Dealing with Insurance Companies

It is important to understand your health plan benefits when dealing with insurance companies. Here are some tips to help you get through the insurance process:

1) Make sure you have a copy of your health plan.

2) Keep records including a list of the facilities where you were hospitalized, procedures and services you received, medical providers that were seen, and equipment that was provided.

3) Keep all explanation of benefits (EOBs) received from the insurance company and review them for accuracy.

4) Ask for a copy of your bill from the facility where you were hospitalized.

5) Keep all statements received from providers and compare them with the insurance company’s explanation of benefits.

6) When dealing with an insurance company, call and ask for a case worker so you do not have to explain the situation every time you call for help.

7) Understand the insurance terms used in your policy. Here is a list of frequently used terms that are important to know:

Co-insurance – The percentage that an insured individual must pay toward the cost of medical services.

Co-payment – A fixed fee that an insured individual must pay toward specific services such as office visits. This fee is usually a flat fee and not expressed in percentages.

Deductible – The amount an insured individual must pay out of pocket for services before a health plan begins covering costs.

Explanation of Benefits (EOBs) – These are statements sent to insured individuals from their insurance companies. These statements explain what costs have been covered, which claims have been denied, and the patient’s payment responsibility.

In-network – An insurance company will have a network of providers and facilities that have negotiated discounted rates with them. These particular providers are considered “in-network”.

Lifetime Maximum Benefit – This is the maximum amount that a health plan will pay toward medical claims in an insured individual’s lifetime. No additional payments will be made by the insurance company once an individual has reached the lifetime maximum benefit.

Maximum Dollar Limit – This is the maximum amount of money the insurance company will pay in a specified period of time toward an individual’s medical claims. Limits may be based on the type of illness or type of service.

Out-of-Network – These are the providers and facilities that do not participate in an individual’s health plan. Insured individuals will pay a higher percentage of costs if they use an out-of-network provider.

Out-of-Pocket Maximum – This is the maximum amount an insured individual must pay for coinsurance in a specified period of time (usually a calendar year). It does not include the amount the individual must pay for their deductible. There is usually an out-of-pocket maximum for your in-network claims and a different out-of-pocket maximum for your out-of-network claims.

For more information about dealing with insurance companies, you can visit the following link: www.stroke.org

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