Understanding Referrals and Insurance
Misplaced medical referrals and surprise bills can be frustrating. Read this advice to make your patient experience smooth.
If you have ever worked with the administrative staff of Pediatric Surgical Associates, then you know Amy Combs and Mary Leigh Dickerson. In addition to running the day-to-day operations of the practice, they process referrals and insurance, from prior authorizations to claims and beyond. Amy and Mary Leigh have mastered the world of medical paperwork, which can be extraordinarily confusing. For families confounded by codes and claims, here’s some helpful advice:
Step One: Getting the Referral
Getting a referral to a specialist is a decision made by you and your pediatrician. Your active involvement will minimize any miscommunication and increase the likelihood of a smooth referral process.
When referred by your primary care provider or pediatrician to a specialist, here are a few basic questions to ask:
- To whom am I being referred and why?
- What is the specialty and how does that connect to the other care I receive?
- Is the specialist someone your provider would use for his or her own child?
- Who at this office is sending the referral? (This makes it easier to follow-up if something gets lost in the shuffle.)
- What is the name and contact of the person to whom the referral is being sent?
- When can I expect to hear back?
Once the referral is made and the consultation is complete, the question about payment arises. This is when insurance comes into the picture.
Step Two: Getting Everything Covered
Since insurance is a third-party process, it can get very complicated. With so many different carriers and levels of care offered by each, it is challenging for your primary care office staff to determine if the office you are being referred to is in or out-of-network. Before any appointment is made, ensure the specialist accepts the company AND the type of plan. If your policy has changed at all, be sure to call ahead and ask. Once the appointment is over and the service has been delivered, there is no way to reverse the charges incurred.
- Know your carrier and the type of plan.
- Keep the latest version of your insurance card with you.
- Understand your deductible. That is how much you pay before insurance starts picking up the bill.
- Know if your plan has a co-insurance, which is different than a deductible. Often the co-insurance is a percentage that you “split” with the insurance company above, and beyond the deductible. If you have one, budget for it!
Once you have a plan in place for care, you may need prior authorization. Prior authorization is justification as to what you need and why you need it, so the insurance company can determine if it will be covered. Proceeding without prior authorization means that you accept and agree to pay for anything insurance does not pay.
Here are some other tips to avoid an unexpected bill:
- Ask the doctor’s office to estimate how much the procedure will cost.
- If your procedure is NOT covered by insurance, ask the office staff if they can call the insurance company and make an argument on your behalf.
- Understand that you are going to receive multiple bills from each party involved, including, but not limited to, the specialist, anesthesiologist and hospital.
- Hospital costs (otherwise known as facility fees) are the most expensive, and although those cannot be estimated or controlled by the doctor’s office, you can call the hospital and request an estimate.
Step Three: Getting Help When There’s a Problem
With so many moving parts, sometimes things happen. The office might apply the wrong insurance code to the actual care received, or the insurance company might send the wrong amount to the provider.
If this does occur, be ready:
- Keep the Explanation of Benefits forms that come in the mail-- don’t throw them away.
- Have those papers handy when your bill comes and match up the charges to make sure that they are correct.
- Call the insurance company and ask for clarification if you do not understand. Take notes!
- If the insurance company cannot explain the charge and the doctor cannot either, you can dispute it.
Your doctor’s office should be there to help and not inhibit. Good practices will work with you and call the insurance company as many times as it takes. Your surgeon or specialist should be there for you and your family for better or worse; the office staff should be too.
For more information on keeping your child safe and well, visit www.pedsurgical.com.