As the insurance process may lead to many misunderstandings and misguided expectations, in this blog we will be shedding light on Bumrungrad’s insurance payment process and the coordination with the insurance companies — focusing on two areas:
- Clarifying some key terminology and touching on the implications they have on processes
- Explaining what happens during the discharge process and why you should not expect to immediately leave the hospital once you are cleared by your doctor to go home
To best serve our patients, Bumrungrad has built a network of direct billing partnerships with nearly 80 international insurance companies, over 30 Thai/local insurance companies, and over 40 assistance companies. Now, what happens if Bumrungrad does not have a contract with your insurance company? If we do not have a direct billing contract, patients can “pay and claim,” or the insurance company can engage an assistance company we are working with.
Policies and Coverage
Often our staff is asked about details of a certain individual policy, but we hope you understand that each of these insurance companies have numerous policies, therefore it is often best to clarify personal coverage with the insurance or broker directly. But in general, health insurance policies have either in-patient or in- and out-patient benefit coverage policy; if you are only covered for in-patient treatments, generally speaking, you would need to cover all out-patient treatments on your own.
Please note, our doctors will not admit a patient without medical justification, so people only covered for in-patient treatments should not assume they can use their insurance benefits for otherwise outpatient services. If the insurance company deems an admission unjustified, it is in their right to reject the claim and the patient would need to cover the cost of admission, as well as investigation or treatment, on their own.
Direct Billing or Pay and Claim
If you have out-patient coverage, and depending on your insurance and policy, it is possible that you will be requested to “pay and claim,” meaning you will be responsible for your reimbursement process. Please notify the hospital staff that you need a so-called
claim form and medical certificate, which you will receive after your payment is complete, along with your original receipt. Afterwards, you will need to submit the documents to your insurance company so you can get reimbursed.
Under some circumstances, the out-patient process is dealt with “cashless,” although you will still need to sign the invoice. The hospital then submits the claim forms along with your invoice directly to your insurance company. Should some items be rejected by your insurance company, we would then ask you to return and settle the bill for the outstanding amount.
Insurance Coverage and Out-of-Pocket Expenses
Some policies have so-called
deductibles. Deductibles are the first portion that has to be paid by the insurance holder. Once the amount is reached, the insurance covers the subsequent medical expenses based on the policy.
Co-payments are “cost sharing,” policies, which means that the insured pays a specified amount of incurred medical expenses and the insurer pays the remainder.
Other insurance policies have “limits,” which is a
ceiling on the coverage for either a disease or disability. A policy limit can also determine a maximum on how much can be claimed within the
insurance policy period.
Insurance companies usually exclude so-called
pre-existing conditions, which is a medical illness or injury, usually chronic diseases, with an onset prior to starting the current health plan. To find out more about ex- or inclusions of your plan, you should consult your insurance provider or broker.
Accident vs Healthcare Coverage
Now let’s make the distinction between
accident vs
healthcare coverage, as some healthcare policies
do include accident insurance, but some do not.
Accident insurance is for an unforeseen bodily injury, which does not cover diseases or illnesses.
Healthcare insurance refers to coverage that indemnifies or reimburses the patient’s medical expenses for losses caused by bodily injury or illness.
Pre-Authorization or Prior Authorization
Before some investigations can be undergone, medications can be prescribed, or procedures can be performed, the hospital needs to request approval from the insurer, known as a “pre-authorization” or “prior authorization.” This usually happens if the cost exceeds certain thresholds, or if it is in a grey area which might not be covered or can be deemed not strictly medically necessary. In some instances, this can take some time, and it can happen that we have to schedule another appointment.
However, needless to say that treatment goes ahead if it is an emergency situation.
The Patient Discharge Process
Every patient is excited to go home and rush to get ready to leave once they learn the doctor has approved their discharge. But when they are asked to wait, they become restless and annoyed after a few hours.
Please understand that there are various steps that need to be checked off before patients can actually leave the hospital — even with pre-authorization from the insurance company.
Here’s what goes on:
- The doctor writes your discharge summary and medical report (most likely after he or she finished his/her or rounds).
- He/she prescribes your take home medication.
- The pharmacy reviews the order and the pharmacy robot prepares your medication.
- After that, the bill is closed.
- The final bill is sent to your insurance provider, even if you have received the guarantee of payment (GOP) beforehand.
- Your insurance provider reviews the expenses and informs the hospital what is covered, and what has to be covered by the patient. Some policies have co-payments, deductibles, exclusions or excess provisions; in most cases, insurance won’t cover extra expenses such as phone calls or extra meals.
- Should the hospital not have a direct billing agreement with your insurance provider, your provider would need to assign an assistance company which functions as intermediary. This process is common, but as you can imagine, it delays the discharge as there are additional steps needed.
- You have the option to wait for the confirmation, or leave a deposit for the full amount in cash or by credit card; the deposit will be returned after the hospital receives the final confirmation of coverage.
- The cashier then informs you once the bill is ready, which you will need to sign. If there is an outstanding bill, we would ask that you settle the remaining amount. You will be given the receipt and your medical report.
- Afterward, you receive your home medication and instructions on how to take them.
As you can imagine, completing this takes several hours and involves several groups of people and various departments, and not just within the hospital. Next time you are waiting for your pre-authorization, payment at the cashier, or discharge, we ask that you please be understanding and kind to hospital staff knowing that there are numerous steps involved before they can conclude the service.
Should you have any further questions, please get in touch with our insurance department.