Understanding Insurance Benefits
Insurance benefits can be complicated and confusing at times. Below are answers to some questions most often associated with the care of venous and lymphatic insufficiences.
How do I know the exact price a patient will have to pay out-of-pocket for their products?
We will verify the patient’s insurance benefits, calculate the price of the medical products with the insurance coverage, and then call the patient with an estimated cost if the order were placed. The actual out-of-pocket price of the order could be significantly less than the estimation, depending on the circumstance.
What does the deductible mean?
The deductible is the amount of money a patient must first pay out-of-pocket, before the actual insurance benefits kick in. For example, if a patient has a $250 deductible and 80% coverage, the $250 will have to first been met for the year before products begin to be covered at 80% of their price.
What is an out-of-pocket expense limitation?
Lets take the example from above: once the patient meets their $250 deductible and their insurance is covering their products at 80%, where does the 20% co-insurance that the patient is paying go to? It goes towards an out-of-pocket expense limitation. If this patient were to have a $1,000 out-of-pocket expense limitation, then all money the patient pays to the insurance company goes towards this $1,000. Once the $1,000 is met, the insurance company will pay for services at 100%.
What does it mean when a product requires pre-authorization?
Certain insurance policies require products to be pre-authorized based on certain criteria. Sometimes products require mandatory pre-authorization if they are over a certain price. Also, certain products require pre-authorization just based on the item, for example nighttime products (CircAid, JoviPak, ReidSleeve, Tribute) generally have a higher chance of requiring pre-authorization than daytime products (Juzo, Jobst, Medi). The pre-authorization process can take anywhere from 30-45 days, or sometimes less.
What is a benefit “cap-per-year” or yearly maximum?
Sometimes the patient’s insurance policy will carry a Durable Medical Equipment (DME) or Orthotics & Prosthetics dollar maximum for the year. For example, if the patient has a $2,500 cap-per-year, then once the patient receives $2,500 worth of DME products for the year, coverage will no longer be given for products that are deemed DME.