Every time someone goes to the doctor, they want to know if the visit and treatment is covered by insurance. Unfortunately, there is no simple answer to that question. In the distant past, care was much simpler and each visit with your family doctor had a small set cost that covered everything preformed.
Today it is a complex financial industry with thousands of players each getting paid, from the insurance industry, to the medical suppliers, to the manufacturers of every widget and needle to lastly, the physician.
The cost of everything gets itemized and factored into the cost of each visit and treatment. The insurance industry and Medicare have complex formulas to figure out how much every service is worth and what can be charged. Unlike going to an auto mechanic who tells you the cost of the parts and labor, the medical industry is very different. A physician can determine how much it will cost in order to provide a service, but each insurance company decides how much they are willing to pay on their end, and the doctor is stuck with that amount. Rarely is a medical service fully reimbursed to the provider; often it is at 30-40 cents on the dollar.
Am I Covered?
The first question on coverage is whether you have medical insurance. Every person now can qualify for insurance and there are a variety of plans available. Total cost and coverage are the remaining issues. The benefit of the Affordable Care Act (nicknamed Obamacare) is now everyone can get medical insurance and no one can be denied. Unfortunately, that means everyone needs to understand the insurance they have purchased, and realize every service provided is set by the coverage that you bought. Most physicians try to work with the patient and insurance to determine the best option in management of any medical problem. To stay in business, most physicians must have specialists in their offices to make sure they have the necessary prior authorizations in order to see and treat an individual.
The insurance industry has set a guideline that a service should be covered if it is deemed medically necessary. The amount of coverage depends on the individual plan, deductibles and co-payments required. Furthermore, the service may need to be approved by a primary physician in addition to the ordering physician, and it may need special approval by an insurance company’s medical expert.
Wait, What?
At this point, most people are totally confused and are concerned about the cost of seeing a doctor. If you have a problem that is not going away, then you should always start with your primary physician. A good history and physical exam should tell most physicians what is wrong and the treatment that will solve 90 percent or more of the problems without expensive intervention. If the problem does not resolve, then involving the next level of experts, tests and treatments may be necessary. Obtaining referrals, checking for authorizations and determining your copays and deductibles are now issues. Both your referring doctor and specialists can help explain the particular costs that may occur if you contact their business offices.
If you have insurance, the cost of your medical care is dependent on the insurance coverage, especially the amount each visit costs due to the deductible amount and copay required. Each insurance company sets a reimbursement rate for every conceivable medical service provided. The answer to how much anything will cost you can only come from a physician’s billing office and your insurance company. Unfortunately this is not a simple answer. If you ask a physician how much it will cost you, they will have no idea since they get paid at the whim of each and every insurance payer at different rates for the same services.