Health Insurance 101-3 Reimbursement

Reimbursement is a fancy term that insurance companies made up for payment.  The dictionary defines this as

1.     To make repayment to for expense or loss incurred

2.     To pay back; refund; repay,

Reimburse is also defined as: to repay or compensate (someone) for (money already spent, losses, damages, etc)

Technically, the money is supposed to already be paid.  The insurance company is supposed to be paying their insured back a portion of what they have paid out to the doctor, hospital, contractor, electrician or whomever. 

If your doctor is having trouble collecting the money, he or she may ask you to pay the bill and negotiate with your insurance company.  If your doctor does not participate with the insurance company (see this http://dr-lasermed.blogspot.com/2011/09/health-insurance-101-2-participating.html ), you may very well get the check. 

Your doctor’s office will often know what the insurance company is going to do.  If they tell you that you are responsible for the bill, don’t argue.  They know what they are talking about. 

(Italics mine as is sarcasm.)

Health Insurance 101-2 “Participating Provider”

There are two parts to this one.  The first is “participating”.  This means that the insurance company has a contract with someone or something.  The insurance company has agreed to pay directly to this “provider” in a “prompt” fashion.  In return, the “provider” agrees to give the insurance company a significant discount on the charges.

Basically, the insurance company threatens otherwise to wait forever and/ or pay the patient for the service.  Then the “provider” has to try to get the money from the patient.  However, many patients think that the check from the insurance company is money for them to spend.  This is especially true if it is a large amount of money.  The “provider” may be taking payments for years.  The “provider” benefits by getting the check directly from the insurance company. 

We all know that it is corporate blackmail, but nobody can actually prove it.  The insurance company will say that they trust their clients to bring the check directly to the “provider”, and the “provider” must take that risk if they don’t want to “participate”. 

The second part of the statement is “Provider”.  What is a “Provider”?  In health care talk, this can be a pharmacy, a hospital, a home health agency, a chiropractor, an optometrist, a physical therapist, a nurse practitioner, a physician’s assistant, a nursing home……. and maybe a physician.  I didn’t spend eight years in training after college to be lumped with all of these other “entities”.