Are you ever confused by a medical bill? Do you know the difference between co-insurance and a copay?
Kamala Hagen, manager of business services at Henry Mayo Newhall Hospital, the department that manages all patient billing for the hospital, is here to talk you through medical billing and its sometimes very confusing terminology.
Selected Podcast
Important Information to Help You Understanding Medical Billing
Featured Speaker:
Kamala Hagen
Kamala Hagen is manager of business services at Henry Mayo Newhall Hospital. Business Services manages all patient billing for the hospital. Transcription:
Important Information to Help You Understanding Medical Billing
Melanie Cole (Host): If you pay medical bills, you might have noticed that some of the terminologies can be a little confusing. Understanding some of the more important terms can go a long way to helping you get the insurance that will work for you and help you figure out exactly how much treatment might cost. My guest today, is Kamala Hagen. She's the Manager of Business Services at Henry Mayo Newhall Hospital. Business services manages all of the patient billing for the hospital. Welcome to the show, Kamala. Let’s start with some of the more basic terminologies. What is a copay?
Kamala Hagen (Guest): Copays are a dollar amount that you pay when -- say you go to the Emergency Room and you’ll have a $25 copay. Some of the problems are that patients will go to the Emergency Room maybe twice in a day and they don’t realize that that copay applies each and every time they come.
Melanie: So, then what’s the difference between a copay and coinsurance?
Kamala: Coinsurance – if you have a plan that’s like an 80/20, the insurance company will pay 80% of the fee or the contract rate, and the pt is responsible for 20%.
Melanie: So, they do differ. Now, copays also apply when you take your child to the pediatrician, or you go for a strep check or another just visit for being ill, correct?
Kamala: Correct. If you have like an HMO plan and you have to see your primary care physician, you may have a copay of $10 or $25
Melanie: So then, what is a deductible, and do your copays go toward that deductible?
Kamala: The copays do not go towards the deductible. The deductible is the amount you have to pay out of pocket before the insurance starts to pay.
Melanie: So, you pay your deductible, whatever it is -- $500, $1000 – and then once you’ve done that, then that coinsurance of 80/20 kicks in?
Kamala: Correct.
Melanie: So then what is an out-of-pocket max? If we hear the deductible, what’s the difference between that and an out-of-pocket maximum?
Kamala: If you have an 80/20 policy, but you have an out-of-pocket max of say $5,000, once you’ve paid out that $5,000, you’d no longer have to pay the additional coinsurance.
Melanie: So then stuff should technically be covered near to 100%?
Kamala: Yes.
Melanie: So, what about something like preventative services? How are they included in some of this billing and terminology that we might hear?
Kamala: Preventative services are usually covered at 100%. They usually don’t apply any out-of-pocket to the patients’ expense.
Melanie: What would be considered preventative services?
Kamala: Mammograms, pap smears, things of that nature.
Melanie: And well-visits, like our physicals and our blood work or the annual physicals that children have to go through, are those considered preventative and covered as well?
Kamala: It really depends on the policy, but a lot of policies do cover them at 100%.
Melanie: And recently, colonoscopies are even considered preventative services, so are they covered, as well?
Kamala: They are covered if nothing is found. If something is found, then it becomes a patient liability.
Melanie: What about in-network and out-of-network? What do those mean, and how do they affect the billing?
Kamala: In-network is – Henry Mayo is contracted with Blue Cross, so we are considered in-network. If we are not contracted with your insurance company, it’s considered out-of-network.
Melanie: Which means what?
Kamala: Which means it’s higher patient responsibility.
Melanie: So, we encourage listeners to go within network just because then their insurance will cover it more fully, yes?
Kamala: Correct.
Melanie: People – maybe they have good insurance, or they lose a job, and then they hear that they might be able to get something called COBRA. What is that?
Kamala: COBRA is an extension of your insurance policy, but you are paying the premium, and therefore, it can be very costly. Usually, your employer will pay part of the premium, and you pay part, but COBRA, you’re paying all of it.
Melanie: So now, as people hear about all of these terms, Kamala, and then they hear about prescription health insurance and prescription medications and what’s covered and whether there’s a copay for that, as well. Speak a little bit about prescriptions, how they are included in this health insurance terminology, and what the difference between something you might for a generic versus a brand name.
Kamala: Prescriptions – I have an HMO, and my prescriptions are covered, and they run about $7. If you’re getting a generic brand, it’s usually a lower cost to the patient than a brand name. Therefore, you’re encouraged to get the generic brand.
Melanie: People receive this thing in the mail that they’re not sure if it’s a bill yet and it’s called an EOB. What is that, and how does it describe, Kamala, the summary of benefits and coverage?
Kamala: An EOB is an explanation of benefits. It will list out any type of copay that you may have, coinsurance, any contractual adjustment that is done with the hospital, and what they have paid on the claim. It can also be a denial for many different reasons. The issue we have today is patients will come to the hospital; they will stay for maybe two or three days. The stay is not considered medically necessary, and the patient is sent an EOB stating it’s denied, and the patient thinks that they are responsible when they aren’t. If we keep a patient and we do not obtain authorization, and it’s not considered medically necessary, we do not bill the patient.
