Okay. Hey, everyone. Thank you for joining our, episode of, Urgent Care Unscripted. And we welcome you to listen to our podcast and watch our podcast. This podcast are about health care and all the complexities that come with, taking care of your, health. 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 the some details of, all the, complexities of, insurance we have with us. Barbara, an author.
And I would ask her to introduce herself and then, Sandra, 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 development for 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's help, we're going to break it down a little bit for our patients and try to make sense of this crazy, insurance, healthcare world. Today we are joined by Sandra as Sandra is with positive results since 2013. And she started as a, medical billing and analyst in Holyoke office and then transferred to the Virginia Beach location and then was promoted to 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 stuff that we deal with on a daily basis. That's right. So let's start with the basics. Can you basically tell us a little bit about the difference between those three very complicated words co-pay, coinsurance and, deductibles? Sure. Of course. So a copayment is usually a set amount that an insurance company sets. For certain. Offices, a primary care is usually lower than urgent care, and specialists are a little bit higher.
And then the ER is the highest of the three. Deductibles is a set amount that the patient has to pay out of pocket before their insurance kicks in and starts paying anything on their claims, usually it's not for PCP appointments, it's usually for the appointments that are, you know, not routine appointments. And co-insurance is a percentage of the allowed amount that the insurance company, deems is is necessary. So, for example, Medicare is a insurance company that uses co-insurance.
So Medicare covers 80% of their allowed amounts, and the patient is responsible for the 20%, remaining. A very basic and fundamental question here. People have insurance and they come for medical treatment. And in the end, they still get a bill. Can you explain to us why do they still get a bill or do they have insurance? So a lot of times they get a bill for clerical reasons.
Maybe the insurance has their date of birth incorrect or their name spelled wrong, or they got married and they forgot to tell the insurance company that they changed their name. So the insurance company doesn't show them as one of their insured anymore. They also don't understand what a deductible is. I can't tell you how many times a patient calls and says, why did I get this bill? And it's because they have a deductible that they didn't realize they even had as part of their plan. Got it.
And then we also hear about pre authorization that before a patient comes in certain situations they have to procure or understand pre authorization what is really pre authorization. And how does it even apply for urgent care clinic situations. So usually a prior authorization in the urgent care setting is if you're out of state and you go to urgent care because you have an emergency and you don't want to go to the emergency room and you have an out of state plan.
Most in network providers don't require the prior authorization. So it's something that I encourage anybody who, is going to the doctor, and they've never been to that doctor before to contact their insurers and just say, hey, I plan on using this provider. Is there anything that I need to do prior to my visit that I need to, you know, take care of before I'm seeing. 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-network providers are providers that reach out to insurance companies and they say, hey, I want to become part of your network. So that way your patients can come and be seen by us at a discounted rate.
So when I say discounted rate, I mean the insurance and the providers, they negotiate a rate that the insurance company and the providers, the providers don't really have much of a say, but the insurance companies deem is, you know, a fair amount to pay for each service provider. With out of network, the the providers don't have that negotiated rate.
So the patients usually pay a 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, 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 sure that you go to an in network provider.
So that way you are utilizing your insurance in the best way possible. Correct. The other question that we hear often, Sandra, is, people get different kind of bills depending on if they are at an urgent care or if they're at a hospital or 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 minimize the surprise and minimize their cost? That's a great question.
So, again, it all depends on the, the insurance company and what they deem is, 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 care is, 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. because it's not something, you know, super emergent.
So it's kind of like the next step up from 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 the the hospitals pay for. And also, you have to remember that urgent cares are not open 24 seven emergency rooms are. So they have to pay. You know, for those I guess you could say overhead fees as well as, you know, just providing the services for you.
And since you mentioned a little bit of that, I, I want to kind of touch base on again is who actually decides how much a patient is going to get charged for 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 minutes to get her to understand that I'm not actually charging her $90.
Her insurance process the claim with a co-payment of $90. And if she has something, you know a question about that she should contact her insurance and figure out why they processed it that way. So a lot of patients assume that it's the provider that's charging them this amount of money, when in all reality, it's their insurance company who processes the claim and tells the provider how much the patient is responsible to pay. Got it.
And then at the end of the day, we also, see patients receiving bills. What are the most common reasons or in what situations did they actually end up receiving a bill? Sandra.
So the biggest reason I 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 insurance card, or mostly like a clerical issue, like patient's date of birth is, you know, one day off or they have the wrong year or they're considered a mail and the insurance has a female just, you know, clerical issues
that are simple fixes, but you don't know until 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 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. 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 card or if they lost something? And can we still see them? We just have a few concluding questions before. If you can summarize, what's the best advice for a patient in those situations?
So in the clinic situation, if a patient comes in and they don't have their insurance card, we can for the most part look up their insurance by using a payer website. So we do have logins for, like for example, Connecticut Medicaid, Cigna and whatever that may be. So we might require a couple additional information from the patient. So for example, Medicare does ask that we, get their Social Security number.
So when we are asking those additional questions, because you don't have your, card with you, it's not because we're just being nosy. It's because we need that information in 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 people when they're shopping for insurance card?
And can you also tell us if 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 patients who don't have emergent issues out of the emergency room to save that for, you know, the the real emergencies. So a lot of insurance companies, including my own, now charge a like a fee. If you go to the emergency room and it's not an emergent issue.
So that's a huge change that we've seen in the most recent. Also, since the pandemic, a lot of insurance companies are shying away from telehealth. A lot of insurance companies waived all of their telehealth, you know, restrictions during Covid because 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.
In regards to when you're shopping for insurance, my, suggestion is make sure you know what you need. If you use prescriptions often because you have some kind of chronic illness, if you go to, you know, the urgent care a lot because you are always worried about being sick. Make sure you understand what your policy entails and what it covers, because a lot of people really the bottom line is they don't pay attention. They see, oh, this one's only going to cost me $50 a paycheck.
Let me choose that one. And then there's, surprised when it doesn't cover anything that they need. So it's really important to one understand what they need. And to make a, educated choice on, you know, what plan that they're going to have to choose. These are so, great advices and great information. Sandra and Barbara, thank you. Also, from the clinic perspective, elaborating on what to, what to be careful of before a patient comes in with insurance. So they are best taken care of.
We appreciate everybody participating. And watching our show. We would look forward to presenting to you 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. 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.