Joey Wahler (Host): It can be a bit overwhelming to newcomers, so we're discussing understanding health insurance. Our guests from Southeast Georgia Health System, Rick Grooms, he's Chief Human Resources Officer; Benjamin Fuller, Manager of Patient Access; and Lindsey Giles is with us, she's Manager of Ambulatory Access.

This is Health Matters from Southeast Georgia Health System. Thanks for joining us. I'm Joey Wahler. Hi there all. Rick, Ben, Lindsey, welcome.

Lindsey Giles: Hello.

Richard “Rick” Grooms Jr.: Hello. How are you?

Benjamin Fuller: Thank you.

Host: Great. Great to have you aboard. Can I call you Ben?

Benjamin Fuller: Absolutely.

Host: Super. So first, for each of you, let's get started with what piqued your interest initially in healthcare in your particular field and how did you arrive at Southeast Georgia Health System? How about you, Rick?

Richard “Rick” Grooms Jr.: Well, I have several members of my family that are participants in healthcare. That's the career path they've chosen. I enjoy the opportunity to help folks. And in particular, human resources is my passion. I get to help folks find jobs, support them in their work every day. And what brought me to Southeast Georgia Health System was the opportunity that exists here. I grew up on the coast of South Carolina. Southeast Georgia is very much the same, and the opportunity to be with a great team and a lot of great folks that work here strikes my fancy.

Host: Sounds great. How about you, Ben?

Benjamin Fuller: I actually started my career in Augusta, Georgia while I was in college. I did not realize I was going to be into healthcare until I started doing it and found that it was my passion at that point. I've always been very comfortable and happy in a hospital setting. So, when I was able to accept a position here in Brunswick at Southeast Georgia Health System, I jumped at the chance, moved down to the beach, and I've been here five years trying to help all of our patients.

Host: Awesome. And Lindsey, what brought you to healthcare and to Southeast Georgia Health System?

Lindsey Giles: My family has been in healthcare and my mother was here at Southeast Georgia Health System. So, it just seems like a great place to work. So, a little over 10 years ago, I joined as a front desk in one of our clinics and have been here ever since.

Host: Excellent. So, as far as health insurance goes and understanding it better, which is what we're discussing today, I mentioned, folks, at the top that it can be overwhelming to newcomers, but it can be overwhelming to non newcomers as well, of course. Speaking of which, Rick, how about we get started by explaining the different types of insurance plans? PPO, Preferred Provider Organization; HMO, Health Maintenance Organization. And there's actually a third one, a CDHP, a Consumer-Driven Health Plan. In a nutshell, what are the differences between the three?

Richard “Rick” Grooms Jr.: Certainly, a lot of acronyms in healthcare, particularly in insurance. PPO stands for Preferred Provider Organization. I like to say that the P stands for predictability. You will be in a network that typically directs your care to a degree. And with that, you have a variety of expenses that we'll talk about later, I would assume, in co-pays, co-insurance deductibles, gives you some flexibility.

A little less flexibility is the plan called an HMO, you said health maintenance organization. In that case, you have a physician that you select and he or she drives your care in a specific network. If you choose to go outside of that network, you're Insurance will not cover that, so you want to follow the instructions of that physician, that provider, to direct your care for whatever those array of services are that you need.

And the CDHP, that stands for Consumer Driven Health Plan, and it's just what you would imagine the consumer, the person being covered by the insurance program has a higher deductible, but he or she can choose where they want to go to manage the cost of that higher deductible accountability.

Host: Gotcha. So, that being said, Ben, let's explain some common terms. How about copay and coinsurance? What do those mean?

Benjamin Fuller: A lot of times people do confuse copay and coinsurance, and there is a difference that people need to be aware of. A copay is usually a flat fee you pay at your doctor's visit. When you go in, it's $25 every time you go. While on the other side, you have a coinsurance that's usually a percentage of the total cost. That percentage is the cost that the patient is responsible for. So if you have a 20% coinsurance, you're going to pay 20% of the bill while your insurance company will pay 80% of the bill. So, it's a varying range of cost while a copay is just a flat rate. Generally, the coinsurance takes place on major procedures, things like CTs, x-rays, things like that, rather than just a physician's office visit.

Host: How about a term that some are likely familiar with from other insurance they have, like auto insurance? What's a deductible when we talk about health insurance?

Benjamin Fuller: A deductible is the portion that the patient is responsible for before the insurance is going to take over. So if you have a $1,000 deductible and you have a procedure, you have to pay that first $1,000 before your insurance will pick up their percentage. So, you always have to pay that deductible and pay attention to how high that deductible is when picking out a plan, because you yourself will have to pay that before your insurance will.

