All You Never Wanted to Know About Health Insurance

Tate and I are big dreamers.  We love to fantasize about the future and often we make our dreams become reality.

Like the clinic.

Around the same time Tate started chiropractic school I was just getting started teaching aerobics, Pilates, and yoga and personal training.  We soon began imaging our future business collaborative; a beautiful marriage of chiropractic clinic and movement studio.

This morning, as we buzzed around the clinic getting ready for the day, we both had a realization of just how precisely our dreams became our reality.

The thing that I didn’t dream about was insurance billing.

I never once dreamed about insurance billing.

In fact, I didn’t know the first thing about health insurance until we opened the clinic.  I was insured under a student plan through college then went uninsured until last April, when I got a private plan.

My job duties around the clinic include light cleaning, patient check-in/out, scheduling, and BILLING.  Insurance is a pain in the ass but I honestly don’t mind because it’s our business (I would never go to a job interview that involved insurance!).

One thing I’ve learned from this job is that most people have no clue how to read their insurance policy, which is no surprise considering the companies seem to make it their prerogative to be as confusing as possible.

I am no expert, not by a long shot, but I thought I would share a few important terms and concepts.

Premium-this is your monthly fee.  You pay this amount every month and it does not go towards your deductible.  How much you pay is determined mostly by your deductible, a higher deductible equals a lower premium.   If you use doctors a lot then it will probably save you money in the long run to pay a higher premium each month and have a lower deductible.

Deductible-the amount you must pay towards services before your insurance starts picking up some/all of the bill.  For example, if your deductible is $500 then you must pay for services completely out of pocket until you’ve paid $500 total. Deductibles are paid down by doctors visits, treatments, etc.  Deductibles reset each year, which is usually a calender year but sometimes determined by the date which you signed up for your plan.

Waived Deductible-for a few services some insurance plans waive the deductible.  My plan waives the deductible for office visits and certain “preventive care”.  This means that instead of paying the full price until I meet my deductible for office visits I only pay a $30 co-pay and there is no charge for “preventive care”, which includes things like one Pap Smear a year.

Co-Payment-the set amount you pay per service/visit after your deductible is met.  Sometimes this is $0!  With a co-pay the amount is set, you pay one rate no matter how much the doctor bills the insurance company, which is different than co-insurance…

Co-Insurance-once you meet your deductible you may be subject to co-insurance instead of a co-pay.  This means that you pay a percentage (usually 20%) of the contracted rate billed your the services you received.   Example:  a patient comes into the clinic, they’ve met their deductible and their plan specifies that they pay a 20% co-insurance for services.  We are contracted (in-network) with their insurance to bill $100 for the service.  The patient pays us $20 and we bill the insurance for the other $80.

In-Network-a provider (clinic, hospital, doctor) is in-network when they have made a contract with your insurance company, stating that they will treat the companies members for a discounted rate.   Yep, that’s right, we as providers take a hit for accepting insurance.  What does this mean for you?  As a member you pay less $$ when you go to an in-network provider.  The Ob/Gyn clinic I’ve been going to lately is in-network with Anthem, my insurance.  They billed Anthem $465 for my September Colposcopy.  Anthem told them that they weren’t paying because I haven’t met my deductible but that I only owe $195 (which will go towards meeting my deductible) because that is the contracted rate between the clinic and Anthem.  Had the Ob/Gyn been out-of-network I would have had to pay the full $465.  Once I meet my deductible I don’t pay anything for most services, as long as I go to an in-network provider.

Out of Pocket Maximum-the max you will have to pay, in addition to your deductible, each year.  My Out of Pocket Maximum for in-network services is $0.  My deductible is $7,500 so the maximum out of pocket I pay in a year is $7,500.

Maternity-I don’t think any plans straight up include maternity coverage, it is considered an add-on and you are charged an additional fee.  Ladies-for most insurance plans you must be a member for six months before becoming pregnant.

Have you ever tried to get a straight answer from a doctors office about how much a service would cost?  I have and it can be incredibly frustrating but now I understand the issue: everyone is charged differently!  As a provider we have our fees then we have a different, reduced, contracted amount with each insurance company.  Some patients pay a co-pay, some pay a co-insurance, some pay the contracted amount, some pay the full amount-even with the same insurance company!  I now have much more patience with with billing offices at other clinics!

Do you have any questions?   Anything to add?

My feelings about our healthcare system will have to be reserved for another time…


    • gracefulfitness

      We do use codes but I’m not sure what you’re asking because I’ve never done it any other way. We submit our claims electronically so I check patients into our system and apply cpt codes and treatment diagnosis pointers to each visit. I can’t even imagine doing this before everything was electronic!
      What do you do now?

      • I’m an Admin Assistant in Behavioral Healthcare. Yeah, I was interested if you had a professionanl coder that you contracted with or if you did it. A lot of offices/clinics do it the way you do, which works great because being a speciality narrows the focus!

  1. Jessica

    Funny, I spent yesterday applying to be a Medicaid provider and trying to figure out all the mumbo-jumbo involved in that! I as well will reserve further comments on our healthcare system.

  2. My husband and I have been working for single-payer insurance for a long, long time. Thirty percent of your health care dollars goes to administrative fees: Faith dealing with Insurance Representative. The important thing for insurance consumers to realize is that even though they pay for health insurance, they probably aren’t getting what they think they’re paying for. Your glossary is excellent information, Faith. Hope you don’t mind that I didn’t keep my opinions about the health care system in the U.S. to myself!

    • gracefulfitness

      Please don’t! It’s a total crock and the more I learn, the more pissed I become!
      It’s totally true that people don’t get what they expect from their insurance, we have patients who pay a $40 co-pay for a treatment we only get paid $41 for. Imagine how disgruntled I am at having to process a $1 check from the insurance company! And those patients think they are in good shape because their insurance is “paying”.

  3. Katie O.

    Omigosh…this is so great Faith…thank you! I have just been starting to understand all this vocab but to have it all spelled out really helps. Seriously, thank you.

  4. I hate our insurance system. There, I said it. Now for another point – I wouldn’t want to have medical issues in this country without being covered. They kinda gotcha – ya know?

  5. barbara

    Where have you been all my life? Gratefully, I did not have to file a major medical claim until just a few years ago. I didn’t know you could/were supposed to challenge items that were not covered. I ended up paying for several things that, had I challenged, might have been covered. Expensive lesson…but learned.

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