While scheduling an appointment at Trinity, you will be asked if you would like to use insurance or “self pay.” If the choice is to use insurance, then all insurance information will be gathered at the first visit. We will set up everything for you and submit a claim for each visit. The charge will be either the co-pay listed on the insurance card or $25.00. After the visit a claim will be sent to your insurance company. The claim tells the company your diagnosis and the treatment received in our office. The company processes this information and creates an “explanation of benefits” or an E.O.B. A copy of this explanation is sent to our office and to you. The EOB tells both of us what amount the insurance company is paying Trinity for visits and the amount you are responsible for paying our office. Our insurance specialist will enter the information into our computer and adjust your account accordingly. Meaning, if you paid a $25.00 co-pay for your visit and it should have been $20.00, you will receive a credit of $5.00 for each visit overpaid. The opposite is also true. If we charged $25.00 per visit and the co-pay was actually $30.00 you will be billed for the additional $5.00 per visit.
Important insurance terms:
In-Network: Doctors can choose to be “in-network” with certain companies. In order to be in-network the doctor must agree to accept the amount of money the insurance company says a service is worth. Then the doctor will write off the rest. For example, the doctor will charge $61.00 dollars for an adjustment, but Blue Cross Blue Shield says that same service is only worth $44.32. That is all they will pay. So the doctor will accept that payment and write off the $16.68.
The amount your insurance company will pay for services is different for doctors who are NOT in network. So if you chose to see a doctor out of network you will probably end up paying more out of your pocket for the services.
Deductible: This is the amount that must be paid out of pocket before your insurance will pay anything on a claim. So for example, if you have a $300.00 deductible then you will pay $300.00 worth of bills to your Doctor(s) before your insurance pays anything. After you have paid or “met” your deductible, your doctor visits will be subject to a co-pay, co-insurance, or may be paid completely by your insurance company. It all depends on your plan.
Co-pay: a set amount that you pay each time you go to the doctor. The insurance company will pay the rest of the visit. Sometimes there is a higher co-pay to see a specialist and a lower one when seeing your regular doctor. For example: You may pay $25.00 each time you go to your family doctor. But you may pay $35.00 when you go to see the heart doctor.
Co-insurance: Co-insurance is a percentage of the bill that you pay yourself; the rest is paid by your insurance company. So if there is a 20% co-insurance you will pay 20% of the charges for your visit and your insurance company will pay the other 80%.
Myths about insurance
Myth 1: “I have insurance so they should pay for everything.” It is rare that an insurance plan will pay all of your medical bills. Most often the company asks you to pay a portion of your medical visits either through co-insurance or co-pays or yearly deductibles.
Myth 2: “If I receive a bill from the office this means that my visit wasn’t covered by my insurance.” Just because you owe our office money doesn’t mean that the services were not covered. Often, by consulting the explanation of benefits (EOB) for that visit you will be able to see why there is a charge. (deductible, co-pay or co-insurance)
Myth 3: “The staff at Trinity should be able to tell me what my insurance plan covers” It is your responsibility to know what your plan covers and what it does not cover. You can call the number on your insurance card and ask them about your coverage at any time.
In reference to seeing the chiropractor, the questions you need to ask about your plan are the following:
Does my plan cover chiropractic visits? If so how many visits per year?
- Will I have to pay a deductible, co-pay or coinsurance on my chiropractic visits? (if you have a deductible to meet you should ask how much you have remaining)
Myth 4: “If I have insurance I have to use it” Some people choose not to use their insurance in our office. Instead they are “self pay” patients. Self pay patients receive a discount for paying at the time of service. For some people who have high deductibles this is better for them financially.
Your rights as an insured:
When you have insurance you have entered into a contract with an insurance company. Every contract or plan is different even within the same company. Your insurance company will also have adjusted your plan based on your health. For example, if you have a pre-existing condition then anything related to that condition will not be covered by your plan, even if it is a service that would normally be covered for anyone else on your plan. The benefit to being in contract with the insurance company is that they have contracts with physicians that will help you get discounted services. (with “in-network” providers)
Every month someone pays your “premium”. Your premium is that amount of money you pay for your insurance normally per month. You could pay it yourself or perhaps your place of employment pays a portion for you. You are purchasing a “plan” from the company. It is important as a customer of an insurance company that you know what your plan does and does not cover. That way you can make sure that they pay for services that they agreed to pay for and you are not surprised when they don’t pay for services they never agreed to cover.
When asking for information about your plan you might have trouble understanding what is being said. Terms like ”subject to deductible”, “subject to co-pay”, “subject to co-insurance”, “in-network and out of network” and “maximum out of pocket” will be used to describe your coverage. In reference to seeing the chiropractor the questions you need to ask about your plan are these:
- Does my plan cover chiropractic visits? If so, how many visits per year?
- Will I have to pay a deductible, co-pay or coinsurance on my chiropractic visits? (if you have a deductible to meet, ask how much you have remaining)