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Insurance jargin you need to know

Posted Oct 23 2008 1:32pm
Ok - so after a stressful day at work I am putting this out there because the bottom line is - you should NOT have health insurance if you don't know this stuff! So stop calling my office and asking me why you have a balance if it went towards your deductible - here is your explanation.

In-network: This means the place you are going (hospital, doctor, etc) is contracted with your insurance company. They MUST accept the contracted rate in which your insurance pays them. This DOES NOT mean you will not have a balance.

Out of network: Providers are nonparticipating with your insurance and can balance bill you for whatever your insurance does not pay. Example: Your X-ray cost you $200. Your insurance only paid $50. That provider can bill you the balance of $150.

Contracted: This means the place you went (doctor, hospital) has a written agreement with your insurance to accept payment directly from them and accept a negotiated amount on your claim (they don't pay it in full and there is a discount).

Claim: The bill for your services

Deductible: This could be an IN or OUT of NETWORK deductible. You may have 2 - you may also have an individual and a family one to meet each year. This is an amount you have to pay each year before your insurance starts to pay claims for you.

Co Insurance: This is usually an amount left after insurance. Such as your insurance pays 90% and you are responsible for 10% of each claim.

CoPay: This is what you pay for a doctor visit, specialist, hospital. Also what you pay at the pharmacy for your prescriptions.

Invisible provider: This is providers that work within a facility that you may not know about but bill separate from the actually place you went. Example: you go for an X-Ray at the hospital. The hospital charges to do the exam (use of the room and equipment). Then there will be a professional fee for the reading of the exam from the radiologist. Sometimes this provider is a separate group from the hospital itself and will bill separate. This also happens with ER docs, lab work, etc.

Reprocessing: Your insurance is looking at a claim they already processed and looking at it again to see if it was processed correctly.

Duplicate: the claim was received more than one time by the insurance OR more then one of the same exam was done on the same day and more documentation is needed.

Coordination of benefits: Every year, some insurance companies waste time wanting you to fill out a form saying that you have other insurance or if things are the exact same as they were - I look at it as a waste of time and an excuse for them to hold up claims.

Explanation of benefits (EOB): What your insurance sends you and the provider of service telling you how they have processed your claim.

Pre-existing condition: UGH I don't like this one! This means that before you had said insurance, you had a condition that they feel they now will not cover your services. Sometimes there is a limitation on this, where after a time period they will start to cover it.

Medical Records: This comes from your doctor, or whomever treated you - NOT the billing office, we do not have this info, sorry.

Ok kids, that's your lesson for today! There will be a quiz on this later in the week.
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