Health Insurance Billing

Behind the Scenes: How does health insurance billing work?

Dealing with health insurance can be tedious and confusing, which is why our office tries to minimize that stress by handling it for you. We want to make sure our patients have the behind the scenes information on insurance billing to strengthen their understanding. When scheduling with an Elixia provider you will be asked if you would like to use insurance or “self-pay.” If you’re choosing to use insurance, all insurance information will be gathered prior to the first visit so that we can contact your insurance company to determine eligibility and coverage. Unfortunately, insurance companies do not guarantee their quote of benefits, so our office cannot guarantee we have received the correct information. It is important that patients familiarize themselves with their insurance plans by calling the insurance.

As the patient, you will not need to submit a bill (also known as a claim), unless you are using an Out of Network provider. If you are seeing an In Network provider, we will set up everything for you and submit a claim for each visit. The charge will be a co-pay or a percentage of the visit according to your benefits, your deductible, or a combination of these.  After the visit, a claim will be sent to your insurance company from our office. The claim tells the company your diagnosis and the treatment received in our office.  The company processes this information and creates an “explanation of benefits” or an E.O.B. A copy of this explanation is sent to our office and to you. 

The EOB tells both of us what amount the insurance company is paying Elixia for your visits and the amount you are responsible for paying our office.  Our insurance billing specialist will enter the information into our computer and adjust your account accordingly.  This means if you paid a $25.00 co-pay for your visit and it should have been $20.00, you will receive a credit of $5.00 for each visit overpaid.  The opposite is also true. If we charged $25.00 per visit and the co-pay was actually $30.00 or you had not yet met your deductible, you will be billed for the additional balance per visit.

Myths About Insurance

Myth 1:  “I have insurance, so they should pay for everything.”  It is rare that an insurance plan will pay all of your medical bills.  Often the company asks you to pay a portion either through co-insurance or co-pays or yearly deductibles.

Myth 2:  “If I receive a bill from Elixia this means that my visit wasn’t covered by my insurance.”  Just because you owe a balance doesn’t mean that the services were not covered.  Often, by consulting the explanation of benefits (EOB) for that visit you will be able to see why there is a charge (Deductible, co-pay or co-insurance).

Myth 3:  “The staff at Elixia should be able to tell me what my insurance plan covers.” It is your responsibility to know what your plan covers and what it does not cover.  You can call the number on your insurance card and ask them about your coverage at any time. In reference to seeing the chiropractor, the questions you need to ask about your plan are the following:

  1. “Does my plan cover chiropractic visits?  If so, are there limits on how many visits?”
  2. Will I have to pay a deductible, co-pay or coinsurance on my chiropractic visits? (if you have a deductible to meet you should ask how much you have remaining

Myth 4:  “If I have insurance I have to use it” When seeing an in network provider this is true due to the contracts. However, if the in network deductible is high, patients can choose to see an out of network provider under “self-pay”. Self-pay patients receive a discount for paying at the time of service, which may be less than paying the in network insurance rate towards an unattainable deductible. 

Your Rights as an Insured

When you have health insurance you have entered into a contract with an insurance company.  Every plan is different, even within the same company. The benefit to being in contract with the insurance company is that they have contracts with physicians that will help you get discounted services (with “in-network” providers).

Your premium is that amount of money you pay for your insurance normally per month.  You could pay it yourself or your place of employment pays a portion for you.  You are purchasing a “plan” from the company.  It is important as a customer of an insurance company that you know what your plan does and does not cover.  That way you can make sure that they pay for services that they agreed to pay for and you are not surprised when they don’t pay for services they never agreed to cover.

When asking for information about your plan you will want to familiarize yourself with their terms such as: “subject to deductible”, “subject to co-pay”, “subject to co-insurance”, “in-network and out of network” and “maximum out of pocket” will be used to describe your coverage. 

Important Insurance Terms

In-Network:  Doctors can choose to be “in-network” with certain companies.  In order to be in-network, the doctor must agree to terms with the specified insurance company to accept the amount of money the insurance company says a service is worth. If the doctor’s fee is higher than what the insurance company allows, the doctor will write off the rest.  For example, the doctor will charge $70.00 for an adjustment, but Blue Cross Blue Shield says that same service is only worth $44.32. That is all they will pay.  So the doctor will accept that payment and write off the $16.68. The amount your insurance company will pay for services is different for doctors who are NOT in network.  So if you chose to see a doctor out of network you will probably end up paying more out of your pocket for the services.

Deductible:  This is the amount that must be paid out of pocket before your insurance will pay anything on a claim. For example, if you have a $300.00 deductible then you will pay $300.00 worth of bills to your Doctor(s) before your insurance pays anything.  After you have paid or “met” your deductible, your doctor visits will be subject to a co-pay, co-insurance, or may be paid completely by your insurance company.

Co-pay:  A fixed amount that you pay each time you go to the doctor. 

Co-insurance:  Co-insurance is a percentage of the bill that you pay yourself; the rest is paid by your insurance company.  So if there is a 20% co-insurance you will pay 20% of the charges for your visit and your insurance company will pay the other 80%.

Maximum out of pocket: A dollar amount limit paid by the patient. Once you have hit your out of pocket maximum for the year, your insurance company may pay all claims after that at 100%. However it is important to ask what accrues towards this out of pocket maximum. For example you may have a $6000 out of pocket maximum, however the copays or deductibles you paid for alternative care are waived from accruing towards that $6000 maximum, meaning it may take longer to reach that out of pocket maximum to have claims covered at 100%.