Insurance Terms
What is a deductible?
The amount the patient pays before insurance starts covering costs
What is the main difference between a PPO and an HMO?
HMOs limit coverage to a network and require referrals; PPOs offer more flexibility
How can you check if a plan is in-network?
Utilize the In Network Contracts spreadsheet, check for history in Salesforce, ask a friend :)
A caller hasn’t hit their deductible—what does that mean for them?
Their insurance will not begin to cover their stay until this amount is met.
What are common insurance system tools you use?
-Portals
-Salesforce (for searching history)
-Network Contract spreadsheet
-Prefix Search
-Your peers :)
What does in-network mean?
A provider who is approved or contracted by a specific insurance company
What is an EPO plan? Bonus points if you explain the exception to the usual EPO restriction (BCBS specific)
An Exclusive Provider Organization (EPO) health plan is a type of health insurance that requires you to use a network of approved providers for your care, with limited or no coverage for out-of-network services (except in emergencies).
What’s the first thing to confirm when checking coverage for treatment?
The first thing you should be checking is that you have all the correct info from your client on the initial call! Without this accurate information, you can't move to the next step in verifying their policy.
What tools or info help estimate total out-of-pocket cost?
-Portal
-Completed VOB
-If all else fails, ask a friend! (Team lead, Ashley, Jake, etc)
List all items you should be asking for from a client on the initial phone call.
1. Name
2. DOB
3. SSN
4. Address
5. INSURANCE - PAYOR, ID & CARD IMAGES!
Explain out-of-pocket maximum.
The maximum you’ll pay in a year before insurance covers 100%
What is the difference between a TRICARE Prime and Tricare Select plan?
TRICARE Prime is a plan that generally offers lower out-of-pocket costs and requires a primary care manager (PCM) and referrals for care, while TRICARE Select is a preferred provider option that offers more freedom in choosing providers but typically has higher out-of-pocket costs.
What does the term "carve-out" mean? Provide an example!
A carve-out in health insurance refers to a situation where specific healthcare services are separated from the standard health insurance plan and managed or paid for differently—often by a third party or through a different insurance contract.
Example: UHC -- Optum, Emblem GHI -- Carelon
"How much will this cost me?"
Scenario:
$500 copay per day, maximum 3 days per admission
No deductible or coinsurance
Out-of-pocket maximum: $4,000 ($2500 accumulated)
Here’s how your benefits work:
You have a $500 copay per day for inpatient stays.
That copay only applies to the first 3 days per admission. $500 × 3 days = $1,500 total
After that, the rest of the stay is fully covered by your insurance.
You don’t have a deductible or coinsurance, so there are no additional percentage costs.
What are signs that an insurance issue requires escalation?
- "Non-Covered"
-"Unavailable"
-Blank benefits section
-Inactive but caller states they have coverage
Define copay and coinsurance.
A copay is a per admit or per level of care fixed amount you pay when receiving a covered healthcare service. It is a cost-sharing mechanism where you pay a set fee and your insurance covers servicve after that fee is paid. Coinsurance is a cost-sharing provision where you pay a percentage of your medical bills after meeting your deductible, while insurance pays the remaining percentage (typically expressed as a fraction on portals and VOBs: 80/20, 60/40, etc.)
What is a Single Case Agreement (SCA) or Gap Exception and when is it used?
It is a special arrangement in health insurance where the insurance company agrees to cover care from an out-of-network provider as if they were in-network, typically for a specific patient and a specific situation.
When it's used:
-No in-network provider can offer the required care.
-The out-of-network provider has a unique or specialized expertise that is not accessible in the member's immediate area
-Continuity of care is important (e.g., ongoing treatment with a provider after insurance changes).
What should you look for in the portal when a caller has Medicaid?
1) Confirm what state their medicaid is through
2) Verify using portal that member is eligible and active & what MCO is listed, ensuring facility is INN
3) Check for additional coverage!!! (Bonus extended answer - verify additional coverage is active, submit VOB for this plan)
A client calls in and states they have a policy through their employer but also have a plan through their spouse. How does coverage work in this situation?
