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What To Ask Your Insurance Provider Before An Appointment

Updated: Aug 15, 2023

Insurance is difficult to navigate even when you think you know your coverage. So let’s talk about it! Here are some things you should ask/know before you go to any doctor’s office.


*THIS MOSTLY APPLIES ONLY TO INDIVIDUALS WITH PRIVATE INSURANCE (IE. ANTHEM BCBS, AETNA, UNITED HEALTH CARE, ETC. NOT MOST MEDICAIDS OR MEDICARE)


*PLEASE NOTE THIS VARIES BY INSURANCE COMPANY, INDIVIDUAL PLANS, WORK PLANS, AND LOCATION. THIS IS NOT TO BE TAKEN AS LEGAL OR HEALTHCARE ADVICE.


First things first. The majority of people have a monthly premium they pay for themselves or for their family. This amount does not go toward a deductible or an out of pocket max, this is just paying for you to have access to insurance coverage. You then have a deductible to meet before insurance starts paying out (most people, some people have a $0 deductible). Sometimes you have both an individual and a family deductible. This means you may have a $1000 deductible and your doctor's appointment was billed out as $500. So you would be responsible for paying that amount and then you would only about half of your deductible amount before you would just owe a copay or coinsurance at another doctor’s appointment. Then you have an out of pocket max that you meet before and insurance covers at 100%. Copays and coinsurance costs usually go towards this amount. Copays are a set dollar amount for that type of service and the location of which it took place (a PCP office may be $30 and a hospital visit might be $100). Coinsurance is a set percentage for services rendered (you may pay 20% of your PCP or hospital visit). Usually you pay EITHER a copay or coinsurance but some people may pay both.



1. DO YOU HAVE THOSE SPECIFIC BENEFITS?


Just because you paid your monthly premium doesn’t mean your plan covers everything. Not all health insurance plans cover mental or behavioral health benefits. So ask your insurance company (for this office) if you have behavioral health benefits. Then ask (for this office) if they cover in-office out-patient behavioral health services.


2. CHECK IF YOUR PROVIDER IS IN-NETWORK OR OUT OF NETWORK.


Each doctor’s office has to become credentialed with an insurance company if they are going to accept insurance. They then have a contract with an insurance company stating they are in-network. Some plans (not all) have out of network benefits, meaning you have a separate deductible, out of pocket max, and coinsurance/copay. Out of network benefits usually do not cover as much as in-network. When you call your insurance company, provide them with the doctor’s office name, provider name, the office address, and sometimes they may ask for the doctor or group’s NPI or Tax ID number (your provider can give you this information, but note not all offices share this information). Ask them if they are in-network or out-of Network. Ask if the doctor you are seeing specifically is in-network because not all doctors in an office may be credentialed with the same insurance companies.


3. CHECK IF YOU NEED PRECERTIFICATION/ A REFERRAL OR PRIOR AUTHORIZATION.


It is a patient’s responsibility to check if they need any of the above before seeking services. Some insurance plans like an HMO may require authorization or a pcp referral in their system in order for insurance to cover services.


4. CHECK THE SERVICES


Ask your doctors office what might be the diagnosis codes and cpt codes they plan on billing out. Then check with your insurance provider if they cover those specific codes. Our office often uses the diagnosis codes F. 88.0 and F. 89.0. Some of our CPT codes (these are the procedure/intake/testing/follow-up codes) are 90791, 90837, 96130, 96131, 96136, 96137, 96138, and 96139.


5. CHECK YOUR BENEFITS


Ask what your deductible is and how much has been met so far. Check what your out of pocket max is and how much you have met. Ask if you have a copay or coinsurance. Your copay and coinsurance may change based off of the code or modality of the appointment. This means if it is telehealth if may be a $0 copay while in office may be $30. For codes this means if 90791 has a $30 copay, 96130 codes may have a 30% coinsurance.


6. ASK YOUR PROVIDERS OFFICE HOW MUCH THEY MIGHT BE BILLING OUT AND ASK FOR THEIR OUT OF POCKET RATES.


7. SOMETIMES A PATIENT CAN SEND ASK FOR REIMBURSEMENT FROM INSURANCE (OR ASK COST TO GO TO OUT OF POCKET MAX) IF THEY HAD TO GO WITH A SERVICE THAT WAS NOT COVERED OR IN-NETWORK.


8. ASK YOUR DOCTORS OFFICE FOR ADDITIONAL HELP IF YOU NEED IT.

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