Texas health insurance policy holders receive a benefit every time they file a claim but are probably not aware that they are receiving the benefit. The most common type of health insurance for individuals and families is classified as a HMO or Health Maintenance Organization or the recent EPO, Exclusive Provider Organization.
If a claim is filed under an EPO or HMO policy, the insured member receives the benefit of the negotiated rate or discounted rate for the medical service received. The discounted rate is available to the consumer when a doctor or medical provider subscribes to the particular carrier’s network. In emergency situations, insured members receive the discounted rates even if a non-participating provider is used. An emergency situation is defined as the potential loss of life or limb. Whether, the claim is for a hospital stay, a doctor’s consultation, a laboratory procedure or an x-ray, the discounted rate for the claim is a significant benefit that many times is overlooked.
Most Texas consumers believe the benefit of insurance involves either the plan deductible being met in conjunction with a large claim or the value of a fixed, office visit copay amount. However, the real benefit of health insurance is the discounted rate as negotiated by the carrier. Unlike the benefit received once deductible has been met, the discounted rate is received from the very first dollar and is applied to all covered benefits.
The amount of discount varies by the service provided. For example, in Texas an average office consultation is approximately $150. The office consultation is defined as a discussion with a physician; no other services such as x-rays or injections have been provided. Depending on the carrier and the HMO or EPO contract, the discount applied to the office visit consultation will lower the average rate to between $70 and $80. An MRI without insurance will be approximately $1,500. If a carrier’s network is used, the average cost for an MRI will be reduced to between $700 and $800. A nuclear stress test can exceed $4,000 but the negotiated rate lowers the fee to $1,500. The benefit of the negotiated rate is especially important when an overwhelming number of claims does not reach $2,000. In each of the above examples, the benefit of the negotiated rate was received even without reaching the deductible.
The HMO or EPO network also eliminates the need for the consumer to negotiate rates with health care providers. It is one thing for an individual to work out a favorable payment arrangement with one doctor, but to establish discounted rates with all of the doctors, hospitals, health care providers, laboratories or medical equipment providers that may possibly be used would be a complicated and time-consuming task. The consumer does not want to be involved in negotiating favorable terms with each health care provider used. Consumers want one entity – the insurance carrier – to negotiate the most favorable terms on their behalf.
Use of the carrier’s network also provides the Texas consumer with some overlooked benefits. All networks provide for utilization review, which means the health insurance carrier is analyzing claims submission to verify that services provided are appropriate for the condition and are billed according to the network contract. The carrier applies utilization review in order to manage claims expenses and ensure accurate charges for services. Pre-certification is a feature that facilitates utilization review, because it alerts the carrier to a potential large claim which may require a more active role by the carrier in the utilization review process.
STATESIDE CAN HELP!
Stateside Insurance Services, since 2003, has focused on providing comprehensive health insurance information, responsive customer service and expert industry knowledge for Texas consumers. Stateside has annually been recognized by health insurance carriers and the Health Insurance Marketplace as a Top Producer in Texas.
Whether the health insurance policy is for an individual, family, small business or supplemental Medicare coverage, Stateside dedicates the time, and our deep industry expertise, to ensure our clients have identified the best health insurance plan for their specific needs.
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