3400 Olentangy River Road, Suite 201
Columbus, Ohio 43202
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614-262-5269 (Fax)
INSURANCE FAQ
What are my responsibilities as the patient?
Patient responsibilities include knowing and understanding what benefits are covered and not covered in and out of network under their health insurance plan. This includes obtaining any necessary prior authorizations for treatments or services, referrals or any other requirements under their health insurance plan. Paying for co-payments, co-insurance and deductibles are also patient's responsibility. Patients should contact their insurance provider prior to any scheduled appointments to verify coverage.
What is Co-Insurance?
Co-insurance is the portion of the medical costs that are shared between the patient and their health insurance company after the deductible has been met. Once the deductible has been met co-insurance contributes to the out-of-pocket expense.
What is a deductible? What is my deductible?
A deductible is the amount of money that a patient pays out of pocket each year before their health insurance company becomes responsible for paying any benefits. Patient deductibles will vary by health insurance providers. Patients should contact their health insurance provider to determine the amount of their yearly deductible.
What is a Co-pay?
A co-payment reflects a pre-determined amount that is paid to a provider by the patient each time services are rendered, i.e., physician visits, specialty physician visits, ER visits, urgent care visits, or for prescriptions.
What is a participating provider?
A participating provider is any physician or other healthcare provider who has an agreement/contract with the insurance company regarding payment of services. A participating provider is under contract to bill the patient only for co-insurances, co-pays, deductibles or any service not covered by the patients benefits and accepts a discounted price from the insurance company. Patients have the option to go to physicians or other healthcare providers outside their network (non-participating providers); however, by doing so; patients will pay a larger out-of-pocket percentage.
What does it mean to be out of network?
Out of network means that the physician or healthcare provider does NOT have an agreement/contract with an insurance company regarding payment for services; therefore, the physician or healthcare provider has NO obligation to accept a discounted rate and may balance bill the patient; meaning, the physician or healthcare provider will hold the patient responsible for any portion of the bill NOT paid by the patient's health insurance company. NON-network providers do not acknowledge usual and customary rates as deemed by that specific insurance provider as payment in full.
What does balance billing mean?
It is the patient's responsibility to pay the remaining balance of any medical bill after their health insurance provider has been billed and has paid their part. The patient is billed for the difference between the total amount of the charges minus the amount that the insurance company allows. This amount also includes charges for any services not covered by the insurance company. Balance billing will ONLY occur if services are rendered by a non-participating provider.
What does PCP mean?
PCP is an abbreviation for primary care physician. This is the physician a patient visits on a regular basis, sometimes referred to as patient's family doctor. They normally are not a specialty physician.
What is the difference between a referral and an authorization?
A referral is a request from a patient's PCP to the patients' health insurance provider for the patient to see another physician, usually a specialist. An authorization is a notification to the patient's health insurance provider that one or more medical procedures need to be performed when prior authorization is needed. An authorization DOES NOT guarantee coverage or payment of the medical procedures that need to be performed.
How many therapy visits am I allowed?
All health insurance plans are different. It is the patient's responsibility to know what services their insurance plan covers, including the total number of visits allowed and when that limit has been met. It is recommended that patients contact their health insurance company prior to the scheduled appointment to see how many Occupational Therapy visits and Physical Therapy visits are "allowed" according to their specific health insurance policy. Both types of therapy visits could be a combined or separate total per calendar year. Make sure this is clarified when speaking to the health insurance representative. Columbus Hand Therapy is an outpatient therapy office.
What is the difference between a HMO and PPO?
Under a Health Maintenance Organization (HMO) patients need to choose a PCP from that HMO's network. Before patients can be referred to or seen by a specialist, patients MUST first be seen by their chosen PCP. A referral from a PCP is required prior to any scheduled visits. Patients who choose to go outside of their HMO network WITHOUT a referral from a PCP may be responsible for the entire medical bill.
