By Martine G. Brousse
"The Medical Bill Whisperer... and insurance stuff too"
Patient Advocate, Certified Mediator
AdvimedPro
Watch the YouTube video
August 7, 2023
The list of acronyms in the healthcare landscape is as limitless as it is complex: CPT, ICD-9, ICD-10, DME, FFS, and too many more to list.
The most important ones for patients to know relate to the type of health coverage they receive. Every patient must what they have and what it means. The financial consequences of not knowing are too dire, and are the primary cause of the mountain of medical debt Americans face every day.
First a disclaimer: The following applies only to Commercial plans.
Commercial plans are those NOT administered by the Federal government (Medicare or Tricare) or by States (Medicaid). They are issued by employers to their employees, or bought by individuals on the open market or Obamacare exchanges. In general, if you are not 65, not disabled and not living in extreme poverty, you have a commercial plan.
For the Basics:
A. Four major types of commercial plans:
· PPO
· EPO
· HMO
· POS
1. PPO = Preferred Provider Organization
· This plan basically divides medical providers (Drs, hospitals, and every other entity or person providing some form of medical care) into 2 categories: those who signed a contract and are then “In Network”, and those who have not (considered “out of network”)
· For you, the patient, it means that if you engage the services of a contracted In Network provider, your cost is lower because the provider agrees to give you a discount and the insurance agrees to pay that entity more.
· PPO can be understood to mean: a (large) list of preferred providers area, accessible and available at a lower cost to you
2. EPO = Exclusive Provider Organization
· Think “PPO” but on a very strict diet. The number of contracted providers is much much smaller but the principe is the same.
3. HMO = Health Maintenance Organization (or “Managed care”)
· This plan also uses the same concept of In vs Out of Network providers, but in a much more restricted way from the start.
· You are assigned a specific PCP (“Primary Care Physician”) within an Independent Physician Association (IPA) or Medical Group who supervises, manages and directs your overall care.
· All services you require must be provided by that PCP and/or within that IPA/Group in order to be considered “In Network” and payable.
· Your PCP is assigned based on your residence.
4. POS = Point Of Service
· Think “blend of PPO and HMO”.
· You can use either option, but at a different cost to you (see below)
B. Benefits to Patients:
1. PPO
· Freedom to choose one’s general practitioner, treating physicians and/or hospital
· Unrestricted access to specialists
· Flexibility of use
· No authorization needed for visits and consultations, and for most outpatient services
· Lowest cost when choosing In Network providers
· Usually the largest network out there (outside of Medicare)
· Faster access to care
· " Preferred patient" status as it requires less administrative efforts by the office
· May also provide some coverage for Out Of Network providers
· May also authorize Out of network providers to be paid at the In Network (higher) rate under certain conditions
· Should cover emergency coverage regardless of status of entity
· State and/or Federal mandates may force coverage at higher In Network rate for Out of Network providers under certain circumstances
2. EPO
· Same as PPO except for no Out Of Network coverage
· Should cover emergency coverage regardless of status of entity
· State and/or Federal mandates may force coverage at higher In Network rate for Out of Network providers under certain circumstances
3. HMO
· Some HMO organizations have extensive networks (Kaiser is one)
· Local network of providers close to your residence
· Efficient medical care
· PCP coordinates all medical info and treatments = less duplication of services, fewer errors, less delays, less miscommunication between physicians and lower risk of side effects
· Lower out of pocket cost
· Should cover emergency coverage regardless of status of entity providing the care and even if out of network
4. POS
· Extreme flexibility of choice
· PCP would still coordinate care
· Should cover emergency coverage regardless of status of entity
· State and/or Federal mandates may force coverage at higher In Network rate for Out of Network providers under certain circumstances
C. Drawbacks to patients
1. PPO
· Must be careful to confirm status of physician or hospital before engaging non-emergency services
· Usually, higher share of cost, including deductible and Co-insurance amounts (what you pay before the insurance does)
· Little or no coordination between different Drs unless you initiate it
· Higher risk of duplication of services (labs, imaging, tests) and therefore of cost to you
· Higher risk of side effects (when Rx may interfere with each other)
· Usually higher in overall cost than a HMO plan
2. EPO
· Limited access to contracted medical providers – one specialist only on the list may lead to delays in getting an appointment
· Restricted choice of medical providers
· Usually, no coverage for Out of Network care (unless emergency)
· Not the best option if you are in need of medical care often or quickly
3. HMO
· Limited to small network within a local medical group or IPA
· Dependent on PCP’s good will in authorizing any visit, treatment or consultation to or by another provider
· Access to care and to appointments, especially to a specialist, often means (long) delays
· Must establish a good relation with the PCP and his/her staff in order to get quicker responses and positive actions
· Depending on your area, care levels might be sub-par
· A real hassle if your PCP denies an authorization (and therefore payment for) to a specialist or an external non-emergency medical provider as your PCP’s payments by the insurance are cut every time they refer you to someone else.
4. POS
· See above: PPO and HMO drawbacks
· But at least you can use both to your best advantage…
D. To complicate it more: Tiers
The last few years, a new concept has been introduced by insurance companies not caring much about you: the Tiers system.
This system rewards you for using one vs. another... provided you can...
There are usually 3 Tiers: Tiers 1, Tier 2 and Tier 3.
All Tiers apply to the contracted providers already within your insurance’s network.
So why are they there?
Medical providers are places in one of the Tiers based on criteria such as cost of their care, favorable results for patients, office staff efficiency, customer service ratings etc.
If a patient chooses a Tier1 provider, he/she can be assured of the best available level of care by the best available physician or facility. The cost will also be lowest.
If choosing (or forced to pick) a Tier 3, the patient may receive care rated as not optimum, and may be charged more for it.
Needless to say, Tier 1 providers are more in demand, less available for a prompt appointment, and may or may not be the best fit for you.
If they are so busy, they may have less time or attention for you than a Tier 2 or Tier 3 provider could offer.
Conclusion:
1. Except in cases of emergency, or when you truly do not have a choice (the anesthesiologist or pathologist during a surgery for example), putting in some time and efforts to pick the right facility or Dr is a must.
2. Become familiar with the type of plan you have, and ask HR, your insurance agent or or the insurance representative questions:
· How does the plan work,
· How much will it costs you yearly
· Can you change the PCP and medical group if not convenient or fitting your needs
· Where to find a current list of In Network providers
· Confirm an upcoming appointment’s status
3. Whenever possible, get it in writing. You never know when such evidence might come in handy to fight a later denial or clear a hurdle with your Dr or insurance.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2023 @themedicalbillwhisperer 2023
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