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Okay. Hey, everyone.

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Thank you for joining our,
episode of, Urgent Care Unscripted.

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And we welcome you to listen
to our podcast and watch our podcast.

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This podcast are about health care
and all the complexities

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that come with, taking care of your,
health.

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Today, we'll be talking about insurance.

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This is a topic that's complex enough.

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That kind of,
could easily confuse anyone.

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So we want to get down to the
some details of,

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all the, complexities of, insurance
we have with us.

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Barbara, an author.

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And I would ask her to introduce herself
and then, Sandra,

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also our insurance expert, is on the call

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and would like to introduce her, to you, 
but starting with Barbara.

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All right. Yes, my name is Barbara. Run!

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All turn to director of operations

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and business development
for A of C Urgent care here in West Haven.

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And that's why Muhammad,
insurances are just a complicated beast.

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And today, hopefully, with Sandra's
help, we're going to break it down

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a little bit for our patients
and try to make sense

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of this crazy,
insurance, healthcare world.

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Today we are joined by Sandra

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as Sandra is with positive results
since 2013.

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And she started as a, medical billing
and analyst in Holyoke office

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and then transferred to the Virginia

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Beach location and then was promoted
to office administrator.

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Welcome to my Sandra for coming.

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Thank you. Thank you.

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I'm excited to be here.

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And we can talk about all of this fun

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insurance stuff
that we deal with on a daily basis.

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That's right.

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So let's start with the basics.

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Can you basically tell us a little bit
about the difference between those three

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very complicated words
co-pay, coinsurance and, deductibles?

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Sure. Of course.

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So a copayment is usually a set amount
that an insurance company sets.

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For certain.

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Offices, a primary care is usually lower

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than urgent care,
and specialists are a little bit higher.

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And then the ER is
the highest of the three.

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Deductibles is a set amount
that the patient has to pay out of pocket

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before their insurance kicks in and starts
paying anything on their claims,

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usually it's not for PCP appointments,
it's usually for the appointments

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that are,
you know, not routine appointments.

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And co-insurance is a percentage
of the allowed amount

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that the insurance company, deems
is is necessary.

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So, for example, Medicare is a
insurance company that uses co-insurance.

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So Medicare covers
80% of their allowed amounts,

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and the patient is responsible
for the 20%, remaining.

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A very basic and fundamental question
here.

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People have insurance
and they come for medical treatment.

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And in the end, they still get a bill.

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Can you explain to us why do they still
get a bill or do they have insurance?

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So a lot of times
they get a bill for clerical reasons.

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Maybe the insurance
has their date of birth incorrect

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or their name spelled wrong,
or they got married and they forgot

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to tell the insurance company
that they changed their name.

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So the insurance company doesn't
show them as one of their insured anymore.

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They also don't understand
what a deductible is.

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I can't tell you how many times a patient
calls and says, why did I get this bill?

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And it's because they have a deductible
that they didn't

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realize
they even had as part of their plan.

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Got it.

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And then we also hear
about pre authorization that before

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a patient comes in certain situations
they have to procure or understand

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pre authorization
what is really pre authorization.

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And how does it even apply for urgent care
clinic situations.

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So usually a prior authorization
in the urgent care setting

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is if you're out of state

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and you go to urgent care
because you have an emergency and

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you don't want to go to the emergency room
and you have an out of state plan.

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Most in network providers
don't require the prior authorization.

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So it's something that I encourage
anybody who, is going to the doctor,

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and they've never been to that doctor
before to contact their insurers

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and just say, hey,
I plan on using this provider.

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Is there anything that I need to do
prior to my visit

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that I need to,
you know, take care of before I'm seeing.

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So that way, my insurance covers it.

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Yeah, that's a great point.

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Speaking of what you just said,
can you explain to the patients

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and to our viewers what is out-of-network

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and in network,
and what does that mean for them?

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Sure.

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So in-network
providers are providers that reach out

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to insurance companies and they say, hey,
I want to become part of your network.

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So that way your patients can come
and be seen by us at a discounted rate.

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So when I say discounted rate,
I mean the insurance and the providers,

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they negotiate a rate
that the insurance company

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and the providers, the providers
don't really have much of a say, but

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the insurance companies deem is,

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you know, a fair amount
to pay for each service provider.

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With out of network,

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the the providers don't
have that negotiated rate.

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So the patients usually pay
a higher amount

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because the, you know,
the provider isn't required

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to give that provider adjustment,
that they are required within network.

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Most insurance companies,
if you call them and say, hey,

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I want to go to an urgent care,
can you send me a list of all the in

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network providers in my area,
there's a list that you can go on

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and check it out.

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And, you know, make sure
that you go to an in network provider.

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So that way you are utilizing
your insurance in the best way possible.

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Correct.

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The other question that we hear often,
Sandra, is, people get different

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kind of bills depending on
if they are at an urgent care

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or if they're at a hospital
or if they're at a primary care physician.

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Why do they get different?

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Kind of well,
depending on where they went.

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And, how can they how can you minimize
the surprise and minimize their cost?

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That's a great question.

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So, again, it all depends on the,

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the insurance company and

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what they deem
is, a fair amount to pay for services.

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So usually at your primary care doctor,
you're going for your regular visits,

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your physicals, your, you know,
your vaccines, your regular daily stuff,

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urgent care
is, you know, if you have an emergency,

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you can't be seen at your primary care,
but you don't want to go to the E.R.

