Health insurance is considered a necessity in today’s culture, but it’s far from being “straight forward”. A few things to remember:
- Health insurance companies are for-profit without national regulations
- Since there are no “standards,” these companies can choose pricing and coverage
- Many will receive a bill a few months after a service (for the remaining balance that insurance refuses to cover)
- Most clinics, hospitals, and labs have to bill insurance 3-10x the actual desired bill (usually based off Medicare billing rates); insurance companies rarely cover the total bill, and patients end up having to pay the remaining balance
- Insurance companies may reimburse for “out-of-network” care (i.e. healthcare services that are not contracted with the insurance company), but instead of the clinic doing the work, it is up to the patient to do the work (which can take a while!).
At CCM, we cannot guarantee coverage or reimbursement from your insurance plan, but we highly encourage pursuit of reimbursement. We do not file insurance claims or assist with this.
Click here for a good resource that goes into more detail on this topic.
A health insurance claim is when you request reimbursement or direct payment for medical services obtained.
The way to obtain benefits or payment is by submitting a health insurance claim via a form or request. For out-of-network claims:
- You, as the requestor for reimbursement, fill out the health insurance claim form and send it to your insurance.
- Reimbursement is between you and your health insurance company.
Some questions to ask your insurance provider:
- Do they have a rate for reimbursement of out-of-network expenses (e.g. 30-70%)?
- Do they require any of the following:
- Practitioner NPI
- Clinic Tax ID
- W-9 Form Submitted by the Clinic
- ICD-10 Diagnosis Codes
- CPT Codes
- Nature of visit (i.e. routine/preventative care or care for a specific ailment)
Call your insurance provider, and document your call (with name of insurance representative, date of call, and time of call).
Step 2a : If verifying coverage of a lab test
- Ask for a yes/no answer about coverage of the test.
- Ask how much of your deductible is remaining
- Ask about co-insurance (usually 20-50%)
- Ask how much annual out-of-pocket expense is remaining
- Ask about the process for filing for reimbursement of a lab if you pay a cash price (which is usually 3-10x less than the price billed to insurance)
*If your deductible or co-insurance is high, and the test is not covered, we recommend the cash price for lab testing
There are a few forms that insurance often requires for a reimbursement request:
- Itemized bill, which has ICD-10 codes, CPT codes, and practitioner information (we provide this in the EMR, under “Invoices,” after payment so the invoice states “Paid in Full”)
- Receipt for services, proving that you paid for the service (this is not through our EMR).
- Claim form (usually obtained from insurance company)
At Center for Collaborative Medicine, our practitioners are licensed through the state of Texas to be able to prescribe and order testing.
- Lab tests through commercial labs like Quest, CPL, Cleveland Heart Labs, and LabCorp require specific codes that we provide.
- When paying for lab testing via the above companies, we provide the codes and orders, and the lab will bill your insurance.
- The business of medicine is not like any other business. For example, if a set of labs “retails” (i.e. cash price) at $300, the lab often bills insurance for 5-8x that amount (i.e. $1500-$2000) but insurance never pays that amount. Insurance chooses what they will cover, which may only be $300, and the rest is up to the patient (or lab) to pay.
- If you have “stingy” insurance, we recommend using a lab’s cash prices and submitting your receipt for insurance reimbursement. There is no way of knowing what insurance will or will not cover.
- There are only a few companies for which we recommend using insurance directly.
- But most of these labs report that when patient pursue reimbursement, they often get 60% or more back.
- Obviously, this is not guaranteed (and ultimately up to individual insurance companies), but it can be worth pursuing!
Some insurance companies will request that a claimant (you, the patient) fills out a form asking for more information about symptoms and reason for visit. These typically ask about acute issues (e.g. accidents, occupational injuries), when the symptom began, or if the symptoms for which you were seen have been treated by others in the past.
The purpose of these questions is often to validate a reason for certain labs or a visit. Since we put ICD-10 codes on each invoice/lab order, which are codes that try to “explain” your symptoms, we recommend matching these codes with your history of symptoms/condition. Sometimes the codes are not straight forward, but focus on those that make sense (e.g. fatigue)! Some of the more obscure codes may be related to immunity (if seeing Meg), so we recommend describing your opinion on how your immune system is functioning in these cases (e.g. always getting sick, unexplained fatigue, reactivated “mono”).
It can take a long time to receive reimbursement. Fight with your insurance for your money, since you are a consumer and have a contract with them (and are paying them)! Yes, it may take a few calls, but keep trying.
If your insurance company requires us to contact them, we do not do this and you will have to point out why (namely, we are not contracted with them and do not work for them).
Some insurance companies request a W-9 from us, or our tax ID. We really prefer not to do this for the following reasons:
- The purpose of a W-9 is to show that money was paid by a business to another business or person (in excess of $600).
- Since we do not receive money from insurance companies, we really should not be required to submit W-9 forms.
- You as the patient may need to fill one out, since you are the one receiving the reimbursement. But this is between the patient and his/her insurance.
- We provide invoices (after paid), stating that there is no balance due and that the entire visit was paid by the patient. This shows the insurance company that you did indeed pay for the service for which you are asking reimbursement.