Understanding Your Insurance

 

Navigating your way through the insurance maze can be a confusing and sometimes frustrating experience.   Changes in the healthcare system have only made it more confusing.   Patients are often hit with Out Of Network Providers, Referrals, Non- Covered Services, benefits, deductibles and co-insurance issues and it is the patient’s responsibility to know this.     We at Cross Timbers ENT PLLC know this is frustrating, and we want to help you navigate through the insurance maze.

Ultimately, it is the patient’s responsibility to be familiar with their plan, know the benefits and providers contracted with their plan.

Here’s a few FAQ’s:

 

Do you take my Insurance?

Insurance plans have changed so much in recent years. So many individual plans and plan groups have been created. Even though your doctor may be participation on the underwriting plan, they may be out of network for your individual plan or group.   For example, your doctor may participate with Blue Cross Blue Shield, but not with the Silver plan.   They are in network for Aetna but out of network for Aexcel, or Scott & White plan.   It’s very tough to know if your doctor is on your individual plan.

Call the customer service number on your insurance card and verify that your doctor is in network.  This is the ONLY way to be absolutely sure that your visit with the doctor will be processed as in network. The doctor’s office may not get this information for you, so always call and verify with your insurance.

 

Do I need a referral?

Many HMO, EPO, and other plans require a referral from your primary care physician to see a specialist.     Again, call the customer service number on your insurance card to verify if your plan requires a referral.   Call your Primary Care Physician and have them issue a referral to your specialist.   For best results bring a copy of your referral to your specialist visit with you to ensure they have your referral on file.

 

How much will I have to pay?

Insurance plan benefits vary per plan. Some plans have a co-pay, or a set amount that you pay per office visit. Some have a deductible, which is a set amount the patient must pay out of pocket before benefits are paid. Most often a deductible is followed by a co-insurance, which is a percentage of the visit or services that the patient is responsible for paying.   For example, you may have a $2000 deductible with a 20% co insurance.   That means that you must pay the first $2000 then 20% of the negotiated rates for your insurance.   These amounts are typically due at the time of service, so be prepared to pay them at your visit.   Note that Co-payments typically apply to office visits only and procedures or diagnostics generally apply to a deductible and co-insurance.

 

Does my insurance cover that?

Our office will make every attempt to verify your benefits, but to be sure of what is covered and at what level/amount, we recommend calling the customer service number on your insurance card to verify your coverage and benefits.   Ask about office visits and in office diagnostics or procedures to get a clear picture of what you may encounter during your visit.

 

What is an Out of Network?

As mentioned above, your doctor may not be in network for your individual insurance plan.   This is referred to Out Of Network.   Some insurance plans have Out Of Network benefits that are generally at a lower coverage amount than for an In Network Provider.   Some plans have no Out Of Network Benefits which means you will be financially responsible for 100% of your charges.   Call the customer service number on your insurance card and verify that your doctor is in network.  

 

What is a Non Covered Service?

Some services are excluded from your insurance plan. This means they are Non-Covered services.   You will be responsible for paying Non Covered charges in full.

Should you have any other insurance questions, feel free to call our office and ask one of our insurance specialists for help. We’re here for you!