Patient Services Solutions

 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

 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

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

 Throughout your life, you will change insurance carriers many times. Sometimes you lose or gain eligibility due to a career change. You may age into Medicare eligibility, you may marry or divorce, may choose to join a plan on the Healthcare Exchange, or may become disabled and eligible for your state's Medicaid or Social Security benefits. Depending on the type of insurance, you may be able to change your plan every year, or you may have to wait until you have a qualifying life event.  Each time your benefits change, you are faced with the same series of questions and considerations. Is your regular physician in your new network? Do you need to get a new referral to continue to see your allergist or cardiologist? Will your deductible be higher or lower? Are your medications still covered? What is your new copay for regular visits? Can you go to the emergency room if if it's necessary?  First it's necessary to understand the difference between an in-network provider (INN) a

 Pharmacy Benefit Managers coordinate between pharmacies, insurance carriers, and other third party administrators in order to  guarantee payment and process pharmacy claims. Pharmacy Benefit Managers are shortened to PBMs, and the number of claims processed by PBMs have grown exponentially in the past decade.  In fact, a PBM probably is responsible for processing the medications your doctor writes every month. And yet, you probably don't even know the name of the company that touches every one of your claims and stores your personal health information (PHI). Although PBMs are engaged in processing your medication they do not work for the patient and they have no interest in the standard of your healthcare.  The three largest PBMs in the industry are CVS Caremark, Cigna (Express Scripts), and United Health Group (OptumRX). These PBMs handle private insurance, medicare, worker's compensation, and auto no-fault.  Drugchannels.net estimates for 2020 ...The big three PBMs—CVS Heal

If you are dealing with a work-related injury, an ongoing health issue, or simply your family's standard medical needs, you probably receive a lot of paperwork. Some of it isn't easy to understand, and sometimes it's not clear if what you received is a bill for services.  Explanation of Benefits (EOB) are statements from the insurance carrier regarding every item billed by a provider. For example, you may go see your primary care physician for an infected finger, but while you're there you may also discuss your current medications, and have your sinuses checked for polyps. Each separate procedure will be submitted to the insurance carrier with a medical billing code, and the insurance carrier decides based on those codes what and how much to pay.   Those are the codes that will appear on your Explanation of Benefits. At the bottom of the statement, normally in small print, there will be a legend defining each code. Sometimes those codes are easy to understand--maybe one

Pharmacy Benefit Manager (PBM ): Third party companies such as OptumRX, ExpressScripts, and CVS Scripts that contract with insurance carriers and coordinate with pharmacies to process pharmacy benefit claims.  The Big Three process over 70% of pharmacy insurance claims in the United States and they they are not obligated to ensuring patient care or maintaining the standard of care. They promise to reduce costs to insurance carriers and profit from minimizing care to patients. Third Party Administrators (TPA) : Third party companies that are contracted with insurance carriers to administer claims, including adjust and adjudicate, guarantee payment, utilization reviews of medical and pharmacy authorizations, contract with providers, and accept or deny liability.  Claims: Payment requests from medical providers or pharmacies submitted to the responsible party.  Responsible Party : The responsible party for a claim is the person or entity legally obligated to provide payment for services

Communication is key in any successful relationship but it's especially important in the world of healthcare.  Patients are at the center of a complicated web of providers, insurance carriers, third party administrators, pharmacy benefit managers, claim adjusters, and federal regulation.  The meeting between a patient and their trusted doctor is only the beginning of a long and complicated journey.  Imagine a common healthcare scenario, such as a doctor's visit for a sore shoulder or an infected cut.  The meeting may last no more than fifteen minutes, but it sets off a complicated chain of events, navigating a system of payee/payor relationships, medical providers, and information processors. In the case of an infected cut, the doctor prescribes two antibiotics, a pill and an ointment, and electronically transmits prescriptions to the pharmacy on file.  A new provider--the pharmacist--has just been invited to the relationship. Here a new series of complications is introduced: i