Health Insurance Articles
Finding Health Insurance Coverage For ENT Examinations
2011-09-07
Ear, nose and throat doctors can both diagnose and treat hundreds of conditions, but before visiting physicians for ENT examinations, insurance policy holders need to check to make sure that they're covered. While standard health insurance coverage will usually pay for the cost of various examinations, some health plans consider ENT examinations to be a form of specialized treatment that requires approval.
Whether or not a policy holder will need approval depends on the type of health plan that he or she has. An independent health insurance policy or a policy through a preferred provider organization (PPO) is likely to honor ENT examinations as long as they're medically valid. The PPO will likely recommend a particular ENT specialist for the examination, and using this specialist could mean lower health care bills. Using an out-of-network physician is always risking when working with a preferred provider organization, as this can lead to more out-of-pocket costs.
ENT examinations may be more complex under a plan from a health maintenance organization. HMOs require their members to see their primary care physicians before seeking the advice of specialists. The primary care physician will decide whether an ENT examination is necessary and will file the required paperwork with the health maintenance organization, which allows the patient to see a specialist without risking an unpaid health insurance claim. Some HMOs may not require a primary care physician's stamp of approval before ENT examinations, especially if they have ENT specialists on-staff, but it's always important to check with the health maintenance organization before proceeding with an exam. Otherwise, an insurance provider may only pay for part of the costs of an examination or deny the claim entirely.
If health insurance is provided independently and not through a managed care plan, ENT examinations will usually be quite affordable. The cost of an examination is likely to mirror the cost of any other office visit from the patient's perspective with a standard office co-payment due at the end of the examination. Most health insurance plans won't object to examinations from an ENT specialist, especially if the examinations have been recommended by other physicians. As with all aspects of health insurance, it's important to read through a policy in order to follow the proper procedure and to understand how coverage works. When an ENT examination is necessary, a health insurer should certainly cover it--a policy can't restrict valid claims simply because of a physician's specialization. Patients should work with their insurance agents and their doctors to schedule appointments with all types of specialists, including ENTs, as this helps to avoid confusing insurance scenarios.