Under a Preferred Provider Organization (PPO) patients choose doctors and healthcare providers within that PPO's network. Patients DO NOT need referrals to see a specialist, as long as the specialist is a participating provider in the network. Under a PPO, patients can choose to go outside of their PPO network; however, if patients choose to go outside of their PPO network, they will incur higher out-of-pocket expenses, because out-of-network benefits will apply. Most insurance plans are PPO's, but patients should verify their plan with their insurance company to be sure.
What is my out of pocket maximum?
This is the maximum amount your health insurer will require you to pay out-of-pocket towards the cost of your care. This can be an annual amount or a lifetime amount. It is the patient's responsibility to know their annual and lifetime amounts. Patients must first meet their annual deductibles before a yearly out-of-pocket maximum would apply. Once the deductible is met, co-pays will count toward the annual out-of-pocket maximum. Once the annual out-of-pocket maximum is reached, patients should no longer be required to pay any costs out-of-pocket for medical services and, in most cases, insurance will then cover 100% of the services rendered.
EXCEPTION: Services rendered by non-participating providers or out of network providers normally will incur a balance bill. This amount is not included in/towards your out-of-pocket maximum. This amount is an additional expense the patient will be required to pay out-of-pocket.
What is the difference between FSA and HSA?
A Flexible Savings Account (FSA), also known as a Flexible Spending Account, is monetary employee benefit that may be offered by an employer for a specific purpose. FSA dollars are a portion of pre-tax employee earnings that are set aside for eligible use. In order to qualify for a tax-free FSA, employees must meet certain qualifications, such as uncovered medical care or child care expenses, as well as expenses associated with elder care. The terms of an FSA, including the withheld dollar amount, must be predetermined. An FSA usually has a "use it or lose it" policy. An FSA has many similarities to a Health Savings Account (HSA). Though unlike an HSA, a FSA is somewhat more limited. An HSA does NOT have a use it or lose it policy. The balance will continue to roll over if not used. An HSA is usually offered with a high deductible insurance plan. An HSA is also offered as a benefit from an employer.
WORKER'S COMPENSATION FAQ
Who files a claim if I am injured at work?
The injured worker, the injured worker's employer, medical providers or a Managed Care Organization (MCO) can file a work-related claim with the Ohio Bureau of Worker's Compensation (BWC). However, the first provider that treats an injured worker is supposed to report a work-related injury to the BWC within 24 hours of the initial treatment.
How is a claim filed with the Ohio BWC?
A First Report of Injury (FROI) must be completed and submitted to BWC. A FROI can be completed and returned by fax or mail. A FROI can also be completed on-line and submitted. If an injured worker has been treated (for example, in the Emergency Department or Urgent Care) a FROI may have already been filed prior to follow-up treatment at a physician office.
What do I need to file a claim?
To file a claim, the injured employee will need his/her address, as well as the name and address of their employer. The claim must contain a detailed description of the work-related accident, including the date and approximate time of the injury. Once treatment has been initiated, the claim must include the diagnosis of the injury and documentation that supports the diagnosis and treatment plan. This is provided by the physician or healthcare provider.
What is a Date of Injury (DOI)?
The date of injury (DOI) is the date when the injury occurred.
How long do I have to file a claim?
Injured employees have two years from the DOI to file a claim. The survivors of workers who suffer a work related death as a result of a work related injury/illness also have two years to file a claim from the date of death.
Is there a timeframe on how long I can be treated for my injury?
For Medical Only Claim
- DOI prior to October 20, 1993 - six (6) years from the DOI.
- DOI on or after October 20, 1993 - six (6) years from the date of the last payment of medical treatment expenses.
- If there is a lapse in treatment for more than one (1) year, the injured worker will need to contact the BWC to see if your claim can be reactivated or if a new claim will need to be filed.
- The injured worker has 10 years from the date of the last payment of medical expenses, UNLESS the injured worker has been receiving continuous payments.
- If there is a lapse in treatment for more than one (1) year, then the claim will need to be reactivated.