Bonus question: what do we need to make sure is completed for these plans to both pay for treatment?
Client's employer based coverage defaults as their PRIMARY insurance. This means it will be billed first, and the insurance will pay its share. After the primary insurance has paid, their SECONDARY insurance (through spouse) will be billed. They may cover additional costs not covered by the primary.
Bonus: A COB (Coordination of Benefits) must be complete. (COB=is a process used by health insurance companies to determine the order in which multiple insurance plans will pay for a claim when a person is covered by more than one policy)
Explain in-network vs. out-of-network and where each plan type can go.
INN: These are providers that are contracted with your insurance. Your insurance pays more of the bill, and you pay less.
OON: These are providers that are not contracted with your insurance. Your insurance pays less, you pay more.
HMO (Health Maintenance Organization)
INN ✅ Yes
OON❌ No (except emergencies)
Must choose a Primary Care Physician (PCP) and get referrals to see specialists. Cheapest, but least flexible. State restricted.
PPO (Preferred Provider Organization)
INN ✅ Yes
OON ✅ Yes
More flexibility; no referral needed. Higher premiums but you can see any provider. Can travel freely.
EPO (Exclusive Provider Organization)
INN ✅ Yes
OON ❌ No (except emergencies)
No referrals needed, but no out-of-network coverage. Often cheaper than PPOs.
What happens if a client who calls in provides a policy through their employer but states that they just lost their job? Provide all possible options.
1. COBRA - Continuation of coverage. Some ex employees are eligible to continue their employer-sponsored plan for a limited period (usually up to 18 months). We can admit someone with proof of Cobra enrollment and payment, even if the plan still shows inactive on portals.
2. Marketplace - Losing a job qualifies for a Special Enrollment Period(SEP) in the marketplace. Depending on income and household size, they may be eligible for subsidies that lower monthly premiums and out-of-pocket costs.
3. Join a family member's plan - if they havea spouse or parent with a health insurance plan, they may be eligible to join that plan through a special enrollment period triggered by the loss of their own coverage - this needs to be confirmed PRIOR to admit.
4. Medicaid - depending on their income and state they reside in, they may qualify and we can assist them in enrolling once they admit to the facility.
How do plan types affect out-of-pocket costs?
HMOs generally have the lowest premiums but require using INN providers, leading to higher out-of-pocket costs. PPOs offer more flexibility, including OON options, but come with higher premiums and benefit costs. EPOs are similar to PPOs but with less flexibility, often having stricter limitations. POS plans have lower out-of-pocket costs for INN care and potentially higher costs for OON care. HDHPs (High Deductible Health Plans) have higher deductibles but may have lower premiums and out-of-pocket costs once the deductible is met.
What should you do if you’re unsure whether a treatment is covered?
Explain to the client that you need more time to have our insurance team verify their coverage and that you will call them back as soon as it's complete. Submit a VOB coded as "High Priority" and make sure that a Benefits Specialist is on it ASAP!
“What will this cost me?”
Scenario:
$2,000 annual deductible($500 accumulated)
20% coinsurance after deductible
$6,000 out-of-pocket maximum(no accumulations)
You have a $2,000 deductible, and you’ve already paid $500 this year. That means you still owe $1,500 before your insurance starts to share costs. After meeting your deductible, your insurance covers 80% of the cost, and you’re responsible for a 20% coinsurance for all services until you reach your out-of-pocket maximum of $6,000. Once that has been met, your insurance will pay 100% and you will not have any more out-of-pocket costs for your stay.
Deductible:
This is the amount you pay first, each year, before your insurance starts to help.
Coinsurance:
After you’ve paid your deductible, you and your insurance share the cost. (ex: 80/20 - 80% insurance responsibility, 20% member responsibility)
Out-of-Pocket Maximum:
This is the most you’ll have to pay in one year for covered care (not including your monthly premiums). After this amount is reached, insurance pays 100% of covered costs.