Statements of Financial Responsibility

by Marc Manor

So, there you are at your pre-op appointment with your surgeon and you are asked to sign a “Statement of Financial Responsibility” or similar document.  This document is the “Cover Your Assets”/CYA insurance for the providers involved in the procedure.  Even the most minor surgeries can cost tens of thousands of dollars, so it is not surprising with the expense of healthcare these days, providers want some CYA.  I think they also do this to motivate patients to submit complete and current insurance information.  These acknowledgements are required by providers even if you have comprehensive healthcare coverage. Here are a few steps you can take to increase the chances your claims are properly processed.  

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Here are some things you can verify with your provider and insurance company to make sure you have the required coverage:

Authorizations.  Most insurance plans, especially those operating under a Health Maintenance Organization (HMO) will require authorizations for various procedures.  Insurance claims are coded when processed.  The codes all represent different services and procedures.  Sometimes things like anesthesia are coded and claimed separately and the insurance company could require authorizations for both the procedure and the anesthesia.  If your procedure is routine (meaning you have in a non-emergent situation) don’t hesitate to ask your doctor’s office or call member services at your insurance company.   

Referrals.  Referrals are almost always required when you are in an HMO insurance/healthcare environment.  Make sure your surgeons were properly referred from your Primary Care Provider (PCP) so you don’t get stuck with a large bill that the insurance company will not pay.  Chances are, if you visit a specialist not in your HMO network and not referred by your PCP, you will likely have to pay the full cost of those office visits as well.  

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Exclusions.  Some healthcare plans, especially those that are not compliant with the Affordable Care Act (ACA) may have many exclusions for pre-existing conditions and other services.  Be sure you are familiar with your plan’s coverage and benefits before having a non-emergent procedure.

Claims to “Original Medicare”.  “Original Medicare” is a term used for those who have their claims paid directly from the Medicare government agency.  Beneficiaries that have only “Original Medicare” with no supplement or “Medigap” coverage will likely be billed about 20% of the cost for most procedures and services.  Since there is no cap or limit to what that 20% might be, it is a good idea to keep your co-insurance responsibilities under consideration if you do not have any supplemental or secondary coverage while using only “Original Medicare."

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Claims for services not covered under Medicare.  There are instances where providers will perform services or request diagnostic tests that are not covered under Medicare.  This is rare but not unheard of.  Some providers will give you a heads up on these “uncovered” items but some will not.  Most plans have an appeal process for claims.  In some instances you may get discounts but this is another example of how clear lines of communication between providers and patients can help avoid “surprises.”  

Veterans.  Veterans who use the Veterans Administration (VA) healthcare system should also make sure they are sure who is paying any bills for their procedures and services.  Many veterans are referred to private practices and surgery centers under the VA Choice program.  Veteran coverage under the VA program can be different from Veteran to Veteran so be sure you verify who will be paying claims and what your financial responsibility will be if any.

I get calls from time to time regarding the “Statement of Financial Responsibility”.  Clients ask if this means they do not have coverage for their procedure or service.  Most often their procedure will be covered in accordance with their plan benefit schedule. However, with medical bills being what they are, it is always best to verify your coverage and benefits prior to the procedures.  It is not much different than asking your mechanic to provide you with an estimate of repairs before looking under your hood.  Knowing can put you at ease before your procedure because, after all, you need to get well!

Marc Manor is a 30-year military veteran who is now dedicated to teaching his 

fellow Americans how to make the most of their Medicare and Supplemental Insurance benefits. As an independent agent, Marc has access to a wide variety of carriers with an abundance of resources to find tailored solutions. There is no charge for a consultation so call 904-222-0698 or email: marc@marcmanor.com.