Host: How about an out-of-pocket maximum?

Benjamin Fuller: The good thing about an out-of-pocket maximum is once you hit that, you don't have to pay anything else. So, you've paid your deductible, you've paid your coinsurance up to that out-of-pocket maximum, and at that point, you don't have to pay anything else. Your insurance will hit that number, and they pay everything past that.

Host: Lindsey, how about what's meant by in-network versus out-of-network provider?

Lindsey Giles: So, an in-network provider is someone where we are contracted as a health system, we have a contract with that insurance payer. And out-of-network, we do not contract with them. So, the patient could have a potential higher patient responsibility for services rendered at a facility that the payer is out-of-network with.

Host: Ben, how about the term preferred lab provider?

Benjamin Fuller: Like Lindsey was talking about before with the in-network and out-of-network providers, a lot of times, insurance plans have specific networks for their labs. So if you have a preferred lab, that means that that is an in-network lab where you may have to have your services done to have a lower cost. It doesn't mean you can't have those services done elsewhere, but you will be responsible for a higher balance. We try to direct all of our patients to in-network labs if we are not considered part of your network with your insurance company.

Host: Ben, how about the term preferred lab provider? What does that mean?

Benjamin Fuller: As Lindsey was describing before, there are networks that are part of the laboratory system as well. If you have to go to a preferred lab, that means that that lab is in-network. With your insurance company, you have an in-network or an out-of-network lab, just like you have in and out-of-network other procedures you may have. So, we always try to direct patients to an in-network lab so you can have that lower cost option. It could be that you don't have any coverage for a lab that is outside of that preferred network. So, we want to make sure you're going to the right place.

Host: And then, Ben, from an insurance standpoint, what should people know about the differences between a scheduled appointment, a walk-in outpatient visit, and then emergency care?

Benjamin Fuller: I think the biggest thing to remember in those differences is the ability for you to be prepared for any of those. If you have a scheduled procedure, you can be aware of where you're going, if authorization is required, upfront costs that you may have, all of those things that come into play since it's scheduled and you know in advance. You may have walk-in procedures or more urgent procedures that your doctor deems necessary to do right then that still may have to be authorized, but we have a little more leeway as they are more urgently needed for whatever reason.

And emergency care takes place in places like our emergency room. Those usually fall outside of the network possibilities of your payment. Urgent and emergent care is treated differently and usually covered more, but it all depends on your payer. So, it is very important for a patient to understand their own benefits and know where they fall within those realms.

Host: Ben, how can someone get an estimate of their financial liability before receiving a given health service? And what do you do as a patient if the cost changes after that estimate?

Benjamin Fuller: So, we do try to give all patients an estimated amount before you have your services done. A lot of times, it may change after the fact, depending on what happened during that procedure. So, it could go up, it could go down, but we try to do the best that we can to give you an accurate idea of what you will be responsible for. When we do that, we have the ability for you to call in prior to your procedure, give us the CPT codes that were given to you by your doctor and that will explain what the procedure is. We can look at your benefits and we can give you an accurate estimate. It could be that after the fact that may increase. We do have payment options. We have future options coming soon that will allow you to do more financing, to set up payment plans, all of those things. But you do have that ability to call in prior, or we will call you prior and discuss those terms.

Host: Okay. So having said that, Rick, speaking of paying the bill, what about FSAs, Flexible Spending Accounts, versus HSAs, Health Savings Accounts? How do their advantages and disadvantages compare?

Richard “Rick” Grooms Jr.: Sure. Um, FSAs. Flexible Spending Accounts and HSAs, Health Savings Accounts, allow you to reduce your taxable income with the contributions that you thereby reducing that taxable income and you pay less taxes out of pocket. FSAs FSAs typically pair with an HMO plan or a PPO plan or a point-of-service plan, and you can use those cards. Typically, you get a credit card or a debit card. Your money is loaded the beginning of the year for an FSA account. You choose how much you want to defer, um, per pay period from your employer, from out of your paycheck. And then, you use that to pay some of the things that we've been talking about, your copays, your coinsurance your deductible, and you can use that FSA card or even your HSA account to pay for not medical expenses but dental, vision, any of those health-related care that you need that occurs over the course of a calendar year.

