A Parent’s Guide to Navigating Insurance Coverage

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action today's webinar is presented by Wendy Richardson our family care coordinator here at the Johnson center the webinar was created by gina hill certified Child Life Specialist and Rebecca Flores the Johnson centers registered nurse please note that questions can be typed into the control panel and time permitting they can be addressed at the end for those of you that have requested copies of the presentation we cannot send out the presentation slides however we do post recordings of all of our free webinars

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on the johnson center youtube channel please search us for on youtube and subscribe to get full access to all of our recorded webinars please welcome our presenter Wendy Richardson thanks Tiffany and thank you all for joining me today for this presentation a parent's guide to navigating insurance coverage we chose to present this topic because

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we've noticed common questions about insurance cover ease coverage from all the families that we serve through this presentation we hope to provide solid baseline understanding of insurance coverage including terminology and claims processing in this presentation we will cover types of insurance that are available on the market we're going to talk about the differences between self-funded and traditional insurance policies will define those commonly used

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terms you hear all the time we'll go over how to read a sample clinic bill explanation of benefits how to fill out a claim form we'll walk through what to ask when you're calling your insurance company about coverage will walk through the process of appealing a denied claim will touch on the insurance laws by state and finally we will review some frequently asked questions if there's time at the end I'll take questions from

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you so before we go any further I want to provide a brief disclaimer first we are not insurance lawyers or specialists we've done our research but the information presented here is not to be considered legal advice if you are in a situation in which you believe you have legal recourse with your insurance provider please contact a licensed attorney secondly along the same lines please be aware the insurance laws vary

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from state to state if you have concerns about mandatory coverage regulations please contact your state's department of health and human services finally it's extremely important to bear in mind that every single insurance policy is different well you may have insurance through the same company as your mother brother neighbor or friend your coverage will most likely be different even if your coworker may have even your coworker may have different coverage if

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your employer has offers multiple policies so when we talk about types of insurance we're talking about how you purchase your policy you can purchase a policy through your employer you can purchase a policy on your own in the individual market and if you're interested in learning more about purchasing individual insurance you can review this guide published by The Wall Street Journal listed here or if you're

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eligible you may receive public insurance like Medicaid or Medicare please visit healthcare gov to find out more about public insurance programs whether you're parked whether you purchase private insurance through your employer or individually it's important to note if you have a traditional plan or a self-funded plan when we talk about traditional versus self-funded we're talking about money we're talking about

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whether the money paid out for claims where it comes from we're also talking about who decides what's covered in your plan and what the benefits will be in a traditional insurance policy the plan is negotiated between the employer and the big insurance company they determine the coverage the premiums what is your deductible and money to pay claims comes from the insurance company the employer and the employee premiums

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self-funded insurance is very different in a self-funded plan the details of the costs and the coverage are designed by the employer or the group using the plan so one of the differences is and we have an example at the bottom is that members it can write to and go to the employer and say this is not covered on our plan and a group of us would like it to be included and we have an example at the

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bottom we're a family went to their employer to add a BA benefits to their self-funded plan even includes a sample of the letter that they wrote and they were successful so that's something to research if you have a self-funded insurance plan and that's one of the benefits and a typical insurance company like Aetna or Blue Cross will act as the administrator of the policy so they do all the paperwork you'll have a typical

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insurance card the other difference the self-funded plan is only subject to federal regulations not state regulations so now that we know where your insurance policy comes from let's dive into defining some Universal terms used by virtually all insurance providers and clinicians it's important that you know and understand these terms in order to best understand your

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coverage so a premium think of your premium as your monthly membership or subscription payment I can be taken from your paycheck pre-tax if you have a policy through your employer it can be billed to you if you purchase an individual policy a deductible a specific dollar amount that you pay out of pocket to service providers before your insurance plan pays you anything renews every contract year some services

