Understanding and Planning for
Q: Im in a PPO and Im confused
by the copays I have to pay to my doctors office. Sometimes I have to pay upfront
but other times the office staff sends me a bill after they get the insurance payment. How
is this supposed to work?
A: Lets start at the beginning
the very beginning. Like, whats a PPO? Its a preferred provider
organization, which basically means a list of doctors whose care is covered by your
insurance. Its the most common type of health insurance plan among employed
Americans with insurance. Even though we hear so much about HMOs taking over the world, more
of you actually belong to PPOs 40 percent versus the 29 percent in HMOs.
Another 13 percent are in the old-fashioned but true indemnity plans that pay
a percent of the fee no matter who you see. The rest (18 percent) are in something
called point-of-service (POS), which is basically an HMO with more choice of
term copay should be familiar to anyone in a PPO. Typically, your insurance will pay for
80 percent of the bill once you meet a certain deductible amount in other words,
you must spend $250 (or whatever the deductible is) in medical bills before your insurance
will kick in. Thereafter, you probably pay 20 percent of the bill.
This can get confusing, because different doctors'
offices handle your copayment differently. Some ask for the money upfront, while others
are willing to wait to find out what the insurance company will pay first. This is
generally a matter of policy on the part of the doctor's office. One reason they may
do this is that they probably contract with dozens of different insurance plans, each of
which may have a different amount they're willing to fork over for a given procedure.
instance, your doctor may charge $100 for an extended office visit. But he may have signed
a contract with a health plan to accept $70 for an office visit in exchange for being
funneled patients by being on the plan's "preferred provider" list. So when it
comes time for billing, you may get a bill for $100. But look more closely. Chances
are, the doctor has already sent this bill off to the insurance company and this is merely
notification to you that he's done so. Several weeks later, you'll get notice from the
health plan that it's paid $56 (80 percent of the acceptable charges). The doctor will
then bill you for your share, or $14. What happened to the other $30? The doctor eats it.
may run across a doctor, possibly a mental health professional, who asks you to make up
the entire billed amount. In this case, the doctor has not agreed to accept a lower amount
in a contract with an insurer. At least, that's what ought to be happening. If you have any
suspicion that you're being overcharged, check with your health plan's customer
ran into an interesting twist on the copay. I went to a new gynecologist who spent a good
45 minutes talking with me (fully clothed!) in her office before we even started an
examination. She was friendly, thorough and willing to take as much time as I needed to
talk. Later, she called me personally a few times to follow up on test results and other
issues we'd discussed. When I received her final bill, my insurance company (a PPO) had
decided her time was worth just $50, not the $150 she had billed for an extended visit. I
reimbursements this low, I worry that good doctors like her may just quit, like so many
others have, and thats not in my best interest. So I sent along an extra $50 with my copay,
explaining in a note that I appreciated the time she took with me. I was surprised when I
received my check back a couple of weeks later, with a note saying they couldn't accept
the extra amount.
was both annoyed and curious about a health-care system that doesn't allow me to pay a
doctor what I think she's worth. I ran this one by Dr. Vincent Riccardi, who runs an
organization called American Medical Consumers, and he found it ironic as well.
"That's there supposedly for your protection, so they can't charge the insurance
company $40 and then charge you under the table another $40," Dr. Riccardi notes.
"But it's kind of stupid that you cannot reward your physician for additional time
spent with you. The docs are really getting underpaid, and you have an interest in her
having a realistic income." What to do? I can buy her a gift.
Here's some more
advice from the experts on dealing with PPOs:
|Dr. Riccardi and billing specialist Lynn
Northcutt Gregor both emphasize that PPO members should pay attention to what diagnosis
code the doctor has assigned to your visit. This will decide what the insurance is being
asked to pay. "If you pay for a comprehensive visit, but you think it's really a
cursory visit," you should question the bill, Dr. Riccardi says. Gregor offers
another scenario: If you go to a cardiologist for an irregular heartbeat and the cause
turns out to be stress, and the doctor's diagnosis is "anxiety disorder," his
services could be billed at a lower rate. Diagnoses that fall under mental health services
are often reimbursed at just 50 percent rather than 80 percent.|
|Before you see a new doctor, make
sure she's on your plan's current provider list. These lists change constantly, so
double-check with your insurance company and the doctor's office before the visit.|
|Examine all bills and health plan
"explanation of benefits" forms carefully. Often the insurance form will take
some time to understand, because insurance companies use codes to explain why they've
covered something or not. Look up the code explanations, and if it still doesn't make
sense, call and ask about it.|
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