1. Your Employer Determines Your Benefits - Even though you are paying a premium, your employer determines what is covered in the plan and how the plan is managed. And your employer is paying a larger share of the premium than you are. Insurance is not cheap, and nowadays most employers are seeking plans that are cost effective. That means benefits that were fairly generous 2 or 3 years ago are becoming less generous today.
2. Unlimited Sessions? - Many plans are set up without session limits. However, the plans are managed in such a way that after so many sessions, a utilization review will likely occur. If the provider is asked for a utilization review, the managed care company is trying to determine if the treatment offered is meeting clinical guidelines or medical necessity. Unfortunately, a lot of providers are unaware of the guidelines or don't understand how to properly apply the guidelines. This can lead to waste, fraud, and abuse which causes premiums to increase due to a few bad actors. Guidelines are available online or upon request for each managed care company. Here are a few below:
3. HIPAA TPO Exclusion - HIPAA law (45 CFR Part 164, Subpart E - Privacy of Individually Identifiable Health Information) allows insurance companies to exchange "necessary" information with your provider for treatment or payment as long as you are using the benefit. If you are using the benefit, you are in effect giving your permission for the exchange of information to occur. As long as you are using the benefit there is no HIPAA violation if the insurance company is contacting your provider for a review of your case. You can refuse to allow your provider to speak with the insurance company about your case, but the insurance company can deny benefits due to a lack of information. Let's say you went to your bank for a loan, but refused to give them any information as to why you need the loan or how you intend to pay it back. Chances are you will be denied for the loan, because the bank doesn't have enough information to make a decision. The same principle applies to your benefits.
4. Out of Network Providers Do Deal with Insurance Companies - If you are an out of network provider, but your clients use insurance, you will deal with insurance companies. Especially if your client wants to be reimbursed. It may include doing a clinical review to authorize services. If you are a provider who doesn't want to deal with insurance companies, don't take clients who use insurance.
5. There is No Reimbursement for Talking to Insurance Companies - If the provider is asked to do a review to justify services, the insurance company will not reimburse the provider for that time. If the provider is in network, he cannot bill the client for that time, unless there is already a written agreement in place that the client will pay for time talking to managed care. If the provider is out of network, they can bill the client for that time. (Personally, I would not see a provider who would charge me for speaking with the insurance company, especially if the provider believes the treatment is necessary. That's just the cost of doing business.)
Image courtesy of Ambro at FreeDigitalPhotos.net
Image courtesy of Ambro at FreeDigitalPhotos.net
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