Demystifying Insurance

Connecting with the insurance company through online verification portals and direct calls with the insurance company to obtain the detailed coverage information. This includes items such as level of care specific coverage and benefits, in-network and out-of-network coverage, annual deductibles, coinsurance amounts, copay amount, out of pocket maximums, and authorization requirements.

Providers in the health insurance plan’s network are called “in-network providers”. Coverage amounts such as deductibles, coinsurance, and copays will be lower when utilizing an in-network provider.

Providers outside of the health insurance plan’s network are called “out-of-network providers”. Coverage amounts such as deductibles, coinsurance, and copays will be higher when utilizing an out-of-network provider.

The annual deductible is the amount paid out of pocket by the policy holder before an insurance provider will pay any expenses. In general usage, the term deductible may be used to describe one of several types of clauses that are used by insurance companies as a threshold for policy payments. The deductible will generally reset once a year and for most the plan year resets on January 1st. There may be different deductible amounts for in-network vs out-of-network.

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. There may be a different percentage for in-network vs out-of-network.

A  copay is a fixed amount for a covered service, paid by a patient to the provider of service before receiving the service. It may be defined in an insurance policy and paid by an insured person each time a medical service is accessed.  It must be paid before any policy benefit is payable by an insurance company.  There may be different copay amounts for in-network vs out-of-network.

The out-of-pocket maximum is the most you may have to pay for covered services in a plan year. After this amount has been spent on deductibles, copayments, and coinsurance, your insurance plan pays 100%s of the costs of covered benefits. There may be different thresholds for in-network vs out-of-network.

A review of the current clinical presentation that determines the medical necessity of services being requested. The review of this information is typically done prior to an admission and based on the medical necessity guidelines and criteria used by most health plan providers. Sometimes called prior authorization, prior approval or precertification.

Concurrent reviews are reviews done between the insurance companies and Utilization Team for the purpose of obtaining continued authorization of the services being provided.

A Single Case Agreement is a patient-specific contract between an insurance company and an out-of-network provider. The SCA allows for the patient to see the out-of-network provider using their in-network benefits. Sometimes the insurance company will offer an In-Network Exception in lieu of the SCA. This means that the out-of-network provider agrees to be considered in-network and is reimbursed as if it were an in-network provider.

A type of health insurance plan where coverage is provided to participants through a network of selected health care providers (such as hospitals and physicians). The enrollees may go outside the network but would incur larger costs in the form of higher deductibles, higher coinsurance rates, or no discounted charges from the providers.

A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO

A more restrictive type of preferred provider organization plan under which employees must use providers from the specified network of physicians and hospitals to receive coverage; there is no coverage for care received from a non-network provider except in an emergency.

A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.