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like annual well visits are exempt from deductibles and you could have separate deductibles for different types of services like a medical deductible versus a behavior deductible you hear people talk about high premium low deductible and vice versa hi premium low deductible means you pay out more each month for your membership and when you have medical bills you have to pay less out of pocket before your benefits kick in conversely with a low premium high

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deductible plan you pay less each month but you have to pay more for medical services before your benefits kick in in network your insurer negotiates with a wide range of doctors specialists hospitals labs and pharmacies to pay a set price for things these are the providers in your network your insurance provider will typically pay a higher percentage of your claim if you receive care in network out of network these are

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providers outside your network who have not agreed to any set rates your plan may require higher co-pays deductibles coinsurance for out of network care your plan may not cover out of network care at all leaving you to pay the full cost yourself so more on out of network you'll most likely pay the entire cost of the appointment at the time you're there unless other arrangements have been made coverage comes in the form of

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reimbursement you're out of network provider may or may not submit those claims on your behalf so again commonly used terms the in network is where your doctor negotiates special rates with your insurance provider and out of network they have no relationship with your insurance provider so a Venn diagram of two circles that never meet a co-payment you probably all know about co-payments a specific charge for a medical service

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or supply so for example your insurance may require a twenty-dollar co-payment for an office visit or a brand-name prescription drug after which the insurance company often covers the remainder of the charges so for example you have an office visit and the doctor charges you a hundred dollars your insurance policy says you have a copay for that service of twenty dollars the doctor's office will charge your copay at the appointment and your insurance will be billed the remaining eighty

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dollars remember how you paid in full at your out-of-network appointment and are expecting reimbursement if there's a copay on that service that amount will be used to calculate how much you will be reimbursed after that appointment so in-network co-pays are paid by the patient up front at the time of service an out-of-network co-pays are calculated into your reimbursement later coinsurance is the percentage that

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you're required to pay for covered medical services after you've satisfied any co-payment or deductible so for example if your insurance company covers eighty percent of the cost of a specific service you will be required to cover the remaining twenty percent as your coinsurance so again this is after your deductible has been met so the difference is that a copay is a set dollar amount usually paid upfront and coinsurance is a percentage that is

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usually build after insurance has paid their percentage being billed later for services only applies to the in-network services will address the claims process of out of network coverage later another commonly used term annual maximum maximum dollar amount your insurance will pay in a contract year so there may be separate maximum for specific services like a ba or medical visits diagnostics and your

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policy may also limit services by number of visits per contract year and also make a note when is your contract year it could be january to december or just any period of 12 months depending on the policy reasonable and customary charges so often responsible for higher co-pays than expected each insurance provider calculates their own reasonable and customary fee schedule so this is a

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dollar amount an insurance carrier is willing to pay for a specific service it's determined by geographic location they'll say like okay everyone in this zip code is allowed this it comes into play when you go out of network for example if you have a chest x-ray at your out-of-network doctor it may cost 120 dollars but your insurance carrier may determine the reasonable and customary charge for your area is only a

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hundred dollars so here's a diagram that explains the differences for example in network if he might be 250 the reasonable and customary is 200 doctors would have negotiated to write off fifty dollars if you have an 8020 plan insurance would have paid 160 and then you have a copay or coinsurance of twenty percent of forty dollars and your

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total cost to you would be forty dollars you can see in out-of-network that the charge is the same 250 reasonable and customary is 200 but because it's out of network you have a 60-40 plan so it's a hundred and twenty dollars you're forty percent co-insurance is eighty dollars so that leaves you with fifty dollars that hasn't been written off by the doctor because they're not contracted in

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network so your total cost is actually 130 so that's just an example of in-network versus out of network and why they're different so far in our term section we've talked about where the money comes from when we talk to premiums and deductibles we talked about what your insurance will cover when we talked about co-pays co-insurance and reasonable and customary charges now we're going to talk about coding and how your insurance company processes claims

