More terminology:
EOB: This stands for Explanation of Benefits. Once you see a doctor, a claim is submitted to your insurance company for payment. You will get back documentation, called an EOB, that explains how the claim for the visit was processed, and who received payment for what. They will tell you each line item charge, what was billed, how much they “allowed” or covered, and how much went towards your deductible, coinsurance or copayment. If they deny any line items, they will tell you why. You can always appeal denied items.
Appeal: If you want to appeal or fight a denied claim, then you or your doctor’s office can send a letter to ask the insurance company to reconsider their denial. Usually you need a letter explaining why the claim should be covered, and very often is accompanied by medical records. Usually you can fight an insurance company twice (internal a
ppeal) and then it would have to move to an external appeal, which means a third party is hired to review the appeal and renders a final decision. Sometimes an external appeal costs money, but is supposed to be an impartial party since it doesn’t involve the insurance company. They have a copy of your benefits along with the documentation you send.
Coordination of Benefits: Some people have multiple insurance company policies. Let’s say you’re eligible for Medicare and you signed up for Part A & B (Hospital and Doctors), but you also still work and have benefits from your employer. Then your employer’s company decides who is the primary insurance coverage and who is secondary. You don’t get to choose. So if your doctor doesn’t accept your primary insurance but accepts your secondary insurance, you would still consider your doctor as out of network. Let’s say you and your spouse both work and have benefits, and both of your benefits cover your child. Which is the primary insurance for the child? You then use the birthday rule. Take the month of the birthday for both parents (you and your spouse) and whoever has the first birthday (doesn’t matter the year, ONLY the month), that is the primary insurance for the child. The determination of primary, secondary, and even tertiary insurance coverage is called the coordination of benefits.
Hidden Health Benefits: Very often, many insurance companies offer special promotions or discounts for patients of which they may not be aware. For example, some insurance companies may offer to pay for part of a gym membership. Some may offer free products that encourage healthy habits.
Filed under: pain management
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