HMO, PPO, POS, or EPO?
How well do you know your healthcare insurance plan?
“Hello, my name is Christina and I am looking to speak with Jane*.”
“Hi Christina, this is Jane. How may I help you?”
“I am calling from the Neurology practice where you have an upcoming appointment. I need to discuss with you a few things about your insurance coverage in relation to the appointment.”
“Do you not accept my insurance?”
“We accept the insurance, but there are some upfront costs that you are responsible for that we like to inform our patients prior to arrival. Are you aware that you have an in network deductible?”
“What is that?”
“That is the upfront amount you must pay every year before your insurance covers anything.”
“But you take my insurance. How much is that?”
“Your in network deductible, which means it is applied towards the doctors that accept your insurance, is $1000.”
“$1000!?! I have to pay that tomorrow?”
“No, no. You only have to pay what the visit is worth tomorrow. That is $240, but if you need and agree to testing that will be additional and can be discussed with the doctor tomorrow. Our doctors take deductibles into consideration when figuring out their treatment plan so hopefully that makes things easier for you. Also I would like to mention that once you come out of your pocket $1000 towards all your doctor visits, your insurance kicks in at 90%, leaving you responsible for 10% of all visits until you reach your out of pocket maximum.”
“Out of pocket maximum?”
“Yes. That literally means how much money comes out of your pocket towards your medical bills. Your out of pocket maximum is $4,000. Once you put $4,000 towards your medical bills, your insurance then kicks in at 100%.”
“But I pay $250 every month for this insurance and you’re telling me I still have to pay when I go see the doctor?”
“Unfortunately, yes. That $250 you pay every month is your premium and that is to keep your insurance active. Deductibles, coinsurances, and copays are all different and separate costs from each other.”
“Wow. Well, I thank you for taking the time to explain it to me. Is there anything I can do to adjust my deductible or something?”
“You mean with us or your insurance? Because if you mean you cannot pay the full $240 at the time of the visit, we can always work a payment plan with you.”
“That would be very helpful, but is there anything I could do with my insurance as well so I don’t have to keep paying this? I can’t pay $5,000 every month for medical insurance.”
“You can, by changing the plan you chose. If you get the insurance from your employer you can discuss the other options they offer, if any. If it’s from the Marketplace, you would choose a different plan from there. I will say, plans with no deductibles mean higher premiums, but you try to work out what is best for you with the information I provided you.”
This is just one of the daily conversations I have with my patients. My partner pokes fun when I say “my patients” as if I am their doctor, but they are my patients, in other ways where the medical care is not provided. My current position is Director of Operations at a multipracticioner Neurology practice with four locations in NYC and one location in Long Island. I have worked my way up to Director, I literally started from the bottom. The Director of Operations has a lot of responsibilities in the back office that no one else handles. I monitor the patient schedule to make sure the structure is followed, verify the patient’s insurance has been checked and there are no outstanding issues, and obtain specialty medication authorizations are just to name a very few. There are also staff schedules, inventory, equipment checks, credentialing and state inspections to name a few more. I ensure all practices are running smoothly and patch up any bumps, potholes, and sinkholes. I was not always the Director of Operations and I have not always worked in Neurology. I love my job because my extensive experience has molded me into a walking information booth when it comes to all things medical insurance and care.
The year is 2004 and I am a senior in High School with five months until graduation. I have never had a job. I have attempted to get one, but was never hired and my feelings were HURT. Here I was, a 17 year old teenager, and probably the only one on the planet who could not get hired at Burger King or KFC.
Back in those days, we had to sit in the restaurant we were applying at and take a 100 question test with a pencil and bubble sheet. You know those questionnaires that are taken electronically now,
“If you caught Tom stealing would you tell your manager, steal with him, or mind your business?”
“If you saw Molly crying in the bathroom do you mind your business, tell your manager, or give her a tissue?”
“Are you barely on time or do you barely have time?
“Would you overwork, lie, stress, manipulate and starve yourself for this company or do you have standards and boundaries, therefore forcing us to fail you on this test?”
I sat there for hours and hours taking those tests and never getting any call backs. I was too ashamed to ever tell anyone KFC, Burger King, and McDonalds did not want me, so I never figured out the reason until way into my 20s. I wasn’t a snitch. I had morals. I was too kind, all the wrong answers for the test. Who knew those were all the wrong things employers were looking for.
I did wind up getting a call; a call for a job I never applied for. My boyfriend’s (at the time) sister, worked front desk at a Pain Management and Rehabilitation office in Brooklyn, NY and they needed help. I was hired at the interview simply because I dressed the part (probably because of my recommendation too). These were the days of paper charts and paper doctor notes, so everything needed to be filed. Faxes needed sorting and records needed to be pulled in preparation for the next day. Every piece of paper that came across my hands, I read. I learned about back pain, lumbar radiculopathy, gait disorder, treatment plans, preferred medications, MRI results, referrals, authorizations, doctor letters…I read them all. I not only had the desire to learn while I was there, but I loved science and the combination of both was lethal.
All employees working in a doctor office, medical facility, or hospital setting must partake in HIPAA training and certification. This must be updated annually. We are authorized individuals with access to all patient medical records once you become a patient to their particular facility. We are also bound under the confidentiality agreement.
Then the Medical Biller needed help coding. I had no idea the immeasurable experience I was gaining at this practice and I learned plenty during my four years working there. I loved this job because it gave me the cement foundation to the professional I was becoming.
