Medical Insurance Guide

Let me just start by saying it is always the responsibility of the patient to know and understand his/her medical insurance policy! As the person who signed the contract, you should know exactly what it is you have purchased.

Secondly, individual doctor's offices file your insurance for you only as a courtesy. They do not necessarily have to file for you and could, in fact, charge you up front and let you file on your own. It all depends on the office policy of that particular doctor and whether or not he/she has contracted with your insurance company. If they are, indeed, contracted, they will file for you. You should always ask when you make an appointment if the doctor is contracted with your insurance.

Now, to the meat of it all! There are many different types of insurance policies available but your main policies are PPO (Preferred Provider Organization) and HMO (Health Management Organization).

PPO insurance means you can go to the doctor of your choice. But there is a catch! Although you get to choose, if you choose a doctor who is not listed in your preferred provider directory, your policy will only pay at "Out of Network" rates. This is a reduced rate where you pay more of the percentage and co-pay for using a non-preferred provider. There is yet another catch. Your policy may not have out of network benefits. Here is one of those areas where it is up to you to read and understand your particular policy. If you do not have out of network benefits, you (the patient) are fully responsible for all the charges accrued for that visit and they are payable at the conclusion of your visit.

There are three parts to PPO insurance policies. (Not all policies have all three so you must read your contract)

1. Co-pay - This is the money you pay off the bat for your visit. There are three levels of co-pays.

A) Office Visit; which is for Primary Care Physicians (General Practitioners, Internal Medicine Doctors, Rheumatologists and Gynecologists). These are the doctors who handle your general health and well being.

B) Specialist Office Visit - This is the same as office visit except that the co-pay is higher and is for visits to Specialists (Any other type of doctor not listed previously)

C) Emergency Room Visit-This is usually the highest level of co-pay and is what you pay when you visit the E.R.

2. Deductible - Your deductible, just like in your auto insurance, is the amount you must pay out first before your insurance policy starts to pay out. The deductible sometimes applies to office visits as well, depending on individual policy but usually it applies to in-office procedures such as injectables and any bodily invasive surgical procedure. This can be cryotherapy, biopsy, use of a laser, excisions, etc.

3. Co-Insurance - This is the percentage that your insurance company will start to pay for in-office procedures after your deductible is met. The insurance company usually pays the higher percentage while the patient is responsible for the smaller amount.