The major difference between an FSA and HSA One, HSAs pair with consumer-driven health plans, or some people call those high deductible health plans. As I mentioned earlier, FSAs pair with HMOs and PPOs. The FSA, those monies have to be spent within the calendar year that you made the election to defer the money. So, for example, if I want to defer $1,000 for the year for 2024, I have to expend all of those pennies of $1,000 end of the calendar year 2024. Otherwise, I forfeit those funds. With an HSA, I roll over those funds year over year. And additionally, and depending on the, on the plan and how it's designed, you might be able to invest those funds once you reach a certain account balance. Typically, it's around 2000, but it might be more or less, depending on the organization, and you can use that funding for future expenses, for that specific calendar year that you made the deferral elections. Both of them are tools to use, but

you

Host: Lindsey, back to you for a moment. For those visiting a doctor's practice for the first time, what should they expect?

Lindsey Giles: As a new patient coming into one of our physician practices, what to expect is pretty straightforward. When you arrive, we would collect your insurance and driver's license, a photo ID. We would register you, collect some of your basic demographic information to get you in our system if you're not previously in there. And then, that's when we would really analyze that insurance card and submit eligibility to make sure you actually have coverage for that data service and then determine if you had a coinsurance or a copay.

Host: And Lindsey, how is Southeast Georgia Health System using new technology these days like for online check-in to, of course, improve the patient experience?

Lindsey Giles: Currently, we are working with a company to expand the technology that we have here at Southeast Georgia Health System for our patients. We currently have a registration intake where the patient will receive a text or email prior to a scheduled appointment where they can complete all of that paperwork prior to coming into the office.

There's that AI technology where we can take a picture of your insurance card on your cell phone and it uploads directly into our system where we can run eligibility and collect all of that vital information that we need prior to you even arriving. We also allow for digital arrival, which is that online check in. Similar, you will receive a text prior to that scheduled appointment. You come in, have a seat, select the link, and then you are checked in, and then our clinical staff comes and gets you. So, you kind of bypass that front desk and all that additional paperwork that you would be seeing.

Host: Yeah, people tend to dread the paperwork once they get to the office, right? They just want to see the doctor or whomever they're there to see. Are enough people taking advantage of those ways of avoiding that that you just described? Or are some people still dreading doing the paperwork but doing it anyway?

Lindsey Giles: Now, we've actually have a large percentage that are currently using that digital avenue to collect that information. Even today, we are working to expand that even further, not just in the physician practices, but also in the hospital, and to collect some of that clinical information too. So, it's an exciting thing, and I think it's where everyone's headed in healthcare.

Host: So, in summary, if you could all chime in on what your message would be to those joining us about choosing the right health insurance plan and navigating hospital care in general. Let's start with you, Ben.

Benjamin Fuller: I think one of the things that patients need to pay attention to is to be aware of their insurance. You have the ability to get in touch with your insurance company, check their website, know what your plan is, know what it covers, know what your deductible looks like, know what your coinsurance looks like. Being aware of the networks that you have the ability to take advantage of. The more informed you are about your own insurance, the better off you're going to be financially and in your own healthcare.

Host: How about you, Rick?

Richard “Rick” Grooms Jr.: Yeah, Ben, you made a lot of great points. I think I would echo a couple of additional points. Affordability. They're based on the type of insurance programs that are afforded to you by your employer. Some cost more than others. Consumer-driven health plans, typically with that higher deductible, are going to cost less than an HMO or a PPO. But in choosing those plans, you have to think about the affordability, not just of the payroll deduction or the premium, but what can you personally afford in terms of your copays, your coinsurance, your deductible, and how you use-- you and your covered dependents-- if you cover them on your plan, how do you use that health insurance? What are your healthcare needs and what's your healthcare status? So that when you make that decision on which plan you want to purchase for yourself and your family, which one is going to be the best one for you.

Host: And Lindsey, what's your advice?

Lindsey Giles: To piggyback off of Ben and Rick, they make very great points. But to know that you're not alone when selecting that insurance. We here at Southeast Georgia Health System are always eager to help you understand those terms, because it is a very confusing world out there when it comes to health insurance and all of the possibilities when it comes to selecting a plan.

Use us as a resource. We're happy to help you dig into what's your deductible, what's the maximum out-of-pocket and all of those terms. Is there urgent coverage? Is there emergent coverage? Inpatient, outpatient, all of those terms that can be very confusing for someone out there shopping for insurance.

Host: You're not alone is the main message there. I'm sure people joining us are very comforted to hear that indeed. Well, folks, we trust you're now more familiar with understanding health insurance. Rick, Ben, Lindsey, valuable information. Thanks so much again.

Lindsey Giles: Thank you.

Benjamin Fuller: Thank you.

Richard “Rick” Grooms Jr.: Thank you.

Host: And for more information, please visit sghs.org/understanding. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks again for being part of Health Matters from Southeast Georgia Health System.