News & Updates

A rough guide to insurance at a health clinic, part 1

We get a lot of questions about insurance here. “Do you take x?” “Can you direct bill for y?” “Why did it only cover that much?”

Well I’m going to try and break it down based on my experience at the front desk.

First off, a disclaimer! Please understand that this is for how things are working, for us, currently. Insurance companies can and will change their policies and procedures at any time. Parts of what I mention can also vary from clinic to clinic.

Ok! Today’s topic of choice is primary and secondary insurance coverage.

Primary versus secondary insurance coverage

As a patient it is important to know the difference between the two. Your primary coverage is the plan that has been set up in your name originally and/or your only source of coverage. This is the plan you submit to first! Your secondary plan is a plan that you have been added to as a family member/partner/etc. If your family has multiple plans and you are looking to submit for children, well, that’s a whole other story. Their primary insurance is defaulted to the parent/guardian’s plan whose birthday is first in the calendar year. No, I don’t know why but that is an easy way to track it.

At Arbutus, we do direct bill claim submissions electronically for the following private insurance companies:

  • Pacific Blue Cross
  • Medavie Blue Cross (incl. DVA/VAC, RCMP, etc.)
  • Great-West Life
  • Sun Life Financial
  • Manulife Financial
  • Chamber of Commerce

As well as, the following provincial plans:

  • ICBC
  • MSP – Premium Assistance

Nine time out of ten we are able to submit for your primary plan if it is with a company listed above – we are just going to ignore provincial plans at this time. Most times we will know right away if you are fully covered. That being said, we will of course ask you to pay anything not covered on the date of service. That’s our office policy.

If the claim defaults to a pended state and we are not able to confirm immediately with your insurance company (most offices close around 5pm EST) then we will void the claim submission, collect the full appointment fee, and ask you to submit yourself. This one is my least favourite as we really do want to direct bill for you as much as possible. It makes our lives easier, and we know it makes your life easier too.

Secondary plans can be a little trickier. Not all plans we direct bill for allow us, the provider, to submit secondary plans electronically. In those cases it falls on the patient to submit that appointment’s secondary claim. A good example of this is Great-West Life, where if both your primary and secondary are with them we CAN direct bill both plans. If your primary is different, like Pacific Blue Cross, and your secondary is Great-West Life, then we CAN’T direct bill your secondary.

One challenge is that we don’t know your plan specifics when submitting for the claim. We go to the “provider” website for your insurance, and fill in your name, plan numbers, appointment length, and cost of your appointment. To which they say either yes, and how much, or no, with a brief reason why. We always recommend taking a moment to review your plan specifics so you will know what to expect when we submit on your behalf.

It is always nice to surprise a patient explaining that their plan covers more than they thought. Explaining that their plan pays less than they thought is less so.