Skip to main content

Posts

Is My Birth Control Covered by My Insurance?

 In general, yes your health insurance coverage will include birth control methods at no cost--that is, the plan must cover birth control without copay whether you have met your deductible or not. Healthcare plans available through the healthcare exchange and plans provided by employer must provide this coverage with two exceptions--religious employers and non-profit religious institutions, such as hospitals. If your religious employer refuses to cover contraception, you will be required to pay out of pocket. If your non-profit employer refuses to contract or pay for contraception, a third party administrator will make arrangements for this benefit to be provided to you.  Healthcare plans must provide coverage for FDA approved contraception methods. Per the guidelines at healthcare.gov, these are the approved method Barrier methods, like diaphragms and sponges Hormonal methods, like birth control pills and vaginal rings Implanted devices, like intrauterine devices (IUDs) Emergency cont
Post a Comment
Read more
Recent posts

Why Won't the Pharmacy Help Me?

 Each time a prescription is faxed, electronically transmitted, or brought into the pharmacy, critical information is being communicated from the doctor to the pharmacist. If any of that information is missing, confusing, or contradictory, the pharmacist will be unable to fill the prescription and release the medication to the patient. That information must be clarified. And yet, more and more, pharmacies are refusing to make the phone calls necessary to fix the miscommunication.  In the past two years, pharmacies have been faced with a tremendous shift in responsibility. This is mostly due to the realities of the Covid-19 pandemic--care such as testing and vaccinations have shifted away from clinics and towards pharmacies. Pharmacists and pharmacy techs were named as necessary workers during the shutdowns, and thus, had an increase of exposure to the virus--this resulted in a depletion of the regular workforce overall. With an increase in responsibilities with a decrease in necessary
Post a Comment
Read more

Why Did My Insurance Deny my Prescription?

 Because healthcare is a complicated web of decisions and payments, the doctor's treatment decision is not the final word, it's only the beginning of the discussion. Medications are particularly vulnerable to denials for a wide variety of reasons, a few of which I will be discussing in this post.  The insurance who received the claim is not the appropriate payor.  This is a pretty common mistake that happens at the pharmacy level. Sometimes the information in the pharmacy system has not yet been updated, such as when an insurance plan expires or begins. Sometimes the pharmacy has multiple plans on file to choose from and select the incorrect option. Sometimes it's not clear if the medication is for personal, auto, or work related injury. As the pharmacy does not know they have submitted the claim incorrectly, they cannot necessarily tell you why the medication is denied. Before you panic, be sure to verify the information the pharmacy is using. Make sure that the plan infor
Post a Comment
Read more

What is a Utilization Review?

Utilization Reviews (UR) are used by health insurance carriers as a type of managed care to ensure that medical treatments are appropriate and efficient. Medicare may require a Utilization Review to verify that patient is not being over-prescribed pain medication. Worker's Compensation carriers may request URs to ensure that patients are not being over-treated by shady doctors. Your private insurance may require a Utilization Review to ensure that all first-line or recommended treatments have been attempted. Utilization Reviews are retrospective--that is it's a review of treatments that already have happened--but may be required before carriers provide prior authorizations for new services.  Utilization Reviews have strict criteria and rely on evidence-based evaluations. Your own doctor will submit the medical history, evidence, and recommendations and the insurance carrier will assign a neutral doctor to review the paperwork, evidence, and treatment plan before issuing their o
Post a Comment
Read more

What is an Insurance Election Period?

 Because of the nature of insurance plans, you cannot simply enroll or unenroll whenever you wish. Every insurance plan as an annual period called the Open Enrollment Period where you may add, drop, or change the plan without penalty. Generally, if you receive your insurance through your employer, you don't have to do anything to maintain your enrollment--it will continue automatically, but if you would like to change or tier level, switch from HMO to PPO, or unenroll entirely, the Open Enrollment Period is your annual opportunity. Open Enrollment also applies to those who are enrolled in Medicare, Medicaid, or TriCare plans.  But you do not always have to wait for Open Enrollment to change your insurance plans. Legally, there are a series of qualifying life events that will provide a time frame--generally 30 to 60 days--in order to make any necessary changes without penalty for adding or dropping a plan.  These qualifying life changes include:  Marriage or Divorce Gain or Loss of
Post a Comment
Read more

What is a Third Party Administrator?

You likely know the name of your private insurance carrier and you may even know the name of your employer's worker's compensation insurance carrier--but what you may not know is that these insurance carriers have little to do with your actual claims.  Instead of doing the back-office work themselves, they contract with Third Party Administrators, or TPAs.  TPAs are responsible for a wide number of tasks. They may conduct Utilization Reviews for medication and medical procedures and issues authorizations or denials. They may handle pharmacy benefits, or contract directly with the pharmacy benefit managers (PBMS) that process the pharmacy claims. They handle all billing for medical providers, and pay those providers based on contractual agreements. The TPA may have complete control over every financial aspect of your private insurance or worker's compensation claim. Sedgwick or United Healthcare may be your insurance carrier in name only.  Insurance carriers contract with TP
Post a Comment
Read more

What is a Denial?

Everybody who has dealt with an insurance carrier has dealt with a denied claim--whether that's medical insurance, homeowners insurance, renter's insurance, or auto insurance. What that means is sooner or later, you will also receive a denial for payment from an insurance carrier. But why does that happen when you pay your premiums, deductibles, and copays? Why does it seem like you are financially obligated to pay your bills, but the insurance carrier can just pick and choose what they pay?  In some cases, they can pick and choose what they pay because that is the contract you have agreed to. For example, when you enroll in a health insurance plan, you agree that you are able and willing to see their Network Providers. Network Providers are doctors, nurses, clinics, and hospitals that have agreed to accept payment from insurance carriers at agreed upon rates. A doctor may charge you five hundred dollars an hour for his time, but may agree to accept two hundred dollars from the
Post a Comment
Read more