01/29/2020
"I have the same insurance that I did last year, why are you charging me more than you used to if your prices haven't changed in years?"
One needs to keep a few things in mind about insurance coverage.
1. Medical insurance is a contract between three parties: the insured, the insurer, and the provider. All three agree to terms in order for it to work.
2. The insurance contract typically requires the following: the insured chooses a plan with specific costs (premiums, deductibles, co-pays and co-insurance) and benefits, the practice agrees to a non-negotiable discount determined by the insurer, after the discount the insurer pays the provider a portion of the amount billed with the remainder being assigned to the insured person according to the terms of the plan.
3. The provider doesn't decide how much the patient gets billed, the plan the patient is covered under does. The provider is obligated to charge the patient this amount, it's part of the contract and terms of getting paid by the insurance plan. If the provider fails to charge this to the patient, it risks being dropped by the insurance company.
3. A specific plan from a specific insurer can change it's terms and coverage from one year to the next.
4. This year you might have a different plan from the same insurance company which has different terms, which require you to pay a different amount.
5. In summary, an insurance plan requires the patient pay the insurance company (premiums), the provider performs therapy for the patient (treatment), the provider accepts a discounted value for claims (adjustments), the insurer pays the provider (benefits), and the patient pays the provider out-of-pocket costs (deductible, co-pays, co-insurance).
The rule of thumb for insurance plans is that the lower the premiums, the higher the patient's out of pocket costs (deductible, co-pay, co-insurance amounts). What doesn't vary is how much the provider gets paid, it just affects who pays what portions of the benefits, insurer or insured.