Urgent Care Unscripted: Episode 2 - Navigating Health Insurance

We simplify insurance so you can focus on your health. Learn how to navigate your coverage stress-free.

In this episode of *Urgent Care Unscripted* of our podcast *Urgent Care Unscripted*, we break down the complex world of health insurance. Learn how to understand your benefits, avoid common billing surprises, and make the most of your coverage when visiting urgent care.

🩺 Topics Covered: Navigating Insurance, AFC Urgent Care, West Haven healthcare, walk-in clinic, urgent care tips, patient education, healthcare podcast.

🔔 Don’t forget to like, comment, and subscribe to *Urgent Care Unscripted* for weekly episodes covering health tips, urgent care services, and wellness education. 

📍 Visit us in West Haven: https://www.afcurgentcare.com/west-haven/

📞 Call us: [phone]

#InsuranceHelp #UrgentCareExplained #WestHavenHealth

Disclaimer:
The information provided in the Urgent Care Unscripted podcast is for general informational and educational purposes only and is not intended as, nor should it be considered a substitute for, professional medical advice, diagnosis, treatment, or legal counsel. Always seek the advice of your physician, licensed healthcare provider, attorney, or other qualified professional with any questions you may have regarding a medical or legal matter. Never disregard professional advice or delay in seeking it because of something you heard on this podcast. The views and opinions expressed by hosts or guests are their own and do not necessarily reflect those of AFC Urgent Care or its affiliates. Reliance on any information provided by this podcast is solely at your own risk.

Episode Transcript

(00:00):
Okay. Hey, everyone.
Thank you for joining our,episode of, Urgent Care Unscripted.
And we welcome you to listento our podcast and watch our podcast.
This podcast are about health careand all the complexities
that come with, taking care of your,health.

(00:23):
Today, we'll be talking about insurance.
This is a topic that's complex enough.
That kind of,could easily confuse anyone.
So we want to get down to thesome details of,
all the, complexities of, insurancewe have with us.
Barbara, an author.
And I would ask her to introduce herselfand then, Sandra,

(00:43):
also our insurance expert, is on the call
and would like to introduce her, to you, but starting with Barbara.
All right. Yes, my name is Barbara. Run!
All turn to director of operations
and business developmentfor A of C Urgent care here in West Haven.
And that's why Muhammad,insurances are just a complicated beast.
And today, hopefully, with Sandra'shelp, we're going to break it down

(01:06):
a little bit for our patientsand try to make sense
of this crazy,insurance, healthcare world.
Today we are joined by Sandra
as Sandra is with positive resultssince 2013.
And she started as a, medical billingand analyst in Holyoke office

(01:27):
and then transferred to the Virginia
Beach location and then was promotedto office administrator.
Welcome to my Sandra for coming.
Thank you. Thank you.
I'm excited to be here.
And we can talk about all of this fun
insurance stuffthat we deal with on a daily basis.
That's right.
So let's start with the basics.
Can you basically tell us a little bitabout the difference between those three

(01:51):
very complicated wordsco-pay, coinsurance and, deductibles?
Sure. Of course.
So a copayment is usually a set amountthat an insurance company sets.
For certain.
Offices, a primary care is usually lower
than urgent care,and specialists are a little bit higher.

(02:14):
And then the ER isthe highest of the three.
Deductibles is a set amountthat the patient has to pay out of pocket
before their insurance kicks in and startspaying anything on their claims,
usually it's not for PCP appointments,it's usually for the appointments
that are,you know, not routine appointments.

(02:34):
And co-insurance is a percentageof the allowed amount
that the insurance company, deemsis is necessary.
So, for example, Medicare is ainsurance company that uses co-insurance.
So Medicare covers80% of their allowed amounts,
and the patient is responsiblefor the 20%, remaining.

(02:58):
A very basic and fundamental questionhere.
People have insuranceand they come for medical treatment.
And in the end, they still get a bill.
Can you explain to us why do they stillget a bill or do they have insurance?
So a lot of timesthey get a bill for clerical reasons.
Maybe the insurancehas their date of birth incorrect

(03:19):
or their name spelled wrong,or they got married and they forgot
to tell the insurance companythat they changed their name.
So the insurance company doesn'tshow them as one of their insured anymore.
They also don't understandwhat a deductible is.
I can't tell you how many times a patientcalls and says, why did I get this bill?

