VOB stands for verification of benefits. All treatment providers must verify coverage and figures specific to each plan before they can give you an accurate estimate on what your out of pocket expenses will be, if any. This can be hard to do, and it is important to know that they are doing there best to estimate.
Not a Guarantee of Benefits
If you have every called your insurance company before to find out information about your policy, you’ve heard the representative say, on a recorded line, “this is not a guarantee of benefits.” It is their standard disclaimer, because their main job is not to provide benefits to their customers, but to increase profits for their shareholders. There is plenty of evidence in history to support this, including recent court cases and even ongoing lawsuits with different insurers.
That being said, treatment centers will usually do their absolute best to help you get the maximum amount of coverage from your policy to help reduce your out of pocket costs.
The Components of a VOB
On pretty much every insurance card there is a Group Number and a Member ID. The card usually also says whether it is a PPO, EPO or HMO plan. When a VOB is done they verify what type of plan it is. PPO stands for Preferred Provider Organization, which is a policy that allows people to see providers in network as well as out of network, though the benefits of in vs. out are likely different. An HMO is a Health Maintenance Organization, where there are only in-network benefits, with the exception of emergencies. An EPO is an Exclusive Provider Organization, which is in between an HMO and PPO. It provides for a few more out of network options for a bit more choice, but is not quite as open and is less expensive than a PPO.
Each plan will have an indicated deductible. There is usually one for in network coverage as well as an out of network deductible. The in network deductible is typically lower since the providers agree to accept lower fees for the services they offer. Deductibles can be anywhere from a few hundred dollars to $10,000 or more. A deductible must be met before the insurance carrier pays for any of the claims filed, and they ensure this by withholding the amount of money that is equal.
The next part of coverage that is verified is the percentage of coinsurance. For example, the plan may pay for 80% of the agreed upon amount for in network coverage, and 60% of the allowed amount for out of network coverage. The reason for the difference is to force more patients into in network providers and to force more providers to agree to lower fee schedules, which isn’t a bad thing. In some cases, out of network coverage can be very costly to insurance companies, which is why they try to push as many people and providers in network as possible.
Another major point of verification is the out of pocket maximum (OOP max). This means that once a person has paid up to a designated amount for healthcare that year, the insurance plan should then cover 100% of the agreed upon charges. The OOP max can be anywhere from $5,000 to $25,000 per year, and also vary for in network and out of network.
Keep in mind that the deductibles, coinsurance amounts and oop max amounts not only apply to in network and out of network coverage, but they also have individual vs. family amounts. For example, an the deductible might be $3,500 per person and $9,000 per family. This means that if someone else in the family had to use benefits already during the year and met the family deductible, then the remaining individual deductibles are considered met. The same goes for oop max.
Many policies now have accreditation requirements for higher levels of care and out of state treatment. This means that if you find a program in another state that you like that it may need to be accredited by The Joint Commission or CARF in order to use your benefits there. This would be in addition to their sate license to operate.