Is this Covered? Explanation of Benefits in a Nutshell.

In this era of high deductible plans, flex and health care spending accounts, accountable care organizations, preferred provider organizations, health maintenance organizations, requirements for referrals and “medical necessity” other than what your physician recommends, the questions, “Is this covered?” is anything but straightforward.  Moreover, the answer may change throughout the year depending on your deductible, co-insurance, and out of pocket maximum.  Also, the answer is not known for sure until the claim is submitted by the practice as a request for payment, and a response may not be received for 30-90 days, and if an appeal and resubmission is required, it could be 4-6 months until you and the practice receives a final answer.  You the receive an explanation of benefits that shows the amount he insurance was billed, what was the allowed amount, insurance adjustment, and what is your responsibility based on your deductible, copay, co insurance, and out of pocket maximum.  A few common sources of confusion are:

What is the billed amount?:
This is a somewhat artificial amount billed to the insurance by the practice. It is higher than what is ever expected to be paid based on the fact that the insurance contracts have s clause whereby the insurance company decides how much they will pay the physician, and it will always be less than or equal to the billed amount.  Different insurance companies vary widely in what they choose to pay.  It is common practice for the physician to “bill” for twice what Medicare pays, knowing they will only be paid what the insurance company has decided to pay, in order to avoid the unlikely situation in which the contracted amount is more than the billed amount.  So, it is misleading to look at the billed amount since it is not the paid or expected amount, unlike a bill at most other places!  So, a “billed amount” of $500 is only expected to be paid at about $300.  What does this mean to you at Rainier Medical Weight Loss and Wellness?  Let me try to explain!

Our programs can be paid for out of pocket and may end up costing you less  or the same as going through insurance.  For example, if you pay out of pocket using credit or debit card, check or Care Credit, for our weekly coaching and online support, the cost is $200, paid at the start of each month.  If you choose to go through insurance and have out of pocket costs due to copay, co insurance, deductible, out of pocket maximum, no referral, non preferred provider, or lack of medical necessity, then it may cost you $210-$280 and you will not have online support and will be limited to visits while a provider is in the office (insurance will not cover coaching visits if Dr. Sutherland or the nurse practitioner is not in the office even if you are not seeing her).  So, speak with our insurance specialist about which option is preferable to you. 

Leave a Comment

No User Photo