1) What is benefit verification?

Benefit verification is the process in which Favored Medical Billing Service (FMBS) obtains your in network as well as your out of network benefits to assist in determining out of pocket cost to your provider or potential insurance reimbursement. (Reimbursement based on client/provider agreement).

2) When should I request a benefit verification?

Once you have decided on a provider of care, the next step is verifying your coverage to ensure your provider will be covered by your insurance plan. Womancare is happy to send this in for you.

3) What is the benefit of claim submission and how does it work?

The benefit of claim submission may vary for each client.

  • Some claims are submitted to obtain credit towards the client’s deductible, coinsurance, and or out of pocket with their insurance policy for monies already paid to their provider.
  • Some claims are submitted for reimbursement to your provider for services rendered.
  • Some claims are submitted to obtain reimbursement for monies paid to your provider (reimbursement based on client/provider agreement).
  • Unless your provider is in network or contracted with your insurance plan there is no way to provide an exact reimbursement amount you may receive.
  • Providers that are out of network, claims are paid based on a calculation your insurance company has designed and is NOT shared with the provider nor FMBS.
  • In cases where the client has a high deductible (any amount over 5,000) little to no money is reimbursed as each deductible must be met prior to insurance pay out.
  • If you are unsure of your deductible or out of cost this information can be obtained from a benefit verification. You may contact your insurance directly and request the allowed amount for CPT 59400 by calling the member service number on the back of your insurance card.

4) How does the insurance determine the reimbursement / check amount?

  • Providers that are out of network claims are paid based on a calculation your insurance company has designed and is NOT shared with the provider nor FMBS.
  • Based on the average insurance allowed of $3,500 please see the example calculation below.
  • Insurance Allowed Amount – Deductible/Coinsurance/Copay=Payout
    $3,500.00 allowed amount
    $500.00 deductible
    $350.00 coinsurance percent of 90/10%
    $2,650.00 payout amount

5) Why am I NOT getting a refund?

Refunds are based on the verbal or written agreement between you and your provider of care. FBMS is unable to dictate whether a refund is due.

6) Why do I still owe my provider even when my insurance has paid?

Shared Cost Model:
If your providers practice is based on a “shared cost” model your provider can request monies from you that may or may not coincide with your insurance benefits to share in the cost of their charge amount. When you deliver, and a claim is submitted to your insurance provider the expectation is that your insurance provider will pick up the remaining amount to meet your providers “shared cost” charge amount. Depending on the amount collected or deficiencies in collection, and the agreement between you and your provider you may still have monies due for the care provided.

Balance Billing Model:
If your provider is out of network/non-contracted any monies paid to your provider by your insurance company in addition to monies paid by the client, your provider reserves the right to collect up to the billed charge amount listed on the claim for services rendered.

Reimbursement Model:
If your provider is an out of network/non-contracted then they may bill your insurance and you may receive a reimbursement after Filing fees, Deductible and Coinsurance are met.

7) Why are the totals submitted to my insurance company different from the amount I was quoted from my provider or monies paid to my provider?

Due to auditing regulations, FMBS, as a billing company, is required to attain a set billing schedule based on national rates. These rates may differ from the provider’s charging schedule.FMBS billing schedule or billed charges submitted to your insurance payer does NOT mean:

  • Provider Maternity Care base rate begins at $8,700.00. If additional services such as labor time, lactation, etc. is provided, this will increase the amount.
  • Provider Infant Care base rate begins at $890.00 for initial care provided at birth, If other care is provided, it will increase the bill amount.
  • Facility Birth Room is billed at $9,800.00 per day for mother and $9,400.00 per day for infant.
  • Outpatient services performed at the facility such as IV treatment / Pap / ultrasounds / IUD placements/Hearing screens billed at $5,000.00 to $6,000.00
  • That additional monies outside of what has been discussed and agreed upon with your provider are due.
  • Additional monies will NOT be due to your insurance company.

8) How long does the claim process take?

Once FMBS has received your claim request within 24 hours (in most cases) a claim will be submitted to your insurance electronically. Your insurance will receive the claim approximate 72 hours from the time FMBS has sent your claim.You can log onto your personal insurance account and begin to follow the claim 7 business day from the time the claim was submitted to FMBS Your insurance has by law 30 business days to fully process and release the claim from the date it is received in their system.

