How much does my insurance cover?

Tatinha · Feb 13, 2014

There are many nuances between insurances, too many of them, too many details. That is why offices even have one person dedicated to dealing with Insurance reimbursements and all. Coming up with a list would require full knowledge of every plan your institution accepts, it would have to be constantly updated and it would be a great potential for inaccurate information, that would leave patients angry. A friend of mine asked his dental office if he would be covered for a certain procedure, they said yes, but when he received a bill for 3000 dollars and no coverage.....the office had a hard time fixing the problem and ended up giving a great discount. He was lucky to get a discount, as most institutions make you sign a document saying you are responsible for any care not covered by insurance. The best way is for the patient to ask his/her own insurance. Not the best way to do health care, I agree, but that is all we have in America. I would never say to a patient that a service is covered, as I can not know for sure. Be careful and cover yourself.

And for financial forms upfront... the also would be great, but our system cannot even agree on how much to charge on anything. Because of pricing secrecy, institutions usually do not tell you for example, how much is going to cost you to have a baby, or have an MRI etc. If your institution can come up with a menu with pricing that could be done. Acctually, that is what all institutions should do. Afterwards, have you ever ordered food or bought a car without knowing the price first?

Sam J. · Feb 14, 2014

A question we hear frequently is will my insurance cover this diabetes education? We understand how Medicare and Medicaid works, the problem is there are so many various private insurance plans available, what do you do when presented with this question?
Our current response is the patient is responsible for knowing this and they are the ones that need to call the insurance company and determine how their insurance will cover it. I believe this is generally inefficient and is lacking in customer service. I certainly understand it is the patient's responsibility, however, if we can have this information upfront, provide it to them, they will be able to know they can or can't afford it or maybe a payment plan or work on financial assistance forms upfront. Any help in your process or procedure when it comes to answering this question would be appreciated!

Part of the stated goal of the ACA is to reimburse providers for their time educating patients, because the usual model penalizes providers for spending time on prevention or education.

SHGR, MSN, RN, CNS · Feb 16, 2014

I think what you are looking for is health care pricing transparency. Try starting here State Actions Related to Transparency and Disclosure of Health and Hospital Charges

My understanding is that a potential patient could call around to find the best price on, say, a hip replacement and each health care system is supposed to be able to provide their own cost so the patient could compare.

BlueLightRN · Feb 16, 2014

As a nurse it's not my responsibility to know what every insurance covers and it's not my responsibility to know the cost either. If I had to call every patient's insurance when would i have time to do my job? I agree that it'd be nice to know but I just don't have the time.

enuf_already · Feb 16, 2014

As a nurse it's not my responsibility to know what every insurance covers and it's not my responsibility to know the cost either. If I had to call every patient's insurance when would i have time to do my job? I agree that it'd be nice to know but I just don't have the time.

I agree with this. The big problem is knowing whether something is covered and at what percent could be dependent on the day you call.

For example: I have a high deductible insurance. If you call today and I have not yet met my deductible, nothing will be covered. After I go to the pharmacy tomorrow and pick up my meds, my deductible will be covered and a percentage of my bill may be payed. When I reach my 100% out of pocket maximum, everything that is a covered expense will be paid.

But the caveat is that each plan has exceptions to their rules. Diabetes education may be covered, but prediabetes education isn't.

While it would be wonderful for an office to be able to tell a patient what is covered under their plan, it would take someone working full time to be able to accomplish this. I personally think it is better for the patient to hear it straight from the insurance company. Then it is not the physician's 'fault' when something is not covered.

SHGR, MSN, RN, CNS · Feb 16, 2014

I disagree to a point that it is "not the nurse's responsibility" to know what is covered. The OP does diabetes education so there really are only a few things provided (likely group class, one on one with RN, one on one with RD) and thus should at least have a ballpark idea what is and is not covered with the most common insurances and the out of pocket cost too if a person chooses to pay for it him or herself.

Like it or not, at this point Medicare is not covering prediabetes education although there is some pending legislature to do so. http://thomas.loc.gov/cgi-bin/query/z?c113:H.R.1257:

Also, here is an example of transparency (not my hospital, just an example of what is being done)

Pre-diabetes classes - The Christ Hospital

Sam J. · Feb 16, 2014

As a nurse it's not my responsibility to know what every insurance covers and it's not my responsibility to know the cost either. If I had to call every patient's insurance when would i have time to do my job? I agree that it'd be nice to know but I just don't have the time.

If I may be so bold- it's 'everyones' job in healthcare to be aware of costs. Knowing who pays for what might, now, be a different story. The fact is, the age of 'if you have to ask the price you can't afford it' is soon coming to an end, in the form of transparent pricing. Like it, or not.

BlueLightRN · Feb 17, 2014

If I may be so bold- it's 'everyones' job in healthcare to be aware of costs. Knowing who pays for what might, now, be a different story. The fact is, the age of 'if you have to ask the price you can't afford it' is soon coming to an end, in the form of transparent pricing. Like it, or not.

It's billing's job. The patient can ask billing to call their insurance.

BlueLightRN · Feb 17, 2014

If I may be so bold- it's 'everyones' job in healthcare to be aware of costs. Knowing who pays for what might, now, be a different story. The fact is, the age of 'if you have to ask the price you can't afford it' is soon coming to an end, in the form of transparent pricing. Like it, or not.

Also, is the nurse in the hospital required to know how much each bag of IV fluid and the cost of each pill for each patient and every insurance? No? My point exactly. It is not possible to know what every patient's insurance does and does not covered and the costs. That's just ridiculous. I took offense to that, because costs are NOT my responsibility, patient care is.

SHGR, MSN, RN, CNS · Feb 17, 2014

Also, is the nurse in the hospital required to know how much each bag of IV fluid and the cost of each pill for each patient and every insurance? No? My point exactly. It is not possible to know what every patient's insurance does and does not covered and the costs. That's just ridiculous. I took offense to that, because costs are NOT my responsibility, patient care is.

The OP asked about diabetes education.

SteveDE · Feb 17, 2014

Well, I started the post and I was posting in the diabetes nurse topic category and I specifically asked about diabetes education. I did not ask about IV fluids, however, costs are your responsibility as a nurse to a patient and as a nurse for a facility, if you don't think costs are your responsibility drain a couple of those IV bags in the CFO's office...you will find out how important cost is to a nurse..now back to my original question of determining insurance coverage dealing with diabetes education please. I posted this in the diabetes nursing area because it dealt with diabetes education, as we should all know diabetes is a very expensive disease in terms of finances and those finances cause my patients increased stress, that increased stress causes lack of compliance and increased glucose. My responsibility is to help them learn a healthier lifestyle and often times that healthier lifestyle deals with cost.

As an ER nurse, I'll run through thousands of dollars of care to save your life or limb right now without thinking or looking at a price tag. When I clock in as diabetes educator, I'm looking at how I can help you maintain a healthy life, long-term, and therefore finances are important for many people, including myself. Thank you for all of your responses, many are similar to what I think and others have given me some good ideas to go with.