It’s been a while since we have talked about insurance on our blog.  I have always had a love/hate relationship with insurance even before I opened my practice.  I always had insurance but never quite understood all of the terms. So I kind of just went along with what my doctor told me I owed. After I opened my practice and decided to become an insurance provider-again it was a struggle to understand how to bill insurance and also communicate that information to our parents.  If you happen to be a parent reading this from our early days-I am truly sorry! Years later-the world of insurance does not seem to be getting any easier. I just happen to be working on a course to teach other therapists how to bill insurance and last week as I was working on the terms and definitions section of the course- the thought occurred to me that perhaps this information would also be great for the parents of the children we see.  At least start you in the right direction.  Here are some terms you may see or have heard:

1. Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. For example, a $1,000 deductible means your family will pay the first $1,000 of covered services. Copays and premiums usually don’t count towards deductible.

• Co-payment (Co-pay): The fixed amount you pay for a covered service. (Heads up Speech and OT isn’t always a covered service).  If your co-pay is $20, you pay $20 at the time of each visit. Some plans have no co-pays. Sometimes you don’t have to pay a copay until you reach your deductible. Here are some things that affect how much a copay is: The benefits or coverage included in your health plan, what services you receive, using in-network instead of out-of-network doctors and hospital. 

• Coinsurance: The percentage of costs of a covered health care service you pay after you have met your deductible. Let’s say the co-insurance is 20% (you have a 80/20 plan). You take your child for a therapy session that costs $100. Once you’ve met your deductible-the therapist will bill the insurance company $100.  The insurance company will pay $80 and you will pay the therapist $20.

• Out-of-pocket maximum or limit: This is the most or the max you have to pay for covered services in a plan year. If your out-of-pocket max is $5,000, once you have spent $5,000 on deductibles, copayments, and coinsurance, your health plan will pay 100% of the remaining costs of covered benefits for the year. That’s why your coworker may start hustling in for those extra medical appointments or even surgical procedures toward the end of a plan year because they are rapidly approaching the out-of pocket-limit.

• EOB or Explanation of Benefits: this document shows the price of a medical service, the amount the insurance company will reimburse the provider based on negotiated rates, how much your health plan paid the doctor or specialist, and member savings. You’ll also see how much of your deductible you’ve paid, and any copayments, coinsurance or other amounts your patient owes.

• In-Network: this refers to providers (Speech therapists, Occupational therapists, doctors) that contract with an insurance company to provide service.  In other words- providers  that make a deal or contract with an insurance company and participate in its programs.  

• Out of Network: Is the opposite of In network. If you as a provider have not signed a contract with an insurance company or if you have tried and they tell you that they have enough providers-then you are out of network with this insurance company.

As a parent or caregiver if you are looking to start speech or occupational therapy and use your insurance to cover it-it is YOUR responsibility to find out what your insurance plan covers.  The last thing I want to do is to give you another project but you definitely want to be an informed consumer.  When you call your insurance company here are some questions you should ask :

1. What is my coverage for speech (or occupational) therapy benefits?
2. Do I need preauthorization for therapy?  If so how do I obtain it?
3. Is this therapist (the therapist you want to use) in network or out of network?
4. If the therapist is in-network ask: Is there a deductible, co insurance or co-pay with my plan?
5. If the therapist is out of network you may be able to pay out of pocket and submit a claim yourself to the insurance company so you should ask the following: What forms do I need when filing a claim?  Can they be found on the website?  Where? Can I fax or email it to you or do I submit it through mail? Do I need to file my claim within a certain amount of time after the date of service? Do I need a superbill from the therapist? What can I do if you deny the claim?

Always remember to get the name of the provider representative with whom you spoke and a reference number if they have one, along with the date and time of the call.  I also recommend you keep all of this information in a file folder or on a google doc so that you can easily access it.  I hope this is helpful in the making insurance company a little more understandable.