9) What if I need to make a payment?

Most providers ONLY accept payments directly at their facility in which you will need to continue to make payments in that manner.

10) When should claim request be sent?

  • After you have given birth and/or after newborn screening is complete is the best time to submit your claim request to ensure that billing is accurate.
  • If your care was provided by an out of network provider you are able to request claim submission one year from the date of care provided.

11) What is billed to my insurance?

  • Maternity Care: Prenatal Care / Delivery / Antepartum Care / Lactation Care
  • Infant Care: Initial exam and birth Labs / Newborn screening
  • Facility/Birth Center: Use of room at the facility Such as labor and delivery
  • Provider Care: Office Visits provided by your physician

12) What are Allowed/Billed/Charges Amounts?

The CHARGE amount is the amount your provider has decided their services are worth and would like to be paid. Each provider has their own CHARGE amount and their expectation of getting paid that amount may differ. *please contact your provider directly for this amount and process.

The BILLED amount is the amount billed to the insurance company for reimbursement. FMBS uses Medicare rates and multiply those rates by 300%. The BILLED amount has NO relation to your provider’s CHARGE amount and does NOT determine if additional monies are due to your provider.  *Please contact your provider directly to confirm IF additional funds are due after insurance has paid.

The ALLOWED amount is the amount your insurance determines the service/care was worth. Your insurance does NOT take into consideration your provider’s CHARGE amount, nor the BILLED amount. Providers that are NOT contracted do NOT have access to the ALLOWED amount so until the claim is paid your non-contracted provider does NOT know the reimbursement amount. Providers that ARE contracted are given a fee schedule which are a list of ALLOWED amounts for various services. Once the ALLOWED amount is determined, the insurance will deduct your financial responsibility and then pay the claim.  *All estimates for OON providers are based on a $2,000.00 ALLOWED amount.

The BILLED amount for 2016 is:

$8,700.00 for global maternity provider care (this amount is the base amount)
$9,800.00 for the facility for care provider to the mother
$4,000.00 for prenatal only
$890.00 for infant services (this amount depends on care provider)
$9,400.00 for the facility for care provider to the infant

13) How much will my insurance pay?

In most cases your provider is out of network and unfortunately will NOT be able to inform you an exact reimbursement amount for services provided. Out of network reimbursement amounts are based on a usual and customary that only your insurance has privilege to. In some cases your insurance will provide the reimbursement amount to their members.Contact your insurance provider member service department directly. Inform the insurance representative that your provider is out of network and you would like to know how much will be paid for your care.Below are the CPT codes you will need.

  • 59400 which includes prenatal care, delivery and postpartum care.
  • 59426 which includes ONLY prenatal care Once a dollar amount has been provided, minus your deductible and / or coinsurance amount from that amount and the balance will be the amount paid out. IF your deductible is higher than the dollar amount provided 0.00 will be paid out and applied to your deductible.

14) My insurance should have paid more!

FMBS nor your provider can inform you the exact amount in which will be paid on your behalf to your provider or yourself as an out of network provider. The / Your insurance payer dictates the allowed amount (the amount THEY feel the claim is worth) then they / the payer begin to deduct your out of pocket cost (deductible & coinsurance) from that amount and what is left is paid. IF you feel you or your provider should have been paid more you are free to appeal the payment made to your insurance.

15) What type of plan should I look for?

The plan type that works best for the natural birth and/or care using midwives, birth centers, home births, doulas and naturopaths are:

  • PPO / POS plans
  • Plans that have out of network benefits
  • Has maternity benefits
  • NO exclusions or pre-existing
  • Specifically cover physicians that Naturopaths
    I can NOT provide advice on which specific plan to choose but as long as the plan is NOT a state Medicaid or Medicare plan and ONLY a commercial plan such as but not limited to:
  • United Health Care
  • Aetna
  • Blue Cross
  • Health Net
    Any commercial plan name that covers the above list will be accepted.
    Choosing your deductible should be based an amount that you can pay as it will be due before insurance makes any payments towards your claims.  *Deductible that are 4,000.00 and higher provides less provider/patient reimbursement.
    There is no way to inform you IF your provider will be covered OR provider specialty prior to signing up for the policy OR to request a benefit book from the insurance carrier.

