Decoding Your Health Benefits

I recently started receiving acupuncture. I knew that my insurance covered 12 visits a year. I checked the coverage and learned that my portion is a $15 co-pay for the office visit, and then 10% of the treatment. But that’s not how it worked out, and it’s taken several calls to get it sorted out.

Reading the Benefits Website
I started at the website. That’s where it said that the office visit co-pay was $15 (standard medical co-pay) and the treatment was 10% of the cost (standard co-insurance.) It didn’t mention anything about a deductible.

I next looked at their provider list and located acupuncturists in my area. Then I looked at their websites and an acupuncture provider website to find out who treated my condition. I called and made an appointment.

Provider Confirmation
My provider called my insurance before my first visit to confirm coverage and let me know my co-pay would be $22.50. Great. I went for my first visit, paid my co-pay, and then went on my way.

The Explanation of Benefits Arrive
You would think that between me reading the website, and my provider calling them, and my provider reading their website, we would have figured it out. You would be wrong. When my first explanation of benefits arrived, it said I owed $105.00. It also said that the second “treatment” on the same day was not covered. Apparently the provider used the proper billing codes, but the insurance misread them. They’re now reprocessing those initial claims.

I also called to find out what was going on, and was told that they were billing wrong and that I had a $250 deductible. It doesn’t say that anywhere in the acupuncture portion! The deductible for the plan is never mentioned anywhere except at the top of the benefits section.

My Provider Confirms Again
I showed the EOB to my provider, who called the insurance again. Finally they explained that there’s no deductible for office visits, as they said the first time, but there is for treatments. And that they don’t start counting my visits toward the 12 until my deductible is reached. Based on what they’ve said I owe, that started on my fourth visit, so in total I’ll have 16 visits under my plan.

I’ve learned from this to always call first to confirm your coverage. The website has the correct information, but it isn’t always organized in a way that makes sense to the average user, or even to providers. Even if your provider calls to confirm coverage, if it’s an unusual situation, call to verify yourself anyway. As I learned, it can take three or four calls to get it all straightened out!

And then sometimes, as happened with my husband’s surgery, they’re still wrong. Of the $4000 surgery co-insurance they said we would owe, we paid $60. No amount of calling could have figured that one out!

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