What is a Medical Only claim?
A medical only claim is a claim where the injured worker has NOT missed more than seven (7) days of work because of a work-related injury. A medical only claim pays for medical services and treatments only.
What is a Lost Time Claim?
A lost time claim is a claim that causes an injured worker with a work-related injury, to miss more than eight (8) days of work due to the work-related injury. A lost time claim compensates an injured worker for wages lost as a result of their injury as well as covering approved medical services and treatments.
What is a C-9?
A C-9 is a form that medical providers use to request medical treatment and/or to add additional diagnoses to a claim. In most cases, C-9 approval is required prior to treatment.
What does re-activation of claim mean?
If there is a lapse in treatment of more than one (1) year, injured employees will need to get permission from BWC to receive treatment. Providers can send in a C-9 to re-activate the claim. However, BWC has the right to deny this request from the provider. If denied, BWC will require a C-86 motion from the patient or their representative. Injured employees may need to request assistance from their Physician of Record (POR) or a treating provider prior to any treatment date when re-activating the claim. BWC also has the right to deny this request.
What is a C-86?
A C-86 motion is a BWC form that has to be completed by the injured worker or his/her representative to have certain action accomplished on the claim. Usually, this is requested if an additional diagnosis needs to be added to a current open claim. If this is required, BWC will send notification requesting a C-86 be completed. The C-86 must be completed, received AND approved by the BWC before any reimbursement of the claim will be considered. Failure to complete the form will result in the claim being denied. ANY treatment denied by BWC will become the patient's responsibility for payment.
What does it mean to be self-insured?
A self-insured employer makes all decisions as they relate to workplace injuries. A BWC claim number will only be issued if the injury results in more than seven (7) days of lost time.
Who can I see for my injury?
The only rule an injured employee must follow is that they MUST be seen by a BWC provider. All physicians at Hand and Microsurgery Associates, Inc. are BWC providers. Injured employees have the right to be treated by healthcare providers of their choice as long as they are a BWC provider. This information can be found on the BWC website at www.ohiobwc.com or by calling the physician's office. The first treating physician, the one who submitted the FROI, will automatically become the injured worker's Physician of Record (POR).
How do I change my Physician of Record (POR)?
Form C-23 must be completed and submitted to the BWC. If the employer is self insured, the request would go through the employer. **It is important to ask the NEW physician of choice, if they are willing to be your new Physician of Record (POR), realizing that the physician has the right to say NO.**
This is a work related injury but I received a bill. What should I do?
If you are receiving treatment for a work-related injury and receive a bill, inform your medical provider as soon as possible. Injured employees may also need to give copies of their bills to their employers. Do not throw bills away. Always communicate with the medical providers that your visit may or may not be work-related.
How do I know if my treatment has been requested and approved?
Most of the time, authorizations and/or denials of treatment can be monitored on-line. Injured employees who work for self-insured companies will have to check with the employer or the provider.
What is a Managed Care Organization (MCO)?
A Managed Care Organization is a private company that is chosen by an employer to administer (manage) their BWC claims. They are similar to an insurance company.
Am I required to have a Managed Care Organization (MCO)?
Yes. Injured employees are required to have an MCO if their employer is NOT self-insured and has an MCO who handles their BWC claims.
Can I turn down a Managed Care Organization (MCO)?
No. Injured employees can not turn down an MCO. For example: if the injured workers' employer has CareWorks as their MCO, then that is who the injured worker must use to administer the claim.
What happens if my treatment is denied?
If an injured employee's treatment is denied and a bill is generated, that bill is the injured employees' responsibility. Injured employees have the right to appeal any decision made on the claim. Injured employees have the right to continue treatment; however, the injured employee will be held responsible for payment if the denial is not overturned.
What if I am not sure if the injury that I am being treated for is work related?