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so a diagnosis code this code tells your insurance company why you had an appointment or other medical service it's usually a three-digit code it may include decimals and and as you imagine it's used to group and identify diseases disorder symptoms poisoning adverse effects of drugs and chemicals injuries and any reason for a patient encounter we've made a sample here just so that

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you can see and the diagnosis codes these are totally made up and just a sample of a statement and highlighted in purple are the three digit with a decimal and diagnosis codes you'll also have a cpt code that stands for procedure or current procedural terminology so this code tells the insurance company what happened at the

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appointment it's a five digit code and it will identify a specific clinical service so the type of office visit the type of x-ray etc here's a sample showing you on a statement that five digit code so notice diagnosis codes are above and highlighted in purple is your 5-digit cpt code so just as another

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example and the diagnosis code is for the broken leg and the cpt code is for putting a cast on it so again the coding system is determined and maintained by the American Medical Association it's used universally in the United States to process insurance claims in both public and private insurance so those codes are universal a special note codes can only be determined by qualified clinicians to

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change a code on a claim without the approval of a licensed clinician is insurance fraud so you've all seen these and probably wondered about them an EOB that's the explanation of benefits that you get in the mail it's a document provided by your insurance company outlining how benefits were paid out for a specific claim so in network this you will arrive after your care provider has

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processed your claim and if you're out of network it will arrive after you've submitted for reimbursement your EOB may come with a check or a denial of why they're not sending you a check so again the EOB is not a bill it's explaining to you why you're getting money or not getting money here's an example we just made up a cookie yeob here and you could just see all the different elements and

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it'll say deductible what your copay was what the provider was paid what is the patient responsibility and it should also say this is not a bill preauthorization so this is a decision by your insurer that a service treatment plan prescription drug or durable medical equipment is medically necessary it's also sometimes called prior authorization prior approval pre-certification so every insurance

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company may call it something different your insurance may require pre-authorization for certain services before you receive them except in an emergency so here's an example and it's always good just to ask the question does this need to be pre-authorized for example if your child is already receiving 20 hours a week of ABA therapy that has been referred to a behaviorally based feeding clinic so that can be five days of intervention

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six hours a day that can look different from traditional ABA so those additional 30 hours may be considered outside the scope of your ongoing ABA program and you may need to be approved for this special intervention so pre-authorization forms need to be completed along with the documented necessity from your clinician it's always good to ask the question it's always good to put in the forms so that it's approved before you have the

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service so you must wait for confirmation in writing that insurance will cover it and you also have to allow 30 days to hear from your insurance on that so now you speak the language of insurance how do you find out about your coverage you must call your insurance company to determine your coverage for specific services so the staff of the Johnson center has put together a

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worksheet for calling your insurance company do determine coverage and this is really helpful to gather your information even before you start so the link is available on our website and i'll talk more about that oh in fact there's the address so again you want to gather all your details before you get on the phone with them and it asks for things like your clinic and your practitioners ID numbers so like we all

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have social security numbers your clinicians have ID numbers clinics have federal ID numbers practitioners have something called an NPI number this will also help your insurance company find the correct information for your appointments so you want to make a list of those numbers for all your practitioners and and your clinic will provide those to you and keep those in a place that you can refer to easily so the first thing you're going to go through is a

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you know the clinic name tax ID your the credentials which can come into place you want to make a note you know are they a do or an MD and and also their clinic address if they work at multiple locations you want to know that they're you're covered at a specific clinic and also if you are an existing patient with the provider you can call the clinic and ask if they can provide the cpt codes

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that the appointment will be billed under however if you're a new patient this code may not be available or may change once you see the clinician so not jot down what your CPT code is that you're going to be calling them about and if no cpt code can be provided list the nature of the appointment or the therapy so you're going to call the member number on the back of your insurance card and again you don't have to take notes because you can download

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this worksheet off our website and just fill in the blanks as you go so make a note of the person you're talking to and the date and the time of the call and they often just give you their first name and a last initial so every you might talk to six different people on one insurance call so you always write down the new name the date and the time of the call is there a call reference number this is important if you need to

