In-Network Benefits Explained

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If payments or insurance makes you nervous and gives you anxiety, you are not alone! There are so many things to understand when it comes to this that we get questions daily! New patients, current patients, and former patients can be confused about payments and insurance coverage. In an effort to explain how payment for services works, we have broken it down for you here in three main question categories.

 

  1. What is the difference between a clinic ACCEPTING a certain insurance versus being IN-NETWORK for a certain insurance? The short answer is nothing, except the way it is phrased. A clinic will “accept” a certain insurance because they have been approved by the insurance to be “in-network.” The “in-network” classification is attained through a process called credentialing, wherein a medical professional provides documentation and an application request to an insurance company so that patients using that insurance can have their costs covered by the insurance.
  2. What is the difference between a deductible, co-insurance/ co-payment, or an out-of-pocket maximum? The short answer is depending on your specific insurance plan and what you have already paid in medical services for the year, these terms will dictate how much of your bill you will be responsible to pay. A separate post will address these in more detail.
  3. What do I need in order to file insurance claims? The short answer again is nothing. If you provide your insurance information, your provider will be able to file insurance claims on your behalf and the insurance provider will pay us directly!

 

One more topic that confuses patients regularly are EOBs versus statements.

  • EOBs stand for Explanation of Benefits and are issued by your insurance provider to explain the benefits you received from them. It typically includes the dates of service, name of service provider, services billed, discount(s) received for services (if any), the portion of the bill paid by the insurance provider (if any), and what payment is outstanding (if any) as the responsibility of the patient. THIS IS NOT A BILL, it is just a breakdown of what transactions occurred according to the insurance provider.
  • Statements are issued by your medical provider and is sent after all insurance claims have been filed and payments from the insurance provider has been received. It could arrive in your mailbox weeks or even months after your treatment has ended depending on how quickly your insurance provider completes their portion of the transactions.

 

As always, if you have any questions or concerns regarding your insurance coverage and payment requirements do not hesitate to ask anyone of our knowledgeable staff members.

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