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because it's not something,
you know, super emergent.

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So it's kind of like the next step up
from your primary care.

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So it's a little bit more expensive,
but it's not as expensive

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as if you go to the emergency room,
which then has the provider fees.

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The facility fees that the
the hospitals pay for.

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And also,
you have to remember that urgent cares

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are not open 24 seven emergency rooms are.

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So they have to pay.

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You know, for those I guess you could say
overhead fees as well

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as, you know,
just providing the services for you.

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And since you mentioned
a little bit of that, I,

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I want to kind of touch base on again
is who actually decides

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how much a patient is going to get charged
for a visit or let's say, a procedure.

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That's a that is a very good question.

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So it is the insurance companies.

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So, for instance, 
I had a patient the other day say

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I'm only supposed to pay $45,
but you're charging me 90.

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And I had it took me like 30 minutes
to get her to understand that

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I'm not actually charging her $90.

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Her insurance process
the claim with a co-payment of $90.

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And if she has something,
you know a question about that

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she should contact her insurance and
figure out why they processed it that way.

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So a lot of patients
assume that it's the provider

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that's charging them this amount of money,
when in all reality, it's

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their insurance company who processes
the claim and tells the provider

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how much the patient is responsible
to pay.

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Got it.

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And then at the end of the day, we also,

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see patients receiving bills.

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What are the most common reasons or in
what situations did they actually end up

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receiving a bill? Sandra.

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So the biggest reason
I see that a patient receives a bill is

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because they either have their insurance

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company insurance, policy has terminated,
they've changed insurance companies,

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and they didn't give their new insurance
card, or mostly like a clerical issue,

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like patient's date of birth is, you know,
one day off or they have the wrong year

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or they're considered a mail
and the insurance has a female just,

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you know, clerical issues

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that are simple fixes, but you don't know
until you get that denied claim.

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There are, 
you know, reasons why insurance companies

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deny for not,
you know, not medically necessary.

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So if you come in and you're, 
you want to get STD

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tested at an urgent care,
but you don't have any symptoms,

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a lot of insurance companies will say,
hey, that's not medically necessary

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unless you have a symptom.

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We're not just going to pay.

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So you can, you know,
get these tests done.

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So there's a lot of different reasons.

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But, 
the main reason I see is usually like,

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administrative, like clerical things.

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That's, that's great information.

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Thank you, Sandra, for sharing.

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Just when people visit our clinic.

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Barbara, what what can they do

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if they lost their insurance card
or if they lost something?

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And can we still see them?

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We just have a few concluding questions
before.

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If you can summarize, what's the best
advice for a patient in those situations?

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So in the clinic situation,
if a patient comes in

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and they don't have their insurance card,
we can for the most part

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look up their insurance
by using a payer website.

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So we do have logins for,

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like for

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example, Connecticut Medicaid, Cigna
and whatever that may be.

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So we might require a couple additional
information from the patient.

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So for example, Medicare does ask that we,
get their Social Security number.

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So when we are asking

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those additional questions,
because you don't have your,

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card with you, it's
not because we're just being nosy.

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It's because we need that information
in order to make sure we do have your

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insurance on file,

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and we don't get, like Sandra said,
those clerical errors, denials, etc..

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Got it.

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And before we conclude, Sandra,

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do you have any advice for people
when they're shopping for insurance card?

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And can you also tell us
if there is any recent major change

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in policy that impacts people,
insurance plan and so forth.

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So two questions there.

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Yes. So, a lot of insurance companies

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are trying to keep patients
who don't have emergent issues out

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of the emergency room to save that for,
you know, the the real emergencies.

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So a lot of insurance companies,
including my own,

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now charge a like a fee.

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If you go to the emergency room
and it's not an emergent issue.

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So that's a huge change
that we've seen in the most recent.

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Also,

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since the pandemic, a lot of insurance
companies are shying away from telehealth.

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A lot of insurance companies
waived all of their telehealth, you know,

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restrictions during Covid
because they just wanted everyone

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to be able to be seen and,
you know, get the care that they needed.

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But now that we're out of that,
that mess, a lot of insurance companies

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are going back to the, you know,
their regular not allowing telehealth.

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In regards
to when you're shopping for insurance,

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my, suggestion is
make sure you know what you need.

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If you use prescriptions often

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because you have some kind of
chronic illness, if you go to, you know,

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the urgent care a lot because
you are always worried about being sick.

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Make sure you understand what
your policy entails and what it covers,

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because a lot of people really the bottom
line is they don't pay attention.

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They see, oh, this one's
only going to cost me $50 a paycheck.

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Let me choose that one.

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And then there's, surprised when
it doesn't cover anything that they need.

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So it's really important to one understand
what they need.

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And to make a, educated choice on,

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you know, what plan
that they're going to have to choose.

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These are so, great advices
and great information.

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Sandra and Barbara, thank you.

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Also, from the clinic perspective, 
elaborating on what to,

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what to be careful of
before a patient comes in with insurance.

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So they are best taken care of.

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We appreciate everybody participating.

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And watching our show.

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We would look forward to presenting to
you more important topics down the road.

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This is urgent care, unscripted.

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Please subscribe and, follow us,
and we look forward to seeing you do.

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Yep. And keep in mind,
we are at 54 Sawmill Road in West Haven.

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So if you want to come see us

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for any urgent care services,
we are here to serve you.

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Thank you again and have a great day.

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Thank you guys.

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Thank you. So.