Help with co-insurance calculations and corrections...

Well health and insurance system is a fact we all have to admit, they are not functioning as they are supposed to and many people are left aside. I never really payed much attention to insurance calculations because I know for a fact that there are many imperfections, since this crisis is lasting for too long I try to find alternatives to my health problems, and so far cheap online pharmacy has proven its efficiency for me.

Thank you for this brilliant initiative, this could a lot of people because as we all know we can't complain of trouble when it comes to health insurance. So far I tried to keep myself away from this whole mess and now I have no medical exam life insurance, and that makes me hope for the best.

This part of calculation was always an enigma for me, I was actually helpless when facing the bill and I think people have the right to know more about their payments destinations. I don't really trust health insurance because of that and I was actually thinking to apply for no medical life insurance.

Verifying insurance and collecting both the co-insurance and outstanding deductible at the time of service has never been more important.  More and more patients have to pay more of the bill and many just don’t have the money.  There are a few things that you can do to make it easier for your staff to educate patients about their financial responsibility. 

First, load all of your payer contracts to your patient account system.  Doing so will automate the calculation of the total amount due for the specific services rendered.  Your staff will only have to figure out how much is due from the patient which is pretty easy once they have verified the patient’s benefits.  Second, if your center is contracted with most of the payers, get access to their members’ benefit information on the web.  Most of the large payers have robust web-sites with all the information needed to complete the insurance verification step in minutes.  Calling takes way too long.  Third, give them some step by step tools for helping them thru the calculation.  Most business office staff prefers dealing with patients not numbers.

Over the last several years, many healthcare providers chose not to contract with some health plans because they could not negotiate fair rates.  The "out-of-network" strategy worked for years and in some cases was very lucrative for some.  Unfortunately, all good things eventually end. Health plans are closing their networks by limiting benefits when provided by non-contracted providers.  There are a variety of ways that they do this, but all involve shifting more financial responsibility to the patient.  The Blues and some of the other large plans have implemented daily limits of $380, $500, $540 and $600 for services provided by non-contracted providers. 

The limit is often regarded as a "punitive cap" and to some extent, that is what it is.  People often chose PPO plans because they want more choice and power to direct their care.  While PPO members still have the "power to choose" it comes at a much higher cost, hence the term punitive cap.  Consequently, many patients are chosing to be treated by a contracted or preferred provider. 

What to do?  This is the time to do a little marketing and education.  For instance when negotiating a contract be sure you tell the health plan representative what you can do for them to lower their cost of care.  Many Ambulatory Surgery Centers (ASCs) compete directly against hospitals for the same services.  If you can offer competitive pricing for the same quality of service, you just might get their attention.  With technology advancements, more and more procedures can be safely done in an outpatient setting.  Work with your physicians to establish programs for services traditionally done in an inpatient setting.  Then market them to both employer groups and patients. 

Healthcare is becoming a consumer driven market.  It is time to tighten your belt and get serious about the services you offer and the price at which you offer them.  Whether shopping for a car or healthcare services, people expect high quality at a reasonable price.

Understanding health insurance can be tricky to say the least.  Healthcare providers have to play an eductional role, because too few patient's understand their benefits. It is easier to help patient's if you have a grasp of the key terms, such as those below.

• Deductibles - Just like your car insurance, health plans, in particular PPO plans, require patients to pay a defined amount of money before the plan pays.  There are a few exceptions for preventative services, such as the annual exam, colonoscopies for patients over 50, mamograms for women over 40 etc.  
• Preventative Services - Services categorized as preventative services are generally those that can detect problems earlier when it is easier, safer and less expensive to treat the patient.  Health insurers encourage patients to have preventative services by covering them before the deductible is met.  Additionally, preventative services are often fully paid by the health insurer - the patient has no financial liability.
• Co-Pay - Co-pay is the amount of money the patient has to pay for a specific service or benefit.  Co-Pays are most commonly used in HMO plans (i.e. $25 co-pay for a doctor visit).  It was a way for HMOs to share the cost of the service with the patient.  More and more PPO plans are also requiring patients to pay a co-pay for surgical services, drugs etc. in addition to paying their deductible and co-insurance amount.
• Co-insurance - Co-insurance is similar to a co-pay, in that it is a way for the health plan to share the cost of service with the patient.  The main difference is that it doesn't limit the patient's liability to a specific dollar amount.  The patient is liable for a defined percentage of the allowance amount.  The allowed amount is negotiated between the provider and the payer.  Therefore, the patient's liability is often different even if the type of provider is the same.  In other words, the rates paid by the health plan to provider A are often different than the rates paid to provider B.  If the rates paid to provider A are more, the patient will pay more. 
• Out-of-Pocket Maximum - The health plans limit the patient's financial responsibility for a calendar or fiscal year by setting a maximum amount that the patient will have to pay.  It can get tricky to calculate when the patient will reach their maximum amount because sick patients, utilizing their benefits and nearing their threshold are often treated by more than one provider. That's why the health plan is the best source of information to determine whether or not the patient has met or exceeded their out-of-pocket maximum in any one year.