Special Report: Playing the Insurance Game
When you are shopping for health insurance, there are some questions that insurance representatives would prefer that you not ask. What are those questions? Before we can answer that, you must understand how insurance companies establish what they consider cost containments and how they write their policies.
Most policies indicate that the insurance company will reimburse (some amount) for orthotics and prosthetics that are medically necessary. They indicate that the dollar amount reimbursed will be determined by a financial review board made up of their company's medical experts.
Unfortunately, these are very vague terms that are mostly misinterpreted by clients purchasing the insurance. The clients assume that these medical experts are very familiar with the cost of providing orthotic or prosthetic (O&P) care. The truth is that they often are not. It is very common, in fact, for a medical expert to call an O&P provider and ask questions about items used by the client who has received services. These questions are so basic to the use of orthotics and prosthetics that it becomes very obvious that the caller has absolutely no understanding of what is required for the client to make the device function.
Questions, Questions
Therefore, the first question to ask may be, “What knowledge of the O&P field do the members of the financial review board have?” Just because they have medical backgrounds, such as nursing degrees or even MDs, it does not mean that they have any experience in or knowledge of O&P. All doctors are not trained in the O&P field. In fact, the medical directors of financial review boards are often doctors who have practiced in a field that has absolutely nothing to do with O&P.
The second question might be, “Do you have any advisory members on your board from the O&P field?” Throughout the nation, members of the O&P community have offered and are willing to volunteer their time to help third-party payers understand the complexities of O&P.
Some third-party payers are setting very low maximum amounts that they will reimburse in a calendar year. Some are limiting the amount to $2,000 or less a year for replacement parts or for an entire prosthesis or orthosis. There are very few appliances for which $2,000 will cover any major replacement parts, much less provide a complete replacement.
So, the third and fourth questions to ask might be, “How much is the yearly reimbursement coverage?” and “How is that amount established or determined?”
Reimbursement Issues
Let's discuss the word “reimbursement.” The dictionary defines it as “repaying you for expenses that you have paid.” Third party payers expect the client to pay the bill involved and then get reimbursed up to the amount determined appropriate by the payer. The reality is that most clients don't have the cash readily available to pay for the O&P services they want or need. So they look to the service provider to bill the third party payer and wait for the payer to send a reimbursement check. This is usually an accepted method of doing business by the service provider; however, there are some issues that are not acceptable to either the client or the service provider service. They include the following.
The provider may send a bill for the services to the third-party payer only after the services have been rendered. At that time, the third-party payer will determine the reimbursement amount. If the allowed reimbursement is much lower than the amounts billed or if certain parts of the device are nonallowed, then the reimbursement is lowered by those amounts. Supposedly, the client has already paid for the services and is simply reimbursed less than the amount paid to the provider.
What really happens is that both the client and the service provider wait until the reimbursement check comes, and usually the provider looks to the client to make up the amounts not allowed by the payer. Often, the client is shocked by the amount of the bill that has not been covered and is unable to pay the remaining part of the bill. It is not uncommon for the client to say, “If I had known that the insurance company was not going to pay the amount in question, I would not have agreed to have the services rendered.”
This matter has gone before the court system to determine if the client is, in fact, responsible for the amount not paid by the payer. The courts have found that if clients did not have knowledge of their share (the amount not paid by the third-party payer) before they agreed to have the services rendered, they could not be held responsible for those charges.
In light of that ruling, the service providers approached the payers and requested the ability to send a detailed and unchangeable quotation for proposed services to be rendered to the client as prescribed by the attending physician. The purpose of this quotation would be for the payer to then return to the client and service provider a detailed determination of the amounts that will be reimbursed for the services to be rendered.
Unfortunately, the third-party payers have declined to render this service. Their given answer is that reimbursement is determined by the board, which only convenes to respond to claims submitted by the client or on behalf of the client. Estimates of services are not an item the board reviews. That being said, the final question to ask might be, “Will you provide me with an exact dollar amount that you will reimburse me for services that I am planning to have?
People receiving O&P services really need to have these questions answered clearly and to their complete understanding. General answers, such as “Oh yes, we cover those services,” are no longer clear enough for the prospective purchaser of health insurance. More exact questions with exact answers are needed by both parties.
About the Author
Raymond Francis is a
licensed, certified
prosthetist with more
than 40 years of experience
in the O&P industry.
He is the chief prosthetist
for Ohio Willow Wood.
