Let’s demistify a few things concerning insurance. Most of us pay for insurance monthly and at exorbrant costs, especially as we age. The more family members on the insurance plan, the higher the cost. When we “shop” for insurance plans we tend to go with the companies with the lowest monthly cost. The real question is, what is the cost at seeking a lower premium? When we seek the lowest monthly cost, we could be taking a financial hit someplace else within that insurance plan such as higher deductibles, higher co-pays, less services covered, and authorization needed for you to receive services. Here are some key concepts to understand:
- Insurance Types:
- HMO – cheaper plans per month, higher deductables, co-pays, requires authorization to use for physical therapy, prone to deny services, likely no out-of-network services, limited choices to see a provider (PCP, PT, etc).
- Authorization is a fancy term meaning that the insurance gets to determine whether your injury or request for services is needed. What? The insurance determines your care, not you. These systems run off an algorhythm and if you meet the quota, you get services. If not, good luck finding care.
- PPO – moderate to expensive plans per month, lower deductibles, co-pays, extensive in-network providers, often has out-of-network services.
- Medicare/ Medicaid/ Tricare/ federal plans – similar to PPOs, generally have specific requirements to obtain, typically requires a script for services, co-pays are possible.
- Managed Medicare plans - this occurs when a private insurance company manages Medicare and essentially turns Medicare into an HMO, which decreases access to providers of healthcare.
- Key Terms:
- Deductible – this amount must be paid before the insurance starts to take over costs.
- Follows across the healthcare system (surgery, PCP, etc)
- Surgical claims processed very slowly
- Needs to be paid down
- This amount can be as little as $1000 to over $25000 depending on the insurance plan
- Co-pay – this is a fixed amount owed per healthcare visit. Often this value is increased for a specialist, such as a neurosurgeon or a physical therapist.
- Co-insurance – this is a percentage-based amount owed per healthcare visit. Based off what insurance company paid not what the healthcare provided billed.
- In-Network – providers or healthcare facilities that are part of a health insurance plan’s network or providers with a negotiated rate of reimbursement.
- Out-of-Network – providers or healthcare facilities that do not participate in a health insurance plan’s provider network.
Insurance companies are not on the side of the patient, nor the provider. They are profit driven.
- Delay - they have systems and processes in place that add barriers to care and slow down healthcare/recovery.
- Deny – they use multiple and ethically questionable tactics to avoid paying providers with some having “Deny all claims” days.
- Dismiss – they make it extraordinarily difficult to communicate with them.
At The SHOP we are out-of-network with commercial/private insurances and a non-provider with Medicare (pure, no managed plans). What this means is that we have a means to provide certain documentation needed for possible reimbursement to you for our physical therapy services. You, the patient, would go through the process to obtain reimbursement and that reimbursement would go directly to you. This process allows us to treat you holistically, with the utmost compassion, and without barriers imposed by insurance companies. Together, we determine your needs for optimal recovery and prevention. Dr Derrick and I look forward to seeing you at The SHOP in Springfield, MO!
