Friday, July 15, 2005

Maybe a Better Understanding of Your Insurance Coverage

I work in the medical field. I have a few requests for those out there with health insurance, especially if you have an HMO plan. If you have an HMO you have an assigned doctor. It is important that you know what medical group that doctor is in. If you know what group then you know what hospital you should be seen at. I live in CA so I am addressing other Californians. You can not assume if you have a scheduled procedure, or the doctor asks you to go over to the hospital for something else, that you can go to the hospital of your choice. It is vital that you go to that doctor's assigned hospital. Take for instance if you have a UCD doctor then you should go over to UCD hospital for services. If you have a MedClinic or Hill Physicians doctor you should go to a Mercy facility. This is just an example. It just makes the authorization and billing processes so much easier. If you are going to a hospital that is out of your network it is harder to get those claims paid for you. Then your insurance can possibly make you at risk for your bill because you weren't seen at the correct hospital. Also if you have an HMO you should always get an authorization from your medical group for anything that you are having done. If there is no auth, then the insurance can make you responsible for your bill too. If you have a plan that gives you the option of HMO or PPO don't assume that it will be billed as an HMO to save you deductible money. You must have an authorization also for the insurance to process the claim as an HMO for you. If not it will be processed as a PPO, the bill will be higher out-of-pocket for you. Do not let the hospital or doctor tell you "no auth needed". If it is HMO always get the auth. These are some simple examples of how to make you understand your insurance coverage a little better. If you have an emergency and have to go to the emergency room there are laws that protect you and you can be seen at any emergency room. The best advice I can give being in this field is read your coverage book, and make sure you have an auth for anything the doctor says he wants to do; tests, procedures and diagnostic type work. If you have a question, ask me I might be able to help you. Your doctor should be able to answer most of these questions for you also.