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call back if you have an appeal pending because you want to be able to say I talked to Jane at twelve-fifteen on Saturday the 19th this is the call reference number if you need to look up and so you want all your details also some insurance providers employ specialists in their customer service departments these specialists will have greater knowledge of treatment teachers and coding for patients with a

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specific need like autism or diabetes or cancer so ask if you can be assigned a liaison that's a specialist in your area so find out if your appointment coverage is covered under a medical plan a behavior plan they're often they can be even two different companies within your insurance and the description of services or CPT code will help them determine which plan to look into if

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it's a behavior plan you'll likely to be transferred to a whole new department so again who are you talking to what is the number you called who because it's going to be different what time were you talking to them what was the date what's the new call reference number this may come into play later so if you don't have a diagnosis code because you have not yet seen the clinician you may be able to find out which diagnosis code the insurance company will look for in order to cover the cpt code in question

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so the next thing you're going to do is give the representative the clinic's name the tax ID number your providers name and their NPI number so you can ask are the services at this clinic in network or out of network with my policy and then again if you have your CPT codes you can give it to them or the description of the service and you always want to ask is there a time limit

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on the length of the appointment find out do they cover an hour do they cover 50 minutes 45 minutes and if your service is covered what percent will they reimburse you after your deductible has been met so they'll typically say oh we'll pay eighty percent of customary charges after your two thousand dollar deductible has been met for this child so you're going to write down what percentage are they going to reimburse

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you and what is your deductible if the provider is out of network ask if there is a fee schedule of reasonable and customary charges if so what is the reasonable and customary charge for the service that you want to do and if you're out of network you want to say you know what's the reasonable and customary charge for an hour of speech their therapy in my area this question may also require a call to a different department at the

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insurance company again what is the name of the person you're talking to the time you called the date you called ok so then you want to say here's what my clinic charges a hundred dollars an hour for this service insurance says reasonable and customary is eighty dollars so the difference is twenty dollars that I would be out of pocket is the service subject to a deductible if so how much of your deductible do you

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have left to pay this contract here before insurance begins to cover the service clarify that the information is for in-network or out of network because these can be different amounts and remember you may have separate deductibles for medical and behavior services you want to ask is there a copay for each visit with this cpt code in network co-pays are paid at the time of the service out of network co-pays

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are calculated into your reimbursement so you also want to ask is there a maximum number on the amount of appointments I can have of this service per year could be 20 appointments so you want to make a note of that so you don't go over the 20 visits a year that they're allowing you clarify again is that 20 visits in network or 20 visits out of network because they can be different is there a ceiling on the total dollar amount that you'll pay for

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this specific service each year again if they say we will only pay for twenty thousand dollars of ABA per year you want to know what that ceiling is to keep track of it this information is very important when finding out about coverage for ongoing intervention like we said such as speech therapy etc it's always good to ask does a pre-authorization letter or form need to be submitted and approved for this service and if the answer is yes you're

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going to download the pre-authorization form from the forum section on the carrier's website and give it to the clinician staff to be completed and then you want to follow that through making sure it gets faxed calling the next day making sure they actually received it that it's in the queue that they're looking at it and so always a good idea does this have to be pre-authorized before I start the service also is there a certain credential acclivity

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clinicians must hold to conduct this type of service or appointment so for example can diagnostics be done by a counselor typically it has to be a licensed psychologist for certain things you just want to make sure that you know the credentials that they will pay for for those appointments if your service will be out of network and we're on their website can you print a claim form because that will be up to you to submit the claim ask how long it takes to

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process your claim and issue you a reimbursement check and write this on your calendar to follow up you always want to copy all of your claim documents and file them in your binder with these call worksheet notes and if you receive conflicting information on the billing of this appointment you can call your insurance carrier back use those reference numbers and say I talked to Sally at twelve-fifteen on the 19th and this is what they told me that differs