(03:40):
And it's because they have a deductiblethat they didn't
realizethey even had as part of their plan.
Got it.
And then we also hearabout pre authorization that before
a patient comes in certain situationsthey have to procure or understand
pre authorizationwhat is really pre authorization.

(04:00):
And how does it even apply for urgent careclinic situations.
So usually a prior authorizationin the urgent care setting
is if you're out of state
and you go to urgent carebecause you have an emergency and
you don't want to go to the emergency roomand you have an out of state plan.
Most in network providersdon't require the prior authorization.

(04:23):
So it's something that I encourageanybody who, is going to the doctor,
and they've never been to that doctorbefore to contact their insurers
and just say, hey,I plan on using this provider.
Is there anything that I need to doprior to my visit
that I need to,you know, take care of before I'm seeing.

(04:44):
So that way, my insurance covers it.
Yeah, that's a great point.
Speaking of what you just said,can you explain to the patients
and to our viewers what is out-of-network
and in network,and what does that mean for them?
Sure.
So in-networkproviders are providers that reach out
to insurance companies and they say, hey,I want to become part of your network.

(05:07):
So that way your patients can comeand be seen by us at a discounted rate.
So when I say discounted rate,I mean the insurance and the providers,
they negotiate a ratethat the insurance company
and the providers, the providersdon't really have much of a say, but
the insurance companies deem is,
you know, a fair amountto pay for each service provider.

(05:31):
With out of network,
the the providers don'thave that negotiated rate.
So the patients usually paya higher amount
because the, you know,the provider isn't required
to give that provider adjustment,that they are required within network.
Most insurance companies,if you call them and say, hey,

(05:53):
I want to go to an urgent care,can you send me a list of all the in
network providers in my area,there's a list that you can go on
and check it out.
And, you know, make surethat you go to an in network provider.
So that way you are utilizingyour insurance in the best way possible.
Correct.
The other question that we hear often,Sandra, is, people get different

(06:14):
kind of bills depending onif they are at an urgent care
or if they're at a hospitalor if they're at a primary care physician.
Why do they get different?
Kind of well,depending on where they went.
And, how can they how can you minimizethe surprise and minimize their cost?
That's a great question.
So, again, it all depends on the,

(06:37):
the insurance company and
what they deemis, a fair amount to pay for services.
So usually at your primary care doctor,you're going for your regular visits,
your physicals, your, you know,your vaccines, your regular daily stuff,
urgent careis, you know, if you have an emergency,
you can't be seen at your primary care,but you don't want to go to the E.R.

(06:58):
because it's not something,you know, super emergent.
So it's kind of like the next step upfrom your primary care.
So it's a little bit more expensive,but it's not as expensive
as if you go to the emergency room,which then has the provider fees.
The facility fees that thethe hospitals pay for.
And also,you have to remember that urgent cares

(07:19):
are not open 24 seven emergency rooms are.
So they have to pay.
You know, for those I guess you could sayoverhead fees as well
as, you know,just providing the services for you.
And since you mentioneda little bit of that, I,
I want to kind of touch base on againis who actually decides

(07:39):
how much a patient is going to get chargedfor a visit or let's say, a procedure.
That's a that is a very good question.
So it is the insurance companies.
So, for instance, I had a patient the other day say
I'm only supposed to pay $45,but you're charging me 90.
And I had it took me like 30 minutesto get her to understand that

(08:02):
I'm not actually charging her $90.
Her insurance processthe claim with a co-payment of $90.
And if she has something,you know a question about that
she should contact her insurance andfigure out why they processed it that way.
So a lot of patientsassume that it's the provider
that's charging them this amount of money,when in all reality, it's

(08:24):
their insurance company who processesthe claim and tells the provider
how much the patient is responsibleto pay.
Got it.
And then at the end of the day, we also,
see patients receiving bills.
What are the most common reasons or inwhat situations did they actually end up
receiving a bill? Sandra.