Melanie: That’s really an excellent explanation and so important for listeners and patients to hear. Coordination of benefits – because some people have Medicare, some people have Medicaid, they have supplemental insurance – how is one to keep track, and how can you help with that?
Kamala: The important thing for the patient to remember is if they are covered, and their spouse is also covered -- some of the times, patients will come in, and they’ll provide us with the husband’s insurance. The insurance will pay, and then they’ll realize no, the patient has insurance. They will then take their money back, and then the patient is held responsible. If the patient comes to the hospital, they need to know always to be primary. The secondary would be their husband, which would hopefully pick up any balance remaining from the primary payment.
With Medicare and Medi-Cal – Medi-Cal is always the payer of last resort. Medicare would be primary; Medi-Cal would be secondary. You could also have a scenario where the patient has Medicare and a supplemental. Medicare would pay. The supplemental would pick up any remaining patient responsibility. With Medicare, the deductible for being an inpatient is now up to – I believe, $1,300.
Melanie: If somebody needs financial assistance – if they do have this deductible of $1,300, which is quite a lot of money for people, how can they find out about financial assistance through Henry Mayo Newhall Hospital, and how can you help them navigate these waters?
Kamala: We do offer financial assistance. An application is usually provided at the time of service. They can also obtain an application through the registration department, or to contact the business office and we will provide them with that. If they need assistance, we will sit down with them and go over the application and all of the documents that are required. I then review the application, and they can qualify for either 100% discount, or if they are at a certain income, they can qualify for a discount.
Melanie: You mentioned earlier about HMO – and people hear HMO, PPO – what are these different types? What does that mean?
Kamala: An HMO is a Health Maintenance Organization, and you will have a primary care physician, and in order to see other doctors, your primary care physician has to provide a referral for you. With a PPO, it’s a Preferred Provider Organization, and you can go to other providers without that referral, but it’s usually at a higher cost to the patient. It’s also usually a higher premium.
Melanie: So, summarize this for us Kamala, what you want listeners to know – what they ask you every single day when they say, “Okay, I don’t understand this. I don’t know what I need or what’s covered.” What is it you tell them? What would you like them to know right now?
Kamala: Well, what I would tell them is if you have questions, you can always contact our office. We will go over your bill, your EOB, and if you really need to sit down with somebody, please come into the hospital. We will have somebody sit with you and go over everything and try to guide you in the proper direction.
Melanie: Thank you so much, Kamala, for such great information. It’s so important for listeners to hear so they can be their own best health advocate. For additional help and information to reach business services, you can call 661-200-1110, or you can call admitting at 661-200-1050. You’re listening to It’s Your Health Radio with Henry Mayo Newhall Hospital. For more information, you can go to HenryMayo.com, that’s HenryMayo.com . This is Melanie Cole. Thanks so much, for tuning in.
Important Information to Help You Understanding Medical Billing
Melanie Cole (Host): If you pay medical bills, you might have noticed that some of the terminologies can be a little confusing. Understanding some of the more important terms can go a long way to helping you get the insurance that will work for you and help you figure out exactly how much treatment might cost. My guest today, is Kamala Hagen. She's the Manager of Business Services at Henry Mayo Newhall Hospital. Business services manages all of the patient billing for the hospital. Welcome to the show, Kamala. Let’s start with some of the more basic terminologies. What is a copay?
Kamala Hagen (Guest): Copays are a dollar amount that you pay when -- say you go to the Emergency Room and you’ll have a $25 copay. Some of the problems are that patients will go to the Emergency Room maybe twice in a day and they don’t realize that that copay applies each and every time they come.
Melanie: So, then what’s the difference between a copay and coinsurance?
Kamala: Coinsurance – if you have a plan that’s like an 80/20, the insurance company will pay 80% of the fee or the contract rate, and the pt is responsible for 20%.
Melanie: So, they do differ. Now, copays also apply when you take your child to the pediatrician, or you go for a strep check or another just visit for being ill, correct?
Kamala: Correct. If you have like an HMO plan and you have to see your primary care physician, you may have a copay of $10 or $25
Melanie: So then, what is a deductible, and do your copays go toward that deductible?
Kamala: The copays do not go towards the deductible. The deductible is the amount you have to pay out of pocket before the insurance starts to pay.
Melanie: So, you pay your deductible, whatever it is -- $500, $1000 – and then once you’ve done that, then that coinsurance of 80/20 kicks in?
Kamala: Correct.
Melanie: So then what is an out-of-pocket max? If we hear the deductible, what’s the difference between that and an out-of-pocket maximum?
Kamala: If you have an 80/20 policy, but you have an out-of-pocket max of say $5,000, once you’ve paid out that $5,000, you’d no longer have to pay the additional coinsurance.
Melanie: So then stuff should technically be covered near to 100%?
Kamala: Yes.
Melanie: So, what about something like preventative services? How are they included in some of this billing and terminology that we might hear?
Kamala: Preventative services are usually covered at 100%. They usually don’t apply any out-of-pocket to the patients’ expense.
Melanie: What would be considered preventative services?
Kamala: Mammograms, pap smears, things of that nature.