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from what you just sent me here's my reference number for the phone call so that's the worksheet again that you can download off her web website that's very helpful every time you call insurance now let's talk about filing that out-of-network claim so use the invoice from the clinic to find your coding information attached a copy of your claim form that you'll get off your insurance company's website and

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mail it to the claims address also don't put this off they have rules about how far back they'll process a claim like six months and so you want to get it in there so that you can get your money back you're going to keep a photocopy of the entire claim in your insurance binder and record the date you mailed it by federal law insurance must reply so that means they can approve it deny it or ask you for more information in 30 days note on your calendar when to

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follow up on the claim if you don't receive a reimbursement check a denial letter or that they haven't requested more information um always file claims to ensure that any covered services count towards your deductible you may not actually know but it's just good to send it in even if you think perhaps it will not be covered so the next thing that we'll talk about and is the in

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network claims if you go in network the claim will be processed by the clinic or the hospital that you visited if you have a copay they will most likely charge you for it up front and bill you for your coinsurance after your insurance has paid their portion let's talk about Appeals if your claim is denied you have a right to appeal if your services received in network and the claim was processed by your clinics

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billing department contact them for assistance with Appeals if you're out of network claim was denied you can take the following actions to appeal the denial it's very important that you read her insurance policy regarding the appeal process the rules for it the timeframes and the information you need to provide so again those instructions should be outlined and in your EOB

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if not contacts your insurance company or your human resources department appeals may require specific forms or just a letter find that out and note if your insurance imposes a timeframe for appeals so there's multiple levels of Appeals and there's a first second and external appeal level appeals go through a process of ranks with the first being a basic appeal usually done in writing

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if you're denied and you wish to appeal again it will go through a second appeal process that typically involves a telephone or in person conference with the insurance agent some insurance companies offer an external appeal process if your appeal is denied on the basis that is not medically necessary it's experimental investigational a clinical trial a rare disease treatment or out of network this type of appeal is reviewed by an independent and external

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medical expert who will make the final call of either approval overturn or denied in urgent situations an expedited appeal process may be considered examples of urgent situations include approval for hospice care home health or rehabilitation centers so first you need to understand why did my insurance deny coverage for this treatment in order to

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effectively go through the appeals process a reason will usually be given on your EOB if the treatment or medication or service is clearly listed in your insurance policy as an uncovered service there's almost no value in appealing however if there's no mention of the treatment you are seeking or if coverage is unclear the appeal may be more effective so to write an appeal letter when going through an appeal

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process write your own appeal letter you know your child and their needs and their conditions and more than anyone else don't wait or expect your clinical provider to write the letter or to call the insurance company for you when writing an appeal letter be very specific and detailed this is your opportunity to share with the insurance company why a medical treatment would be beneficial for your child's condition will this treatment prevent further illness or disability

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reduce hospital stays and will it save the insurance company money how will not having this treatment worse in your child's condition will the lack of this treatment cause the insurance company to cover more expensive medical treatments something that they want to avoid what treatments have you tried in the past list everything that was tried whether successful or failed why do you think this treatment will be more successful and possibly cost effective for the insurance company than other things

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you've tried in the past the insurance company is going to want data or proof of medical necessity and previously used treatments along with European letter provide evidence from medical records indicating recommendations for this treatment as well as previously tried treatments if lab results demonstrate evidence of treatment necessity provide those as well can you sit the medically

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justified are there published articles and studies that support the treatment of your child's condition provide this information in your letter do not insert magazine articles or newspaper clippings you're trying to convince a group of medical professionals that this treatment is necessary do not write an excessively long letter the details your emotions or thoughts about the treatment keep it brief keep it factual about why you're appealing your child's current medical condition and how this treatment would be beneficial and cost-effective

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how lack of this treatment can be detrimental to your child's health and expensive and publish studies supporting your appeal make dated copies of your letter to keep and send out track of when you sent out the letter and when you should expect to receive a response and above all be patient and persistent and don't give up so let's talk a little bit about insurance laws state by state we cannot possibly cover all state regulations in this