16) How does my insurance know how much I paid my provider?

When you pay your provider for care prior to your insurance being billed, the insurance does NOT know that payment exist until the claim is file.Once the claim is filed and the claim is processed at that time the insurance determines your patient responsibility, which may be more OR less than what you paid to your provider.

In some cases your patient responsibility based on the claim processing can be more IF the claim billed charge amount is more than what you paid your provider and the case in which your patient responsibility would be less is IF the billed charge is less than what you paid your provider.

Whether or NOT you owe additional money to your provider after the claim has processed is based on the contract you signed with your provider and you will need to contact your provider directly to confirm your account status.

Please remember that even though you may pay your provider one amount, it does NOT mean that you will be reimbursed that amount by your insurance nor may you receive full deductible credit for the amount, those amounts are determined by your insurance payer.

17) How did you get the totals?

Deductible:
Your deductible is a flat fee amount provided by your insurance. Based on your date of care OR birth will depend on how your deductible is calculated. IF your benefits are verified and you will give birth or receive care in the same calendar year of your verification then the deductible amount is the current amount minus any monies applied OR your remaining amount. IF you will give birth OR receive care in another calendar year outside of the verification year then the entire flat deductible amount will be accounted for.

Coinsurance:
This is the percentage you are responsible for along with your deductible OR without your deductible. The percentage is based on an average reimbursement of 2000.00.

Copay:
This is the flat amount you are responsible for. For Maternity you may have a one time copay and then your deductible and coinsurance cost. For all other care you will normally have a single deductible.

Special Note:
*If your provider is not contracted, your provider has the right to charge you their cash fee regardless of insurance verification and insurance benefits*If your Office Visit service is subject to a deductible, your provider has the right to accept a flat amount until an EOB is produced by your insurance that provides the exact amount to collect.

18) Authorizations

Authorizations that are obtained by Favored Medical Billing are specifically for your provider and specifically for the care and service they provide.

The authorization provided should ONLY be used for the intended provided and care.

The authorization process is NOT a guarantee of payment and is decided by your insurance provided. The time frame requested for response is 21 business days.

19) Midwife VS Hospital

I recently had the pleasure of viewing a hospital bill for a vaginal delivery in the hospital and WOW! I was first shocked to see that the hospital bills for EVERYTHING, like aspirin, yes Bayer aspirin, has a pricey tag of 17.00! Overall, the hospital bill for a 24 hour stay was 8,000.00. This did NOT include the bill from the OBGYN that delivered the baby, the anesthesiologist, and finally, the doctors that made rounds. This quickly added an additional 5,000.00. The total cost was 13,000.00.

IF the hospital and provider were all contracted/in-network, the out of pocket cost of care ranges about 3,000.00 to 5,000.00 depending on the plan deductible.

See the example below:
Deductible – this amount is due before insurance pays anything to anyone, whether contracted or non-contracted.

Then, Coinsurance – this percent is shared between patient and insurance after the deductible has been met.

Hospital:
Total amount 13,000.00 contracted rate 7,000.00
Deductible 3,000.00
Coinsurance 30% of 7,000.00 – 2,100.00
Total Amount due to Hospital 5,100.00

20) Is It Worth Submitting A Claim?

If the provider is NOT contracted with your insurance, there is no reimbursement schedule (allowed amount) to follow which means we have no idea how much the claim will process for.

Claims are processed as follows:
Claim sent in at what we think the service is worth = billed amount.
Your insurance decides what they think the service is worth = allowed amount.
When the provider is contracted, we know what the allowed amount is and can do the necessary calculations to determine how the claim will process.
When the provider is NOT contracted, we do not have an allowed amount for the calculation.

Calculation:
Allowed amount – patient deductible – coinsurance (% of the allowed amount) = payment.
IF the deductible is higher than the allowed amount, $0.00 will be paid out and it will all apply to the deductible.
Issue with non-contracted providers, we do not know what the allowed amount is, the allowed amount may be high enough for a payout, but we would not know until the claim is processed.

Is it worth submitting a claim?
Without submitting a claim, the amount paid to your provider cannot be applied to your deductible, and maybe all the stars will align so a payment can be released.

