Common Insurance Questions
The following are commonly asked insurance questions:
What is Financial Authorization?
If your insurance company requires prior authorization for a requested service, a financial specialist at Mount Sinai will submit a request to your insurance provider for approval of the service. This approval is called financial authorization. Once financial authorization has been given by your insurance company, we can proceed with treatment. Sometimes there may be a delay if your insurance provider needs additional information from our clinical team. If this happens, we might need to reschedule your appointment, since we cannot proceed with treatment until approval has been given.
What is an Explanation of Benefits?
You will most likely receive an explanation of benefits (EOB) statement from your insurance provider. An EOB is not a bill. It provides details about billed charges and payment against those charges. It outlines what amounts were paid by your insurance provider and what portion of the billed charges, if any, are your responsibility. Any portion of the billed charges that are not covered by your insurance provider, such as a deductible or a co-pay, will be billed to you by the health care provider and should be paid directly to the health care provider. If you have questions regarding the EOB, please call the number listed on the EOB statement to speak to someone with your insurance provider.
What is a copayment?
A copayment is a small fee related to an episode of care. It is determined by your insurance provider. The copayment is a set amount that does not vary—it is not based on the cost of the service. Please contact your insurance provider if you have questions about your copayment.
What is a Deductible?
A deductible is a fixed amount that you must pay each year before payments from insurance provider kick in. Once you have satisfied the deductible, your insurance provider will begin to pay its share of your health care bills.
You have a $2,000 deductible. You see your doctor in January. Your doctor submits a bill for $200 to your insurance provider. You receive an EOB from your insurance provider that says you are responsible for the entire $200 since you have not yet met your deductible for the year. You then receive a bill from your doctor for $200. The $200 you pay to your doctor is applied to your $2,000 deductible. Your deductible balance is now $1,800.
What is Co-insurance?
Co-insurance is a percentage of billed charges that you pay for your health care services. The percentage is stipulated by your insurance provider plan. Usually, you will be required to pay co-insurance after you have met your deductible for the year.
You have a $2,000 deductible for the year, which you have satisfied. According to your insurance provider plan, you are now responsible for a 10% co-insurance. You receive medical services resulting in a bill of $15,000, which is submitted by your health care provider to your insurance provider. Your insurance provider sends you an EOB that says they are paying 90% of the billed charges ($13,500) and you are responsible for 10% of the billed amount ($1,500). Your health provider then sends you a bill for $1,500.
What is “out-of-pocket”?
“Out-of-pocket” refers to the amount you are required to pay for particular health care services during an established period of time. This amount is limited to an “out of pocket maximum” as determined by your insurance provider.
Should you consider a secondary insurance?
A secondary insurance plan can help cover costs that are not covered by your primary insurance provider. After reviewing the coverage agreements of your primary insurance provider, you can decide if secondary insurance would be a good choice for you.
If you are enrolled in Medicare Parts A and B, Medicare will cover 80% of billed charges. Depending on your healthcare needs and personal finances, it may be beneficial to consider obtaining a secondary insurance plan to cover the 20% that is not covered by Medicare.