When booking patients, I’m often asked “Do you accept insurance?”

Many people don’t realize that this is a much more complicated question than they think.  In short the answer is ‘Yes, we do’, however the more relevant question is “Does your insurance allow us to bill them directly?”

While it is true that many wellness clinics do not accept insurance, and are not set up to bill Extended Health Insurers directly, the reality is that many insurers still process paper claims, and do not allow electronic submissions at all.  Others may accept electronic submissions, however only accept claims that are submitted by the patient.  Even within a single insurer, there are some plans that allow electronic submissions, and some plans that do not.

So the question isn’t simply whether or not your insurer allows it, but whether your specific plan allows it.  This is the question that patients should be asking of their insurer.

So how does it work?

In the world of electronic claim submission in Canada, there is one major player: Telus Health.  Their online portal incorporates most of the major insurers in Canada, including Manulife, Sunlife and Great West Life.  They also incorporate several other smaller insurers such as Johnson Group, Desjardins, and Industrial Alliance, to name a few. If the clinic you attend is set up on the Telus Health E-Claims Portal, then they can bill your insurance directly as long as your plan allows it.

The nice thing about the online portal, is that the response is immediate.  No waiting for a paper claim, no waiting for a human to look at the claim and look up your plan rules. Just immediate feedback.  You know right away what is covered, what will be paid to the clinic by the insurer, and the remainder that the patient should pay the clinic as a result. This is known as a “co-pay”.

The exception to this however, is that occasionally a claim is selected to go through an insurer’s manual processing system. When this is the case, the response from the Telus portal is an “ACKNOWLEDGEMENT”.  This means that they have received the claim and it will go for “further” processing.  Some patients get anxious when they hear that their insurance “didn’t go through”, however usually there is no cause for alarm.

There are a few reasons why we get this response.  For the most part, the insurance company is checking that their electronic system is working properly, and adjudicating claims correctly.  Additionally, they sometimes audit random claims as an anti-fraud measure.

If, when your claim is submitted, the response from Telus is an acknowledgement, not to worry!  It is just routine, and very often the claim is processed as normal.  It may take a few days longer than normal, however they are usually processed without incident.  In some cases, even though the payment instruction submitted via the portal has been set to go to the clinic, the payment gets reassigned to the member instead.  This results in an outstanding balance with the clinic, and the payment for the appointment in your bank account! If this happens, you should expect a phone call from your clinic asking you to settle the balance yourself.

So much for the convenience factor of direct-billing, right? Well, at least you know they are doing their best to make sure that people aren’t taking advantage of the electronic system.

What about Green Shield or Blue Cross?

Green Shield and Blue Cross – the Not-For-Profit insurers in Canada – both also allow electronic submission for most plans.  Like the other insurers mentioned above, the ability to submit electronically and assign payment to your healthcare provider directly, depends strongly on your individual plan.  However, they do each have their own online portals, and are not associated with Telus.

In contrast to the Telus portal, these portals require the specific therapist (Physiotherapist, Chiropractor, Massage Therapist etc) to be set up on these portals.  It is not sufficient for a clinic to be set up with a profile, but each individual practitioner requires their own.  This is why you may come across some clinics that provide direct-billing for Manulife or Sunlife, but not necessarily Green Shield or Blue Cross.

The Green Shield portal (ProviderConnect) and Blue Cross portal (Medavie) both work similarly to the Telus portal, in that they provide the same types of responses, and occasionally they also send claims for additional, manual processing.  Again, this is primarily to ensure that their systems are working properly, not necessarily because there is a problem with your claim.

So how do I know if it will work for my plan?

The best way to know is to call your insurance company.  They will ask you some questions to confirm your identity, and generally they will answer any questions you may have.  The important questions to ask are “Do you allow electronic submissions?” and “Do you allow Assignment of Benefits”.  The second question is the key question to know if they will pay the eligible benefit to the clinic, or if they will only reimburse you.  If your plan allows Assignment of Benefits, then they are allowing you to assign the payment for the services rendered to the practitioner (or healthcare clinic) directly.

As a healthcare clinic, we are able to call on behalf of patients to ask these types of questions, however some insurers (specifically Manulife) will not discuss plan coverage without the patient being present in the office to give verbal consent.  We at MiltonBackDoc offer this service as a convenience, and most often we are successful in determining your plan rules around direct-billing without much hassle.

So the next time you are preparing to use your Extended Health Benefits, consider calling your insurer to determine if the services you are planning on using are covered, what percentage is covered, and if electronic submissions and Assignment of Benefits are allowed.  Then when you call a clinic looking to use their direct-billing services, you can ask them if they are set up with your insurer.  This way everyone is on the same page, and things go as smoothly, and conveniently as possible.

For a full list of the insurers that MiltonBackDoc is set up with for direct-billing click here.