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presentation but we want to plant the seed and arm you with the right tools and knowledge to find out what your rights are in terms of insurance coverage in your state so first you want to check with your state department of health and human services to find out your insurance rights in your state there might be state mandates for coverage of minors or autism coverage that you need to know about so remember

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first those self-funded plans that did not have to adhere to these state mandates they only have to adhere to federal ones here's an example of a state mandate we just plucked South Carolina but if you have a self-funded plan they don't have to follow these rules so in South Carolina they require a health insurance plan to provide coverage for the treatment of autism spectrum disorder to be eligible for benefits and coverage the individual

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must be diagnosed with asd at age eight or younger the benefits and coverage provided must be provided to any eligible person under 16 years of age note speech language services are not specifically designed defined in the statute coverage is limited to treatment that is prescribed by the insured's treating medical doctor in accordance with a treatment plan and although behavioral therapy is not specifically defined the statute does set out a cap

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of 50 thousand dollars a year for coverage of behavior therapy so again this is different in every state you need to check and see what do they demand in your state for your coverage will briefly talk about HSA versus FSA and some of you may have a health savings account or a flexible spending account both our accounts with debit cards that they can be used to pay medical bills and expenses both take

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funds from your paycheck pre-tax there's a lot more to be said about HSA and FSA but for the purposes of this presentation we're only going to touch on them briefly please talk to your HR manager about your options at your company if you are interested in learning more so HSA typically available on high deductible plans funds roll over every year annual contribution limits apply can be used for any medical

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expense a flexible spending account also only available on high premium low deductible plans funds do not roll over if you do not use them they are lost annual limits apply and are much lower than an HSA and can be used for any medical expense also you know just ask your HR manager about your options where you are the following are some helpful questions to ask your provider prior to your visit make a note of the date and

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the name of the person that you speak with and remember if you're covered by insurance and you're out of network expenses may be higher therefore it's important to ask if payment plans or grants are available from your clinic oftentimes they have those in place and you just need to ask so 10 questions that we hear about and to ask your healthcare provider do you participate in my plans Network do you have an insurance coordinator or other staff

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member who can assist me will you file claim forms for out-of-network services on my behalf so I don't have to do it well your office check with my insurance plan to confirm if preauthorization is needed for the service that I want can you tell me which procedure codes you will likely submit for the services I receive so those are good questions can you provide me with your practitioners and yah number will I be required to provide

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proof of insurance before scheduling an appointment do you offer payment plans discounts or grant opportunities for services can we use our FSA or HSA card to cover the expenses and 10 what labs or tests may be ordered for my visit and will they be covered by my plan and even if you are at the clinic and labs are suggested you can step away get on the phone call your insurance and say hey I

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need to do this diabetes test is this test covered and before you actually get the labs done your HR department can be a wealth of information so before sitting on hold with your insurance company with your worksheet out to fill in the blanks check with your HR department as they may be able to answer many of your coverage questions so here are some questions for your HR department do you have a list of

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in-network primary care providers do you have a list of referrals for specialty care providers am i required to stay in network to receive coverage or as out of network coverage included will this office assist me in submitting out-of-network claims when is open enrollment and at what point can i make changes to my current insurance plan so thank you for participating in our insurance webinar be sure to visit our

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website WWJ in center org for more resources and information there's the address to print out those insurance call worksheets that you'll want to use before and getting on the phone with your insurance company we also have references listed all the places that we have gleaned information on this

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it ok so thank you again and I'm sorry that we don't have time to take any questions this will be posted on our Johnson Center YouTube channel so you can go to youtube and search for johnson center for this presentation thank you

A Parent’s Guide to Navigating Insurance Coverage | Wendy Richardson

Table of Contents

More in Lectorium

SMALL BUSINESS

SENIOR PRESCRIPTION COVERAGE

DENTAL COVERAGE

SENIOR VISION COVERAGE