After I reached my peak working at Pain Management, I promoted myself to Medical Secretary at an Orthopedic clinic associated with St. Luke’s - Roosevelt Hospital in NYC. I say I promoted myself because I was diligent in finding a position of growth. I knew I was worth $15 an hour (this was 2008) and I knew I would get that rate in NYC.
Adult Orthopedics excelled my skills. I lassoed the medical billing and coding information I learned and tossed it right into my resume. I was now a Medical Biller on paper. Some would call that lying, but I knew what I was doing and I was fascinated by what I was learning.
Everything in the medical insurance world is coded with numbers. If you thought outside the box and had a photographic memory like me, memorizing the frequently used codes in your specialty became easy. I learned the sequence of codes, modifiers, and how to figure one out if I didn’t know. Everything was grouped in classes. Certain codes would automatically approve services and this was key in the authorization world. MRI authorizations became a breeze and my patients never had a problem getting it done. I also “checked out” patients, which meant I provided them with all their referrals and prescriptions after their visits, learning more in depth about patient complaints, treatment plans, and insurance coverage. I was always reading the breakdown of a patient’s insurance. This was crucial in my learning curve as this is where I started to put the pieces to the insurance world together. My skills excelled because here I began actually billing claims to the insurance companies and appealing any denials that came back. Insurance companies found any minute reason not to pay the doctor and I loved sending it right back and receiving a paid claim. I loved this job because this is where I leveled up. The more I learned, the more my patients learned about their insurances. I was upfront with my patients and they loved it; someone who finally told them the truth about their healthcare coverage.
“I’m not sure of your finances, but I can tell you that a higher premium means lower office costs when seeing doctors. So you choose what’s better for you, to pay more monthly and save at doctor visits, or pay less monthly and more at visits. This usually depends on if you’re a frequent visitor of doctors. I hope this information helps when choosing insurance in the future.”
This became my daily saying when breaking down a patient’s insurance costs. My patient’s began to learn their plans and their rights within their plans. No one at the time of sign up ever took the time to break down insurance plans to the patients. If you do not ask any questions, you will not get any answers and this right here is where you will end up with an expensive health insurance plan.
After Adult Orthopedics, I worked in Pediatric Orthopedics and if I was able to choose, I would always work in Pediatrics. It is such a pleasure and less pressure to constantly be a professional. Kids are fun. Here was the first time I worked with Medicaid and low income families. I loved this job because it taught me free healthcare and 100% paid services to doctors are attainable. I left Pediatrics because the doctor retired, he could not handle the huge change that was about to take place in healthcare: Obamacare.
Obamacare changed the healthcare game because it gave everyone an insurance card. The part Obamacare did not promote, nor disclose upfront were the high premiums, deductibles, and in office copays that majority of plan holders will have. I have seen premiums at $500 a month with $4000 annual deductibles and $75 office copays. This potentially means if you are not a frequent visitor of doctors, you may be paying for health insurance and paying for your visits simultaneously because you never get the chance to meet your deductible. In that case, dropping your plan may be in your best interest. You will discover the self pay fees at the doctor’s office are significantly less than that of the insurance company.
After Pediatrics I took a break from work and decided to go to school. I could no longer argue higher pay just based on my experience. I needed certifications to increase my salary bracket. I also became pregnant with baby #1. In the next year, I would become a mother and a certified Medical Billing and Coding Specialist. I passed the test with a 95%; all my experience gave me the knowledge I needed to pass. The 5% loss was due to me failing to memorize HIPAA articles and clauses, but that is fine because no one is going to ask me to recite Section 2 Article 3.4, but they will ask me about confidentiality and patient rights.
I finally felt like a Medical Billing expert. I went on to work in Podiatry, then a surgical center that performs colonoscopies and endoscopies. I loved this job because it taught me what was needed to build a healthcare facility. We made policy binders from scratch, emergency preparedness, fire inspections and training, and most importantly passing the accreditation by the Joint Commission. I had experience from almost every corner of healthcare and I was proud of that. As a result, I was the best healthcare worker that I can be for my patients. Having the confidence that the information I give to my patients is right is one of the best feelings in the world.
After the surgical center, I moved on to become the Director of Operations at my current Neurology Practice. I love my job because I teach the people the truth behind their health insurance. Health insurance is extremely important in society and it is one of the biggest misunderstood, misconstrued, miscommunicated, and misguided resources out there. I love my job because I advocate against all that. I love my job because I learned my job; I know and understand my position to the capacity where I genuinely help my patients.
If anyone reading this feels they need advice or have questions regarding their healthcare insurance or the medical care they are receiving/need to receive, please reach out to me through Facebook or Instagram DM. I became a Medical Billing and Coding expert for this exact reason.
Here are a few helpful tips when visiting a doctor office:
- Always bring your insurance card
- If you have an update or change in insurance or demographic information, let all your doctors know immediately especially if you’re receiving consistent treatment.
- If you have any previous medical records that pertain to your current doctor visits and you plan to bring it up, please make sure you have those records on hand for the new doctor to review.
- It is your responsibility as the insured to know the plan you signed up for. This includes deductibles, coinsurances, and copays. It is in your best interest to know your insurance plan to receive the best possible care.
- Deductibles and copays must be paid at time of visit, but coinsurances are not.
- Adjustments and payment plans are always options, please ask.
- Ask questions. Sometimes it may feel like a burden to do so, but it is in your best interest to do it.
I hope this article reaches people and it helps them. I will come back to update the tips as I think of more. It is very important for people to receive the best possible medical care without draining their finances dry so I will continue to help those who need it by any means necessary.