21) My insurance says they cover at 100%

Your plan may state they reimburse at 100% / 40% / 30% etc.. , BUT at the allowed amount of your insurance plan, and not at the providers billed amount. If you would like to find out what the allowed amount is for your plan, please use the link below to do so.

http://www.favoredmedicalbilling.com/patientfaqs.html#seventeen

22) Understanding the Upfront Cost Collection Process

Contract Fee
The contract fee is the set amount enforced by your insurance plan as the allowed amount (what your insurance feels the service is worth) when the provider is in network or contracted with that specific insurance plan. **There are NO contract fees for out of network or non-contracted providers.

Deductible
This is a flat amounts determined by your insurance plan that the patient is responsible for prior to the insurance plan making any payments on the patient behalf.

Coinsurance
The Coinsurance is a shared percentage between the patient and the insurance plan.

Out of pocket
The out of pocket is a flat max amount that the patient is responsible for out of their own pocket … the out of pocket works in a number of ways
1. The deductible and or coinsurance amount that is paid by the patient helps meet the out of pocket amount
2. The plan has neither a deductible and/or coinsurance so the out of pocket is what is collected

Helpful Hints for out of network
Since there is no contract fee schedule for out of network providers, some providers will use their personal cost for services to collect the deductible and or coinsurance.

In most cases in terms of reimbursement the insurance plan will use:
Medicare rates approx.. $2,300.00

OR your insurance’s “usual and customary”

Verifications are an estimate of cost and not a guarantee of payment.

23) Claim Filing Limits

A claim can be submitted to your insurance immediately AFTER the care is provided.

In maternity cases, it is best to wait until the baby is delivered before filling a claim.

If you transferred from one provider to the other, you can bill services for the 1st provider as soon as you begin care with the 2nd provider.Claims filling limits below: You have up until the below time frame from the date of care (For maternity, infant date of birth) to submit your claim to insurance.

365 days from the date of care
Aetna
Blue Cross Plans
Cigna
Humana
United Health Care

120 days from the date of care
Health Net

90 days from the date of care
Medicaid Plans

24) Connect with Your Insurance

Claim Status Check
Thank you for your inquiry regarding your submitted claim. Because your insurance requests 30 business days to process your claim, Favored Medical does not provide claim status prior to 30 business days of submission. You are welcome to use the link below to create an account directly with your insurance plan to track your claim process or you may contact your member service department using the phone number from the back of your insurance card.

25) Claims Process

  1. Your claim is submitted within 48 hours of receipt to Favored Medical Billing to your insurance plan.
  2. Your claim is received and logged with a claim number by your insurance provider within the first 7 business days of receipt.
  3. Your claim is then “worked” for processing .. 30 business days later
  4. Your claim is processed, either with payment or towards your deductible
  5. Paid claims take an additional 10 business days for a check to be released and mailed.
  6. Please allow proper mail/delivery time At 31 business days
    If you have not received any correspondence from your insurance and do not see your claim on file (if being tracked), please contact Favored Medical Billing for proper follow up.

26) Usual & Customary Medicare Rates

For out of network providers, there is no fee schedule, so most insurance companies will state services are covered at usual and customary rates which are Medicare rates.

27) Why should I pay you?

The service of verifying your benefits and/or submitting a claim on your behalf are all optional services. You are in no way obligated to pay Favored for those services. You can accomplish both verifying your benefits/ submitting claim by contacting your member service department number located on the back of your insurance card.

The benefit of Favored handling these 2 services; provides one less thing for your to do and the understanding of what questions need to be asked for the best success of coverage and processing of claims.

Verifying Benefits:
Knowing or not your provider is covered and at what benefit level sooner rather than later allows you to decide rather of not you want to move forward with the additional fee of 85.00 to submit a claim along with a better understanding of the financial benefit of submitting a claim.

Claims Submission:
Most providers do not handle billing in any capacity and the invoices they provide usually are not equipped with the necessary CPT/DX codes required by your insurance plan for proper processing.

Dealing with insurance can be both time consuming and frustrating which is why we offer these services. Again, these services are optional. Please understand for liability reasons Favored does not follow up or take over requests that were NOT initiated by our company.

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