Patient Services Solutions

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

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

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