Understanding Your Insurance

Insurance. Is. Complicated.

Have you ever received a bill from your doctor and wondered why you still owed something after it was filed to insurance? That’s so confusing, isn’t it. In this video, Tulin, MaxWell Clinic’s Billing coordinator, translates some common insurance jargon for you, so you can understand more clearly how your insurance works. 

The reason you receive an outstanding bill is directly related to your EOB. So, let’s take a look at what an EOB looks like. 

EOB stands for Explanation of Benefits.This is a document your insurance company sends to you and your provider to let you know a claim has been processed. Your EOB lets you know which healthcare provider has filed a claim on your behalf, what it was for, whether it was approved, and for how much. You should always review your EOB to make sure it’s correct. 

Here’s a breakdown of some common terms you will find on your EOB:

• Total Charges – This is pretty self explanatory and is the total of all charges before any deductions.
• Contractual Adjustment, Network Savings, or Write Off – This is an amount subtracted from total charges and is based on a contractual agreement between the provider and the insurance.
• Allowed Amount – Total Charges minus Contractual Adjustment
• Provider Payment or Provider Due – This is the amount the insurance or “payer” will pay the provider for the date of service.
• Deductible – This is an amount that the insurance requires the patient to pay “out of pocket” before the payer will pay anything towards your visit.
• Copay – A flat amount required by the insurance for each visit. These typically differ based on the type of visit. ***Note*** Not all plans have copays.
• Coinsurance – This is a percentage of total charges you must pay after the contractual adjustment, deductible, and copay have been removed. ***Note*** Not all plans have copays.

So that’s some commonly used language for an EOB.

Occasionally, you might notice that insurance didn’t cover a particular service. If that happens, here’s a few terms you need to know.

• In or Out of Network – These terms refer to whether a provider has signed a contract with your particular insurance company. This can differ not only by company but plans within a given company.
• ABN or Advanced Beneficiary Notice – A notice, usually dealing with Medicare, stating that something will not be covered by your insurance.
• Marketplace Insurance – Insurance not offered through an employer, Medicaid, or Medicare. Also known as Affordable Care Act or Obamacare. Marketplace insurances don’t have the same protections against pre-existing conditions. 

If you are out of network, MWC can’t submit a claim directly to your insurance company, but that doesn’t mean you can’t get reimbursement from your insurance company.  Reimbursement means you pay MWC directly for your service, we give you a receipt, and then you can submit that receipt to your insurance company. 

In order for you to submit claims to your insurance company for reimbursement, the normal paid receipt we upload to your portal isn’t enough. If you need to file a claim for reimbursement with your insurance, we’re happy to create this special invoice, called an insurance invoice for you. All you have to do is ask. 

Here’s what that special invoice will include. On top of the obvious PHI (Personal Health Information) such as your name, date of birth, Subscriber ID, and Group Number, it will also include information about your visit:

• Providers Name
• NPI or National Provider Identification – Think of this as an Employee Number of sorts.
• Location – This is where the services were performed. They, specifically, need to know which of the following it was: Telehealth, Office, Hospital, etc
• Date of Service
• Procedure Codes or CPT Code: These describe what was actually done. Think of these as UPC on goods in the store.
• Diagnosis Codes – These Codes explain the illnesses or disorders that you have been treated for in the past. These codes must justify any procedure or labs performed.
• Item Charges – The amount charged for that procedure code
• Total Charges – The total of all charges before any deductions. ***NOTE*** This is not the amount you should expect to be reimbursed.
• Amount Paid – The amount you paid at the time of service.

Remember, if you need to submit for reimbursement, whether it be you’re out-of network, you use a medi-share, or you need to submit something to Aflac, all you need to do is ask us to generate an insurance invoice. We’re happy to take care of that for you. 

So, there you go… I understand how complicated insurance can be and I hope this helps you navigate through some of those commonly used issues and terms!  If you have any questions at all, just give us a call.