If a patient is being seen for something that may be work related and is waiting for the physician's opinion, it is the patient's responsibility to notify the physician's office when scheduling the first office visit that the reason for the visit may or may not be for a work related issue. This helps eliminate confusion and the need for repeat paperwork. More importantly, it prevents delays in treatment if the physician's office knows up front that the reason for the visit and injury may be work related.
What should I do if I am being treated for a condition not allowed on my claim?
It is the responsibility of the injured worker to know what they are being treated for AND if it is allowed on the claim. If the physician believes that a condition is work related AND should be added to the claim, then the physician's office should fill out a C-9 and submit it to the BWC. However, BWC may decide that the injured employee or his/her representative, (ie: a lawyer), must fill out a C-86 motion. BWC has the right to refuse the request for additional allowances on the claim. If the request is denied, it is the injured worker's responsibility to pay the denied portion of the claim.
What is Maximum Medical Improvement (MMI)?
Maximum medical improvement or MMI means that it has been determined by a treating provider that NO amount of additional treatment will improve the injured workers' condition. Once MMI has been reached, all temporary total benefits will stop.
What is an Independent Medical Exam (IME) and do I have to attend it?
An independent medical exam (IME) or evaluation is performed by a physician who has not been involved in the current care of that injured worker. IME's may be conducted to determine the cause, extent and medical treatment of a work-related injury; whether a worker has reached maximum benefit from treatment; and whether any permanent impairment remains after treatment. An IME may be conducted at the behest of an employer or an insurance carrier suspicious of fraud to verify a claimed work-related injury. Workers' compensation insurance carriers and self-insured employers have a legal right to this request. Should the doctor performing the IME conclude that a patient's medical condition is not work-related, the insurer may deny the claim and refuse payment. An injured worker MUST attend a scheduled IME. If the injured worker does not attend a scheduled IME, they are risking any current and future treatment and benefits.
What is a Functional Capacity Evaluation (FCE) and do I have to attend it?
A functional capacity evaluation is an exam that evaluates an injured worker's limitations and physical capacities while performing job related functions and tasks. An injured worker MUST attend an FCE if scheduled by the employer or MCO. If the injured worker does not attend a scheduled FCE, they are risking any current and future treatment and benefits.
What is a C-84?
A C-84 is a form requesting Temporary Total Compensation (payments for lost wages). This must be completed by BOTH the Physician of Record (POR) and the injured worker. It is the injured worker's responsibility to contact the POR to ensure it is being completed and sent to BWC in a timely manner. Failure to complete this form could compromise the injured workers compensation.
What is a Physician of Record (POR)?
Although an injured worker can receive services from more than one provider (i.e., treating providers), a physician of record is responsible for assuring that timely, appropriate care is being requested and delivered. A claim may only have one physician of record. A physician of record must be a medical doctor, a doctor of osteopathic medicine, a doctor of mechanotherapy, a doctor of chiropractic, a doctor of podiatry, a doctor of dental surgery or licensed psychologist. A physician of record is commonly referred to as a "POR." The POR is responsible for completing ALL C-9 and C-84 requests.
What does settling my claim mean?
This is a decision by the injured worker to settle or CLOSE their claim with BWC. When an injured worker decides to settle a claim, they have agreed NOT to have any further treatment billed to BWC for a specific work related injury. Once a BWC claim has been settled, any treatment for injuries will have to be billed through private insurance or paid for in advance. Payment for treatment now becomes the sole responsibility of the injured worker. BEFORE a claim is settled it is the patient's responsibility to be sure that ALL charges from every date of service related to the claim from ALL treating physicians/providers have been paid in full. If there are any outstanding charges and the injured worker settles the claim with BWC, the injured worker becomes responsible for paying any outstanding charges.
DISCLAIMER:
These Insurance and Worker's Compensation questions and answers are our most frequently asked questions. They are being provided as a courtesy and to be used only as a guide. They are general in nature. They ARE NOT all encompassing and may not address all insurance and Worker's Compensation questions. Insurance questions will vary depending on a patient's coverage and insurance provider at the time services are rendered.
ErgoScience – F.C.E.
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