INSURANCE & PAYMENT

Insurance verification refers to checking the status of a given patient's insurance coverage and verifying their eligibility for a given service covered.

Patient eligibility and benefits verification is the process by which the practices confirm information such as coverage, copayments, deductibles, and coinsurance with a patient insurance company.

• If the patient policy is active.

• When the policy expires.

• If the practices are in-network. 

• If the given procedure is covered under the patient’s benefits.

• If it is, how much of it is covered?

What are Premiums?

A health plan premium is the amount you pay each month for a health insurance plan.

What is a Co-Payment?

The Copays are out-of-pocket costs paid when you receive medical services.

What is a Deductible?

The Deductibles are the total amount you must pay before insurance kicks in.

What is Coinsurance?

The Coinsurance is a percentage you must pay after your deductible is met.

What is an Out-Of-Pocket?

The out-of-pocket maximum or limit is the most you’ll have to pay for covered services in a plan year.

Some health plans require referrals or prior authorization before you receive services from health care providers other than your Primary Care Provider (PCP). When required, your health plan may not pay any of the costs of the services without a referral or prior authorization.

REFERRALS 

A Referral is an order from your PCP to see a specialist or receive certain medical services from some providers. Your PCP helps you decide whether specialist services are necessary for you.

PRIOR AUTHORIZATIONS

Prior authorization is approval from the health plan before you get a service or fill a prescription. The health plan reviews medical records from your providers and decides whether the service or prescription drug meets the plan’s rules for medical necessity.

MEDICAID 

Medicaid covers mostly people with limited income. 

Medicaid is generally free or nearly free. Medicaid pays second.

MEDICARE 

Medicare covers mostly people aged 65 and older, 

Medicare has premiums, copays, coinsurance, and deductibles. 

Medicare pays first,

COMMERCIAL [HMOs, PPOs POS]

HMOs in most cases require patients to choose one Primary Care Physician (PCP),

patients may need to get a referral to see a specialist.

patients must see a provider, or PCP, within your network.

Out-of-network care is allowed in emergency cases only.

PPOs

patients are less likely to have a PCP and less likely to need a referral to see a specialist.

Want to see someone in-network or out-of-network? No problem

EPOs

patients don’t need to have a primary care physician or referral to see a specialist.

There are no out-of-network benefits.