DEMYSTIFYING YOUR INSURANCE POLICY
DOS (Date of Service) This is the date you received treatment. EOB (Explanation of Benefits) The EOB is the information an insurance company provides after a patient has received a medical procedure or service. It provides the details about how much was charged for a procedure, how much the insurance company is approved to pay, the amount already paid, and what the patient owes (often listed as patient responsibility). HMO (Health Maintenance Organization) A type of insurance plan that pays for medical services offered by a specific group of providers. Often the patient must be seen by the specific group of providers and have authorization for treatment, or the insurance will not cover the expense. It is always a good idea to ask if your provider is in network with the insurance company. POS Plan (Point of Service Plan) and PPO (Preferred Provider Organization) A flexible insurance plan that allows patients to choose their health care provider without the need for an initial referral (authorization) from their primary care doctor. Often with these plans, covered benefits are different depending on whether or not the provider is in network, so again, Most people with health insurance do not know much about their policy until they need treatment. When you do read a policy or receive a bill, terms can be confusing. No two insurance companies are the same. In fact, most insurance companies have several different polices, each with their own rules and covered benefits. The best way to plan is to understand. Our front office has put together some definitions to help you navigate the frequently used terms.
you should always confirm with the provider if they are in network with your insurance company.
Allowed Amount The amount the insurance company allows the provider to be paid for services billed. This is often based on the contracted rate for private insurance or government regulated such as Medicare. Patient Share of Cost There is often some patient responsibility in sharing the cost of medical visits. It most often comes in the form of deductibles, coinsurance, or a copay (see below). If you have a secondary insurance policy, it may cover those expenses. Be sure to provide your health care provider with both primary and secondary insurance information. Deductible A specified amount of patient responsibility. The patient must pay this amount for covered charges before the insurance company begins to pay for the charges. At the start of your policy year (most often Jan. 1, but not always, so you need to check), the patient will have to pay out-of-pocket for all charges until deductible is met. There are a few exceptions to this. For example, many annual wellness exams are covered without the patient having to pay.
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