(08:44):
So the biggest reasonI see that a patient receives a bill is
because they either have their insurance
company insurance, policy has terminated,they've changed insurance companies,
and they didn't give their new insurancecard, or mostly like a clerical issue,
like patient's date of birth is, you know,one day off or they have the wrong year

(09:08):
or they're considered a mailand the insurance has a female just,
you know, clerical issues
that are simple fixes, but you don't knowuntil you get that denied claim.
There are, you know, reasons why insurance companies
deny for not,you know, not medically necessary.
So if you come in and you're, you want to get STD

(09:30):
tested at an urgent care,but you don't have any symptoms,
a lot of insurance companies will say,hey, that's not medically necessary
unless you have a symptom.
We're not just going to pay.
So you can, you know,get these tests done.
So there's a lot of different reasons.
But, the main reason I see is usually like,
administrative, like clerical things.

(09:51):
That's, that's great information.
Thank you, Sandra, for sharing.
Just when people visit our clinic.
Barbara, what what can they do
if they lost their insurance cardor if they lost something?
And can we still see them?
We just have a few concluding questionsbefore.
If you can summarize, what's the bestadvice for a patient in those situations?
So in the clinic situation,if a patient comes in

(10:14):
and they don't have their insurance card,we can for the most part
look up their insuranceby using a payer website.
So we do have logins for,
like for
example, Connecticut Medicaid, Cignaand whatever that may be.
So we might require a couple additionalinformation from the patient.
So for example, Medicare does ask that we,get their Social Security number.

(10:38):
So when we are asking
those additional questions,because you don't have your,
card with you, it'snot because we're just being nosy.
It's because we need that informationin order to make sure we do have your
insurance on file,
and we don't get, like Sandra said,those clerical errors, denials, etc..
Got it.
And before we conclude, Sandra,
do you have any advice for peoplewhen they're shopping for insurance card?

(11:01):
And can you also tell usif there is any recent major change
in policy that impacts people,insurance plan and so forth.
So two questions there.
Yes. So, a lot of insurance companies
are trying to keep patientswho don't have emergent issues out
of the emergency room to save that for,you know, the the real emergencies.

(11:23):
So a lot of insurance companies,including my own,
now charge a like a fee.
If you go to the emergency roomand it's not an emergent issue.
So that's a huge changethat we've seen in the most recent.
Also,
since the pandemic, a lot of insurancecompanies are shying away from telehealth.

(11:43):
A lot of insurance companieswaived all of their telehealth, you know,
restrictions during Covidbecause they just wanted everyone
to be able to be seen and,you know, get the care that they needed.
But now that we're out of that,that mess, a lot of insurance companies
are going back to the, you know,their regular not allowing telehealth.

(12:04):
In regardsto when you're shopping for insurance,
my, suggestion ismake sure you know what you need.
If you use prescriptions often
because you have some kind ofchronic illness, if you go to, you know,
the urgent care a lot becauseyou are always worried about being sick.

(12:26):
Make sure you understand whatyour policy entails and what it covers,
because a lot of people really the bottomline is they don't pay attention.
They see, oh, this one'sonly going to cost me $50 a paycheck.
Let me choose that one.
And then there's, surprised whenit doesn't cover anything that they need.
So it's really important to one understandwhat they need.

(12:47):
And to make a, educated choice on,
you know, what planthat they're going to have to choose.
These are so, great advicesand great information.
Sandra and Barbara, thank you.
Also, from the clinic perspective, elaborating on what to,
what to be careful ofbefore a patient comes in with insurance.

(13:07):
So they are best taken care of.
We appreciate everybody participating.
And watching our show.
We would look forward to presenting toyou more important topics down the road.
This is urgent care, unscripted.
Please subscribe and, follow us,and we look forward to seeing you do.
Yep. And keep in mind,we are at 54 Sawmill Road in West Haven.

(13:29):
So if you want to come see us
for any urgent care services,we are here to serve you.
Thank you again and have a great day.
Thank you guys.
Thank you. So.