Using your health plan for doctors who don’t take insurance

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Barby Ingle learned of a new treatment that could help her Reflex Sympathetic Dystrophy that had been plaguing her and making her life miserable for seven years. The problem was that at the time the only doctor who offered the new treatment was in eastern Pennsylvania and she lived in Arizona.

When Ingle called the doctor’s office, she was told they would treat her but only if she paid cash for it upfront. The cost for the treatment, an infusion of the sedative ketamine, was $18,000.

Ingle raised the money and flew to Philadelphia, where she had the treatment. It changed her life. She no longer has severe burning pain throughout her body. (She still needs booster infusions but now can get them closer to home from an Arizona doctor.)

Even better, when Ingle returned home, she submitted her claim to her health insurance company and was reimbursed all but her $100 deductible.

As Ingle learned, you can pay upfront for your medical care and may be able to get reimbursed afterward from your health insurance.

Every health plan has its own rules on reimbursement

Experts warn that not every plan will reimburse you and you may not get nearly the full amount like Ingle did. But it could be worth a try if your doctor doesn’t take health insurance and is willing to treat you if you pay cash.

The traditional way for doctors and hospitals to be paid is for them to bill your health insurance plan directly. After they receive payment from your health insurance, they bill you the difference. That difference typically includes copays, co-insurance and deductibles. And the process can take months.

Health insurance companies still prefer to work that way, says benefit adviser Andrea Kinkade, president of Kaminsky & Associates in Maumee, Ohio. Insurers prefer it because they can negotiate the rates for services upfront and usually negotiate fees that are less than the doctors and hospitals would charge patients without insurance.

But as more doctors are refusing to take insurance, it’s a new paradigm.

“In places like Beverly Hills, Calif., many doctors have eliminated third-party payers altogether,” says Matthew Jacobson, founder of SignatureMD, a Santa Monica, Calif., company that converts traditional doctor practices to concierge plans. Doctors who operate “concierge” practices charge annual fees and in return guarantee patients access to their doctors.

Out-of-network coverage is key to reimbursement

“Every plan is different,” says Jennifer Searfoss, a lawyer and chief executive officer of Searfoss Consulting Group in Ashburn, Va. Check with your plan to see if you can get reimbursed if you pay out-of-pocket upfront for services, Searfoss advises.

It doesn’t matter whether your plan is a point-of-service, a preferred provider organization or a traditional fee-for-service plan. What’s important is that it provide out-of-network coverage, says Carol Taylor of the D & S Agency in Roanoke, Va., Doctors who don’t take your insurance — or any insurance for that matter — are considered out-of-network.

Most health plans pay something for out-of-network providers. However, it’s usually less than they pay for in-network providers, Searfoss says. “If the in-network deductible is $1,000, usually the out-of-network will be $2,000, but it can be different,” Taylor says. The out-of-pocket maximum for non-network providers can exceed the regulatory maximums as set under the Affordable Care Act, Taylor notes.

How much you will be reimbursed also depends on where you live and the standard treatment costs in your market for the medical services you are claiming, Searfoss says.

Not all charges likely to be covered

Remember, too, Taylor says, not all of the billed amount may be covered. If you’re using an out-of-network provider, you may be “balance billed” for amounts that exceed what’s considered usual, customary and reasonable. For example: If the out-of-network provider charges $500 for an office visit, but $125 is considered usual, customary and reasonable in your area , only the $125 would apply to the out-of-network benefits on the plan (count towards the deductible, be applied to co-insurance). If you had met your out-of-pocket maximum for the year, then the insurance carrier would only reimburse $125 and you’d have to pay the $375 difference, Taylor says.

The same concept applies to dental insurance as well, as long as out-of-network providers are part of the plan’s benefits, she says.

Don’t be afraid to negotiate with your doctor’s office if you’re paying cash. Some doctors are willing to negotiate with you just like they do insurance companies, the experts say. It can’t hurt to ask before you book an appointment.

Submit a health insurance claim correctly

If you want to be reimbursed, it’s important to file your insurance claim correctly, Searfoss says. “Very rarely have I seen patients submit their claims correctly the first time.” If your claim is denied because of missing or incorrect information, you can fix the problem and resubmit.

Searfoss recommends asking your insurance broker or human resources department where you work for help on how to submit your claim for reimbursement. Insurance brokers are often willing to help you in order to keep their customers happy, she notes.

You also can find information on how to submit a claim for reimbursement on your health insurance plan’s website. “Most have tutorials about how to submit a claim to them,” Searfoss says.

Your doctor needs to provide you with a detailed bill that lists the services performed. The bill also should have claims codes for each of the services that are being billed. You may need to ask your doctor for additional information if your health insurance requests it.

File insurance claims regardless of reimbursement

Even if you aren’t reimbursed, submit your claim to your health insurance company because it could count toward your annual deductibles. You need to meet your deductible before your insurance plan pays out. If you have a high-deductible insurance plan, “the more you submit, the more you have the opportunity to get back the money you’ve paid out,” Searfoss says.

Expect to wait at least 30 days to receive a check. It could take even longer, Searfoss says. Follow up if you don’t hear within a reasonable amount of time.