? This is the most diverse answer of all. As many cases as plans. Most of the insurances require co-pays for simple visits but have some 80%, 70%, 50% coverage for other services. Well, to pay 30% of the MRI may mean $300-$400 or more. If you do it several times a year because of your chronic condition, you may end up with thousands of dollars in bills. Knowing your total out of pocket is very important. Q5.What is medical necessity and how to avoid denied bills? Often, doctors order tests that are not directly related to the problem you come for. They do it to eliminate other possible problems. But insurance covers only the tests that directly relate to your problem diagnosis. You need to know when to call your doctor back and ask for a letter of medical necessity. spending an hour and know the answers It usually resolves the problem but it may take long weeks. Q6.How about deductible? This answer you should know immediately. Deductibles are often a leverage of premium. The higher the deductible, the lower the premium. But insurances do not pay anything unless you already paid your deductible. Not many services are excluded; sometimes ER visits are but not the other services delivered in ER. You always need to read the small print. Q7.Do I need referrals certifications? Not knowing the answer may cost you heavy dollars. Many plans require special pre-certification and documentation from a doctor for many services and they also allow for a certain number of those services. or pre- out of pocket In our practice, a good example is the light treatment for psoriasis. You always must check your benefits and make sure you meet the requirements. I could go for much longer but I do not want to make you sleepy. Here is the problem=1: if you are healthy and fit, you do not want to get bothered by these boring questions. Plus, every year, more than likely, you have to learn them again because they change. When you need to know all these answers is when you suddenly get sick. And then, often, you have no time to verify the answers because you need medical help. Do not let yourself get to that point. It is worth ahead of the sick time. Michael Bukhalo, MD Arlington Dermatology 5301 Keystone Court Rolling Meadows, IL 60008 Tel. 847 392 5440 | www.arlingtondermatology.net Business Insight Presented by Arlington Dermatology Important Questions Every field, home market, car dealership, and hundreds of others, have several crucial 'must know' questions. The same applies to the medical insurance industry. Yet, we see patients every day who do not know much about that little card in their wallet. You can look up Aetna or Cigna on-line and you find nothing useful unless you enter this very particular plan and member site. This year only, my billing staff counted over one hundred sixty different insurance plans among our patients. Hardly any of the patients knew what is inside their policy. Here are some important questions you should know: Q1.What is covered under my policy? Some insurance plans, especially those purchased in the open market, have only limited catastrophic coverage. All outpatient services are paid out of pocket. Q2.Is this plan an actual insurance or is it just allowance to use discounted network? We have seen it so many times. The ID cards say nothing different than the regular insurance. But when you call the benefit line, you find out there are no claims paid from the plan. The plan allows to discount services according to a common fee schedule but pays nothing. Q3.Can I keep my insurance if I lose my job? This is very important and, in most cases, a negative answer. Most insurance plans are tied to the employers. If you lose your job, you are sometimes entitled to take an extended coverage called COBRA, but you must pay 100% of the premium, which can run into heavy dollars. Q4.What is my responsibility? This is the most diverse answer of all. As many cases as plans. Most of the insurances require co-pays for simple visits but have some 80%, 70%, 50% coverage for other services. Well, to pay 30% of the MRI may mean $300-$400 or more. If you do it several times a year because of your chronic condition, you may end up with thousands of dollars in bills. Knowing your total out of pocket is very important. Q5.What is medical necessity and how to avoid denied bills? Often, doctors order tests that are not directly related to the problem you come for. They do it to eliminate other possible problems. But insurance covers only the tests that directly relate to your problem diagnosis. You need to know when to call your doctor back and ask for a letter of medical necessity. spending an hour and know the answers It usually resolves the problem but it may take long weeks. Q6.How about deductible? This answer you should know immediately. Deductibles are often a leverage of premium. The higher the deductible, the lower the premium. But insurances do not pay anything unless you already paid your deductible. Not many services are excluded; sometimes ER visits are but not the other services delivered in ER. You always need to read the small print. Q7.Do I need referrals certifications? Not knowing the answer may cost you heavy dollars. Many plans require special pre-certification and documentation from a doctor for many services and they also allow for a certain number of those services. or pre- out of pocket In our practice, a good example is the light treatment for psoriasis. You always must check your benefits and make sure you meet the requirements. I could go for much longer but I do not want to make you sleepy. Here is the problem=1: if you are healthy and fit, you do not want to get bothered by these boring questions. Plus, every year, more than likely, you have to learn them again because they change. When you need to know all these answers is when you suddenly get sick. And then, often, you have no time to verify the answers because you need medical help. Do not let yourself get to that point. It is worth ahead of the sick time. Michael Bukhalo, MD Arlington Dermatology 5301 Keystone Court Rolling Meadows, IL 60008 Tel. 847 392 5440 | www.arlingtondermatology.net