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Insurance Terms Defined

Being a doctor in a small office I’ve had the opportunity to work and learn numerous aspects of running things.  Insurance is the primary aspect I hear questions about on a daily basis.  It seems as though each day insurance policies are changing. Regardless if you have a brand new policy midyear, or have maintained your current policy, there are a handful of terms you should understand.

All medical offices have a fee schedule.  A fee schedule is a list of services and the amount billed to an insurance company.  These fee schedules are determined based on location and other aspects which as a patient you could care less about. On a very basic level, paying for insurance gives you the privilege of paying that companies rates.

Medical office rate for exam: $100
Blue Cross Blue Shield Rate for same exam: $80

If you have BCBS insurance, you can only pay up to $80 for that exam.  You get the $20 discount.

Here are a list of other terms you should...

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Preventing Health Care Fraud and Abuse

Health care fraud is a key driver of rising health care costs. About 3% of all health care spending — or $68 billion each year — is lost to health care fraud. There are a few types of health care fraud including:

  • Medical Identity Theft. This is the misuse of a person’s medical identity to obtain health care goods, services or funds.  This can include fraudulent prescriptions, billing for services that were never provided or referring patients for unnecessary services.
  • Upcoding. This is when the provider bills for a service of higher complexity than the service that was provided or documented.  For example, a supplier may bill for motorized scooters, but supply manual wheelchairs.
  • Billing for Services not Furnished
  • Others can be found here

Here are some things you can do to help prevent health care fraud and abuse.

  • Review your health care charges. Look over your Explanation of Benefits from your insurer and receipts from your doctor...
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Understanding Your Health Insurance Costs

It's tough navigating through the challenging world of health insurance especially if you do not have the basic terminology down. Below are some common terms and definitions to help you understand health insurance. Feel free to save this blog for future reference!  

Premium

The premium is the amount you (or your employer) pay for your health insurance plan whether you use medical services or not. In most cases, it’s paid monthly, but can be paid every 3 months or yearly.

Deductible

A deductible is the amount you must pay before the health plan starts paying for your covered services. For example, if your deductible is $1,000, your plan won’t pay for some services until you’ve paid $1,000. In most cases, the higher your deductible, the lower your premium. The lower the deductible, the higher premium.

Coinsurance

Coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible.

For example,...

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HMO vs. PPO

Knowing the differences between medical insurance plans will help you choose the one that’s right for your health care needs.

PPO stands for preferred provider organization

EPO stands for exclusive provider organization.

Both plans use a network of physicians, hospitals and other health care professionals. The difference between them is the way you interact with those networks.

PPO plans give you more flexibility. You don’t need a primary care physician and you can go to any health care professional you want without a referral—inside or outside of your network.

Staying inside your network means smaller copays and full coverage. If you choose to go outside your network, you’ll have higher out-of-pocket costs, and all services may not be covered.

EPO plans combine the flexibility of PPO plans with the cost-savings of HMO plans. While you do not need to choose a primary care physician with your EPO plan and you don’t...

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