If your insurance company wanted to make it easy for you to communicate with them or to submit them bills, they would have designed the system differently. It is generally as clear as mud (see above). However, information is power: if you don't understand how the insurance system works, you will not be able to get the best quality healthcare for yourself or your family. Read all of this page and all of Financial Incentives: Hard Facts for Patients. As I said, information is power. Put some time now into learning about your healthcare.
I have tried my best to make sure that all of this information is correct when I posted it. Insurance companies make changes all the time, they sometimes notify the doctors, many times they don't. For instance, one insurance company might "buy" access to another insurance company's pool of providers, but never notify me that I am now on their plan! They often fail to keep up to date themselves: As of December, 2004, I had not been a provider for Blue Shield for 12 months, yet in 2008 I was still listed on their site as an "in plan" provider. If in doubt, discuss the issue with my office. - Dr. Nelson
As of the date at the top of this page, I accept Medicare, Blue Cross, PHCS, Interplan, and Worker's Compensation. Insurance plans sometimes "sell" provider panels without letting the physicians know and without complying with the agreement to refer patients. These are called "silent PPO's" because the doctor has not been told that his services have been sold. I do not accept these unfair and underhanded agreements among insurance plans. I do not accept Medi-Cal, Blue Shield, United Healthcare, TriCare, Aetna or Cigna, and I do not participate in any HMO plans. I do not participate in these plans because of the limits they place on me when I try to give you the best quality hand care. I don't want anyone placing limits on me when I am trying to provide you with the best healthcare that is possible. I have written an essay on this: please read Financial Incentives: Hard Facts for Patients. If your card says "Blue Cross/Blue Shield", it does not mean "Blue Cross AND Blue Shield". It means "Blue Cross OR Blue Shield, but we won't tell you which." Many national employers have Blue Cross/Blue Shield plans, and they contract with either Blue Cross or Blue Shield on a state-by-state basis, and it is cheaper for them to print one card with both names than to give you a card with the real name of your insurance plan. As of May, 2011, most of these are actually Blue Cross, which we accept. However, you should check with your insurance company to be sure. We will accept your assurance that you are Blue Cross and bill them; however, if they say that you are actually Blue Shield, we will bill you and you are responsible for all charges.
How Insurance Plans Work
You need to know how your particular insurance plan works. To find out more about your insurance, look at your insurance card. There will be a number on the card to contact for more information. You will probably be connected to a recording, not a live person, and probably be placed on hold or be told to leave a number and they will call you back, but be patient and persistent. It is important that you get this information. Alternatively, you can call the health benefits coordinator at work (if you get your insurance through your work) or the health insurance broker (if you got your insurance through a broker). My office is not a good source of information on your particular insurance (for instance, how much is your co-pay? how much is your deductible? how much is your co-insurance?), since we don't know the financial details of your specific plan. For instance, you may have Blue Cross, but did you know that Blue Cross has thousands of individual policies that are negotiated with individual employers? It is simply impossible for us to know the financial details of all of the plans. I can explain for you some terms that you may encounter.
Co-pay: this is the amount that you must pay for each visit, at the time of the visit.
Co-insurance: this is the percentage of the approved cost that you must pay.
Deductible: this is the amount that you must pay each year before your insurance company pays anything. This may vary with the service: office, hospital, or surgery.
"Usual, customary, and reasonable": This term is a great big fraud! It is a term made up by insurance companies to describe how much they will pay for a particular service. It is a fraud because the amount is not the usual amount charged by any doctor, it is not customary in that the amount has never been the amount charged by a doctor, and neither the patient nor the doctor think it is reasonable, and has been the center of many lawsuits for fraud. You see, the lower the insurance company sets this figure, they less they have to pay. And no one but them has any input into the figure! They would have to be financially crazy to set this figure very high, and they certainly are not financially crazy. The amount is often about 30% to 50% of the current charge by the doctors in any given geographic region (this kind of information is publicly available for a fee, in databases maintained by various companies; I get my information from MediCode in Salt Lake City, Utah.)
Global service period: this a the time period associated with a surgery, usually 90 days, during which there is no additional charge for follow-up by the surgeon. There is a charge for additional services such as xrays, casts, or splints, or for the management of any unusual followup services or for any complication. The duration of the global service period varies with the type of surgery and is determined by each insurance company, although they usually use the duration as set by Medicare.