What is Assignment of Benefits?
I am a member of the Chiropractic Assistants mail group, and find that some offices are confused about assignment of benefits.
Patients can become upset when their Insurance Company does not pay for some, or all of their care, so it is very important that you fully explain Assignment at the start of care. We provide this information on a handout, and we ask the patient to sign the following agreement.
What is Assignment of Benefits?
“Assignment of Benefits” is a legally binding agreement between you and your Insurance Company, asking them to send your reimbursement checks directly to your doctor. When our office accepts an assignment of benefits, this means that we have to wait for up to one month for your insurance reimbursement to arrive. We extend assignment to our clients as a courtesy. Assignment may be withdrawn if your Insurance Company practices “Nuisance Behaviors”.
There are several parts to your Health Insurance Policy:
“Deductible” refers to the first portion of care costs incurred during the year. For example, if you have a $200 deductible, that means that your Insurance Company expects you to pay for the first $200 of the care you receive in the given contract year. After that, they will pay their portion for whatever care you receive during that year, or until you have received all the benefits your policy provides.
“Co-insurance” refers to that percentage of cost, which the Insurance Company expects you to pay. If your “co-insurance” is 80%, this means that the Insurance Company will pay 80% of what they consider “usual and customary” (or U&C), and that they expect you to pay all the rest of the costs for any and all services provided.
“Co-pay” refers to a specific charge you may have to pay for a particular service. The most common co-pay is a flat fee for exams and re-exams. This is much less commonly encountered than standard co-insurance charges.
“Nuisance Behavior” Characteristics:
All reputable Insurance Companies utilize something called “Relative Value Units” (or RVU) to determine the usual and customary charge (U&C) that they will pay. The RV unit was designed to evaluate the time, complexity, and overhead costs associated with every service provided by your doctor.
The RV unit is a nationally accepted unit of value, which may be modified by a “locality percentage”. This explains why care in the Chicago region would cost more than in a smaller town that has lower overhead costs.
Some Insurance Companies create their own rate cards, paying fees that are far below what is commonly charged by a profession for a particular service. This type of Insurance Company falls into the “Nuisance Category”. If your Insurance Company ignores the nationally accepted RVU fee system, to reduce their overhead cost, they do so at YOUR expense, because that forces you to make up the difference.
Another nuisance activity is taking longer than 30 days to pay a claim. Most State Insurance laws directs Health Insurance companies to pay all claims within 30 days. Yet, some companies choose to take months to pay valid claims. If your insurance company participates in these unfair and illegal tactics, we will help you file your claim, but we will not accept assignment of your benefits.
When we verify your coverage, there is no way for us to determine if your company will play “fair” by using the RVU system. We cannot predict what they might pay for any particular service, because they do not hand out rate cards to providers. Only you, the policyholder can impact how they choose to behave, because of the legal relationship that exists between you both.
We (may) agree to take on the extra expense of filing your claims, as a consideration to you, but we have no contractual relationship with your Insurance Company. Once your insurance company pays their portion for any date of service, you will be billed for any outstanding balance. If they make an overpayment, we will cut you a check that day, to bring your balance back down to zero.
If you have any issue with how your insurance company reimburses for your care, or manages your claims, it is your responsibility to resolve those issues, directly with them.