You call your insurance and ask them if a service is covered, and they will answer with a yes. You think, “great!” But, there’s more to it than that. We are going to tell you what they will not tell you.
We do our best to get an accurate representation of your coverage, however, insurance representatives frequently quote providers and members incorrectly. As a medical facility, we are at the mercy of the insurance company, so it is important to know what questions to ask.
There are several questions that we ask when inquiring about your coverage.
General coverage that most of you are familiar with:
In or out of network, deductible and out-of-pocket amounts, copays and/or coinsurance, and effective date.
Coverage you need to be aware of:
- Coverage Year
- Calendar Year: Benefits will restart on January 1st.
- Plan Year: Benefits will restart based on the start date of your plan.
- Visit Limits
- Hard max means insurance will not grant you more visits once these are used.
- Soft max means insurance will review medical necessity to see if additional visits are warranted.
- Questions you should ask:
- Ask if visits are combined with any other service. For example, some visit limits are combined with Occupational and Physical therapy, but not Speech therapy.
- Do the visits start once the deductible has been met or at the first date of service?
- Are the visits counted per day or per service? (Keep in mind each service is done by a different provider)
- Have any been used?
- Do certain diagnosis codes allow for no visit limit or additional visits?
- Insurance Referral or Authorization Required
- Many insurance companies require authorization before the patient can be seen at the facility. Failure to obtain authorization will result in no coverage.
- Diagnosis of Age Exclusions
- As a provider, insurance will not tell us what diagnosis or age exclusions are on your plan. As a member, insurance will share this information with you. We see a lot of denials because of these hidden exclusions.
- Does the patient have Autism? If yes, ask the following:
- Is this a self or fully-funded plan?
- If it is a fully-funded plan, ask if the Autism Mandate applies.
- The Autism Mandate does not allow insurance companies to restrict the number of visits covered for patients with Autism. The patient must be younger than 10 years old or be diagnosed before the age of 10.
- You can find more information about the Autism Mandate: https://www.autismspeaks.org/texas-state-regulated-insurance-coverage
Your Next Step
Don’t be afraid to ask any of these questions to your insurance representatives so you know exactly what is covered on your plan. Pro-Tip: Make sure you get a reference number and the name of the representative you spoke with. Occasionally, a representative will quote you incorrectly and you can use this reference number to fight denied coverage.
We hope this information provides you with additional insight on what you should be looking for when signing up for a health plan or reviewing your coverage.
If you have remaining visits or have met your deductible/out of pocket, make sure you take advantage of the coverage you have left and schedule intensives or additional visits before your policy restarts!
