Understanding Medical Insurance Contracts
What most people do not understand is the way medical insurance works. In plain English, it works by insurance contracts. The insurance companies are the ones to blame for this big mess in the healthcare system. They make all the money and love to keep their clients confused as to what it is all about. When the knife slices the reality of what it is and what it isn’t paying for it is too late.
A Medical Provider is a doctor, laboratory, hospital, ambulance company, x-ray lab, etc. Each medical provider signs a contract with each individual insurance company they want to be contracted with.
Every contract is different. With a doctor, it would be considerably different than it would be with a hospital.
This contract simply states that the medical provider will accept this insurance or that insurance and receive a percentage of payment.
Now with each insurance company the percentage changes.
Employers: The employers or business owners sign a contract with the insurance companies. This is where it becomes confusing. There are many different plans with the insurance company.
Medicare
Straight Medicare-
You pay 80% of your bill.
You may have a secondary insurance.
HMO – This is where you have a PCP or Primary Care Physician. You need a referral to see a specialist and authorization to have surgery or some sort of test. These medical providers you will be scheduled with are within your medical contract. You pay a copay with each visit.
PPO – This is when you can make your own appointment with a specialist. You pay more for this insurance and you can go out of the contract of medical providers but it will cost more.
Straight Commercial Insurance – This is when you pay your contracted rate and a percentage of what your insurance doesn’t cover.
This is why when patient A goes to Dr. Brown and has a general examination of blood pressure and a blood test. The insurance will pay a certain percentage and the patient will be charged the rest after something has been adjusted off per the contracted rate.
Patient B same thing, the same doctor. But when patient B receives his Explanation of Benefits (EOB) from insurance the rate the patient is expected to pay is different.
This is because of the name of the insurance company and the type of plan that was picked.
FOR MEDICAL PROVIDERS
My book Appeal and Collection Letters is for you.
If you have any questions please contact me on my website www.lindameckler-author-artist.com
Linda Meckler author of over 25 books and worked in Medical Insurance Billing for over 25 years. Her book Medicare and Other Health Insurances. Explains in simple English how Medical Insurance Works, sample Appeal Letters, and much more.
Copyright Linda E. Meckler 2013 updated 2023