Health Insurance
Choosing health insurance can be a complex process. Health insurance is designed to help people pay for a percentage of their healthcare costs, which may include doctor visits, hospital stays, pharmacy costs or preventive care. It’s wise to check before you change plans or check before you choose plans.
Willis-Knighton’s convenient hospitals and doctors—the largest in North Louisiana--are available to you under many plans, but not all.
Commercial Insurance. Many private companies offer plans that can be purchased individually or as part of a group (employer, affinity group, etc.) Willis-Knighton accepts most of the major commercial insurance plans.
Medicare is a plan administered by the federal government. It offers medical coverage for people who are 65 and older, for younger people with disabilities and for people with end-stage renal disease. In addition, many commercial companies offer specialized Medicare plans and supplement plans. Plans such as Medicare Advantage seek to move people with traditional Medicare to plans that cost less for the patient but are also less expensive for the insurance company since they may cover less of the expenses for a hospital stay or treatment for a health issue.
Medicare Advantage plans require you to use only the hospitals and doctors in the plan’s network for non-emergency or non-urgent care. Ask your doctor if he/she participates in a plan before you choose it. You may need to get a referral to see a specialist. In some cases, you have to get a service or supply approved ahead of time for it to be covered by the plan. You can’t buy or use separate supplemental coverage.
Medicaid provides health coverage to Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by individual states, according to federal requirements. In Louisiana, several private companies administer the plans for residents of the state and these plans may vary as to what they offer or cover.
As a not-for-profit community healthcare organization, Willis-Knighton accepts commercial insurance as well as the traditional Medicare and Medicaid plans.
HMO or PPO?
Health Maintenance Organization (HMO) – This is a plan that limits coverage to doctors specific doctors. Each person must have a primary care doctors who is serves as the “gatekeeper,” or the person who directs your referrals to a limited list of specialists who are also under contract with the HMO. This “narrow network” may not include preferred doctors and hospitals. Participants are generally not covered for “out of network” care, unless it is for an emergency. Premium are generally lower, as is the deductible, if the plan includes one.
Preferred Provider Organization (PPO) -- This is a managed care organization of doctors, hospitals and other healthcare providers who contract with an insurance company to provide healthcare at special discounted rates to the members who participate. PPO plans have more flexibility for the member. PPOs generally offer access to a wider network of doctors than do the HMOs. No authorization is needed to see the doctors you want to see – a referral is not necessary from your primary doctors. These plans may cover services outside the network, but at a lower rate. They are more expensive than HMOs because they offer more benefits. There is generally a deductible.
Costs versus Health
Because insurance is all about risk, insurance companies make the most money on people who present the least risk – those who pay their premiums but don’t use much healthcare. That generates more profit for the company.
People who have chronic diseases or conditions, those who have unanticipated medical expenses (ER visit, surgery, hospitalization, serious disease diagnosis, etc.), and those who are more likely to have health problems due to advancing age cost insurance more money and affect the profits of the insurance companies. People with serious health problems and limited coverage find themselves with large bills that the insurance companies will not cover.
How It Works
Insurance is an agreement between the patient and the insurance company. Hospitals and doctors provide the courtesy of filing insurance claims on behalf of the patient and providing the necessary documentation of care.
If a deductible is charged by an insurance company, most doctors and hospitals request patients to pay their deductibles up front.
Hospital charged are filed with the insurance company, which pays according to the contract they have with the hospital or doctor. The insurance company reviews all charges and, sometime, may deny all or part of the charges. This is because insurance companies employ off-site staff clinical to review the information in the hospital record to decide whether they believe the services were medically necessary. Sometimes the hospital is able to provide additional explanation to denied charges. The remaining balance is what the hospital or doctor charges to the patient directly.
FAQs
How can I find a WK network doctor or hospital?
Check with your health plan or our Find a Doctor page:
How do I know what services are covered?
Checking your benefits can help you avoid cost surprises, so it’s good to review what’s covered and what’s not covered before you access services. This information can generally be found in the coverage document provided by your insurance carrier or their website.
What is prior authorization?
Prior authorization means getting approval before you access services. With prior authorization, your health plan agrees to help pay for the service – and it’s important to know that ahead of time.
How do I know if I need to get prior authorization?
If you’re not sure whether you need prior authorization for a service, take a look at your coverage document or call the number on your health plan ID card.