Understanding your Health Insurance (August 2021)

By Kelly Warf, Au.D.
Susan Forman, CCS-P
David Tojo, M.D.

Many are unaware of what happens between giving their health insurance information to a medical office and the bill they receive from the appointment. Health insurance is an important investment. However, just because you have medical insurance doesn’t mean you won’t be responsible for part of the cost of a visit or surgery. Health coverage reduces your out-of-pocket medical expenses. Let’s break down how health insurance and medical billing works.

First, health insurance is an agreement between you and your medical insurance company. Once you select your policy, you are enrolled in a network of providers who accept that plan. An in-network provider has agreed to the negotiated rates from the insurance company. Going to an out-of-network provider may yield a higher cost for their service. While private insurance companies have negotiated rates, Medicare has set prices.

In your contract with the insurance company, you have agreed to the following expenses in order to receive health coverage:

  • Premium: Monthly payment to your insurance company for health coverage. This must be paid even if you didn’t use your health insurance that month.
  • Deductible: The amount you pay each year for eligible medical services or medications before your health plan begins to share in the cost of covered services.
  • Copay: A flat fee that you pay at the time of visit each time you go to the doctor.
  • Co-insurance: A portion of the medical cost you pay after your deductible has been met. Coinsurance is a way of saying that you and your insurance carrier each pay a share of eligible costs that add up to the allowable amount.
  • Adjustment (Discount): The amount the healthcare provider has agreed not to charge due to a negotiated contract between the physician and the insurance company.
  • Patient Payments: The amount you are responsible to pay which may include a copay, deductible, coinsurance or non-covered services.

At the time of scheduling your appointment, we will request your insurance information and let you know if we are out of network or if a referral is required.

At the Ear, Nose, and Throat Center, we only perform necessary services to diagnose and treat. Since your ear, nose, and throat are all connected, what presents as a symptoms of ear pressure may end up as an evaluation of your sinus cavity. The services, prescriptions, and supplies used during your appointment are submitted to your insurance. The amount that a physician charges for an office visit or a procedure is a standardized fee according to the state/area fees. A claims processor from your insurance company reviews the submission and then decides to accept or reject it. The insurance company then sends its decision to the medical office and policyholder, this statement is known as the Explanation of Benefits (EOB). The EOB explains if the services were accepted or rejected and why. If the health insurance does not cover the service, then the healthcare provider may bill you for the remaining balance. Please note that the EOB is not your medical bill.

The EOB will detail the following:

  • Billed charges: Total amount charged to your insurance company for the appointment. This includes the service(s) and supplies conducted during your appointment.
  • Adjustment: The amount the healthcare provider has agreed not to charge due payment rates determined by your insurance company. Adjustment will also include deductible and copayments.
  • Insurance payment: The amount your health insurance company has already paid.

Our billing department is dedicated to helping you receive your maximum insurance benefit. Call our billing department with any questions 847-465-1250 ext 29

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