What Do I Need to Know About My Insurance Benefits?

Navigating insurance can be intimidating and exhausting. With insurance companies taking on hundreds of new clients every day, it might be challenging to get the individualized attention that you need. At Reflex, we strive to not only treat our patients with professionalism, but also to provide the resources necessary to inform our patient’s decisions in the future.

The first step in equipping our patients with a better understanding of insurance started last July with a six part series of blogs outlining various components of insurance coverage. These are available on our website and provide a resource for patients when insurance questions arise. It is currently open enrollment, so now it is more important than ever for individuals and families re-examine how insurance changes can affect their coverage.

In the New Year

Beginning January 1, 2017 an important change will go into effect at Reflex; bilateral (i.e. both knees) hyaluronic acid injection procedures will no longer be able to be performed on the same day. This is due to insurance companies only covering treatment for one knee at a time, due to their medical policies definition of daily maximums. Due to their requirements and polices, Reflex providers will no longer be able to perform treatments on both knees in the same day. This change does not impact PRP or Stem Cell procedures, since insurance is not billed for these treatments.

Understand Your Insurance Plan

Just as we are preparing for the unavoidable changes, patients should take steps in ensuring a clear understanding of their coverage. Understanding the various terms that your medical provider or insurance company will use will help guide these conversations in the future. Here are a few terms that you should be familiar with when entering into a discussion about your coverage:

Medical Necessity – This term is frequently used in the phrase “based on medical necessity”, meaning that the doctor or health care provider, has chosen a specific treatment or service for you that is consistent with the applicable standard of care.

Prior Authorization – Approval of payment by an insurance company before you receive a medical service. This process allows your insurance carrier to determine eligibility, benefit coverage, and medical necessity, ensuring your care is right for you and your insurance plan.

Preferred Medication List – Insurance companies have the right to determine which medications are covered in their medical policy. For example, MODA’s preferred hyaluronic acid is Gel-One.

Maximum Frequency per Day (MFD) – Simply relates to the highest amount of coverage you can be provided on a single date of service. This term can apply to single claims with multiple codes or multiple claims with single codes, all on the same day.

Our Commitment to You

Here at Reflex, we are dedicated to providing an exceptional experience while helping individuals achieve their desired goals. In an effort to maintain our level of service, we offer the following to our patients:

• Follow up appointments can be the same day as treatment, if pre-authorization is not required by your insurance company.
• A schedule that can accommodate alternate days, alternate weeks or months for patients who need treatment on both knees.
• Additional treatments that do not require prior-authorizations and are not subject to the MFD rules.

As the insurance landscape evolves, our commitment to you remains the same. Reflex will continue to be transparent regarding cost of treatment and will continue to disclose policy changes as they are made.

We understand how confusing insurance can be and how frustrating it can be to navigate policy changes in the insurance realm. The Reflex team remains committed in helping patients achieve their best possible outcomes and is standing by to answer any questions regarding insurance coverage for their knee treatment plan.

Still have questions? Our helpful staff is happy to assist you: (503) 719-6783