Insurance How-Tos

From Dottie Steinhoff:

We often get the call “will my insurance cover X” or “ What is my cost if I see a specialist?” Here is an easy way to go through this. This is very basic so please know that there may be additional needs, long discussions with an insurance rep, etc.

1. For most major insurances, please start with these two things
   1. Get a photo of the front and back of their insurance card
   2. Have the patient go online and fill out the form that gives Amaze the permission to speak to their insurance company.
2. For medications, the formulary is online. A formulary is a list of all medications and how they are covered within the plan. Formularies change yearly and make sure you are looking at the current one. They like to separate this into tiers.
   1. Tier 1 is what we would call “covered medications” Sometimes at 100% and sometimes at 80%. However, others will have copay dollar amounts that are associated with each tier. Usually Tier one is around $0-$10. However, ALWAYS check before telling a patient.
   2. Tier 2 is covered but not preferred. Often will be covered at 20%-50% or so. They often cost anywhere from $20-$100 depending on the price of the med on the market.
   3. Tier 3 is often barely or not covered at all
   4. Occasionally you will hear the term step-edit. This means the provider must use one or two designated meds before the insurance will cover the desired medication. Just because you have met this step requirement, the med is not guaranteed to be covered. Sometimes yes, sometimes no.
   5. Example – I want to use Trulicity for a patient with diabetes. They want me to have tried metformin first and have a note telling them the patient had issues or it didn’t work. Then they will cover Trulicity BUT they may only give Tier 2 price.
3. For Specialists, there is a long hard way and a less long hard way – sorry. My preferred method that really helps is
   1. Get the above cards and permission
   2. Google the specialist you want and pick the highest rated after reading the reviews. When I read reviews I want to know the office is responsive, the front desk is helpful, and the bedside manner is good. (not perfect but a good start). Pick the 3 best in the desired area (or 1 or 2 if that is all you find).
   3. Call these offices and have them verify they take insurance. They should ask you for group and Member ID numbers. If they say they can’t do that (lying but whatever), have them patch you to the billing department or the office manager. Front desk is sometimes high turnover and they may not even know what you are asking.
   4. Ask for the first available new patient appt
   5. Once you have this info reach out to the patient with the covered offices that are booking reasonably. Ask the patient to call and make the appointment. Remember ALL patients need to take insurance card, photo ID, and likely a mask.
   6. Follow up in one week and verify this happened.