Melanie: And well-visits, like our physicals and our blood work or the annual physicals that children have to go through, are those considered preventative and covered as well?
Kamala: It really depends on the policy, but a lot of policies do cover them at 100%.
Melanie: And recently, colonoscopies are even considered preventative services, so are they covered, as well?
Kamala: They are covered if nothing is found. If something is found, then it becomes a patient liability.
Melanie: What about in-network and out-of-network? What do those mean, and how do they affect the billing?
Kamala: In-network is – Henry Mayo is contracted with Blue Cross, so we are considered in-network. If we are not contracted with your insurance company, it’s considered out-of-network.
Melanie: Which means what?
Kamala: Which means it’s higher patient responsibility.
Melanie: So, we encourage listeners to go within network just because then their insurance will cover it more fully, yes?
Kamala: Correct.
Melanie: People – maybe they have good insurance, or they lose a job, and then they hear that they might be able to get something called COBRA. What is that?
Kamala: COBRA is an extension of your insurance policy, but you are paying the premium, and therefore, it can be very costly. Usually, your employer will pay part of the premium, and you pay part, but COBRA, you’re paying all of it.
Melanie: So now, as people hear about all of these terms, Kamala, and then they hear about prescription health insurance and prescription medications and what’s covered and whether there’s a copay for that, as well. Speak a little bit about prescriptions, how they are included in this health insurance terminology, and what the difference between something you might for a generic versus a brand name.
Kamala: Prescriptions – I have an HMO, and my prescriptions are covered, and they run about $7. If you’re getting a generic brand, it’s usually a lower cost to the patient than a brand name. Therefore, you’re encouraged to get the generic brand.
Melanie: People receive this thing in the mail that they’re not sure if it’s a bill yet and it’s called an EOB. What is that, and how does it describe, Kamala, the summary of benefits and coverage?
Kamala: An EOB is an explanation of benefits. It will list out any type of copay that you may have, coinsurance, any contractual adjustment that is done with the hospital, and what they have paid on the claim. It can also be a denial for many different reasons. The issue we have today is patients will come to the hospital; they will stay for maybe two or three days. The stay is not considered medically necessary, and the patient is sent an EOB stating it’s denied, and the patient thinks that they are responsible when they aren’t. If we keep a patient and we do not obtain authorization, and it’s not considered medically necessary, we do not bill the patient.
Melanie: That’s really an excellent explanation and so important for listeners and patients to hear. Coordination of benefits – because some people have Medicare, some people have Medicaid, they have supplemental insurance – how is one to keep track, and how can you help with that?
Kamala: The important thing for the patient to remember is if they are covered, and their spouse is also covered -- some of the times, patients will come in, and they’ll provide us with the husband’s insurance. The insurance will pay, and then they’ll realize no, the patient has insurance. They will then take their money back, and then the patient is held responsible. If the patient comes to the hospital, they need to know always to be primary. The secondary would be their husband, which would hopefully pick up any balance remaining from the primary payment.
With Medicare and Medi-Cal – Medi-Cal is always the payer of last resort. Medicare would be primary; Medi-Cal would be secondary. You could also have a scenario where the patient has Medicare and a supplemental. Medicare would pay. The supplemental would pick up any remaining patient responsibility. With Medicare, the deductible for being an inpatient is now up to – I believe, $1,300.
Melanie: If somebody needs financial assistance – if they do have this deductible of $1,300, which is quite a lot of money for people, how can they find out about financial assistance through Henry Mayo Newhall Hospital, and how can you help them navigate these waters?
Kamala: We do offer financial assistance. An application is usually provided at the time of service. They can also obtain an application through the registration department, or to contact the business office and we will provide them with that. If they need assistance, we will sit down with them and go over the application and all of the documents that are required. I then review the application, and they can qualify for either 100% discount, or if they are at a certain income, they can qualify for a discount.
Melanie: You mentioned earlier about HMO – and people hear HMO, PPO – what are these different types? What does that mean?
Kamala: An HMO is a Health Maintenance Organization, and you will have a primary care physician, and in order to see other doctors, your primary care physician has to provide a referral for you. With a PPO, it’s a Preferred Provider Organization, and you can go to other providers without that referral, but it’s usually at a higher cost to the patient. It’s also usually a higher premium.
Melanie: So, summarize this for us Kamala, what you want listeners to know – what they ask you every single day when they say, “Okay, I don’t understand this. I don’t know what I need or what’s covered.” What is it you tell them? What would you like them to know right now?
Kamala: Well, what I would tell them is if you have questions, you can always contact our office. We will go over your bill, your EOB, and if you really need to sit down with somebody, please come into the hospital. We will have somebody sit with you and go over everything and try to guide you in the proper direction.
Melanie: Thank you so much, Kamala, for such great information. It’s so important for listeners to hear so they can be their own best health advocate. For additional help and information to reach business services, you can call 661-200-1110, or you can call admitting at 661-200-1050. You’re listening to It’s Your Health Radio with Henry Mayo Newhall Hospital. For more information, you can go to HenryMayo.com, that’s HenryMayo.com . This is Melanie Cole. Thanks so much, for tuning in.