The “Did You Know?” Campaign for Golden Triangle Emergency Center- Orange is an informative campaign launched to further educate the public on the services we offer our community, how to understand your bill and the laws that are in place to help you.
Understanding your (EOB)
The Explanation of benefits (EOB) is a form that the insurance companies will send to their members to explain what part of a claim was paid by insurance, what part was not paid, and why.
How to Read Your EOB
An EOB from your insurance company will typically include the following information:
Top of Your EOB: Date of Service and Member identification information, and the claim number. You will need this information to check on the status of a claim.
Under Claim details: You will be provided the amount billed, adjusted amount (Discounted), amount not covered, Co-Pay, Deductible, Co-insurance, what your plan paid and what you owe.
A bill for any amounts you may owe will come separately. Review it carefully to make sure you actually received the services being billed, that the amount your healthcare provider received and your share are correct, and that your diagnosis and procedure are correctly listed.
An Example of an EOB
Highlighted in Yellow is the amount billed by our facility. Highlighted in blue is the amount your insurance company adjusted/discounted off. Highlighted in red is the amount your insurance company paid. Highlighted in green is the amount you a projected to owe.
Diving Deeper into this EOB
In this graph you will see our facility billed $4,302.04 to this particular insurance company. The insurance company adjusted off $3,253.51 or 75% from the total bill and paid $897.67 or 20%. This leaves the patient responsible for $150.86 or 3.5%. However, the problem with this example is the patient has met their deductible and insurance should cover more than 20%.
The Adjusted Amount ( or sometimes listed as discounted amount) is the difference between the amount our facility (GTEC) billed your insurance company and what your insurance company chose to pay. This amount is not what the insurance company paid.
Breaking Down of the EOB
It is important to always check over your EOB closely. You may have received a service that is not covered by your insurance in which case you are responsible for paying the full amount. Your EOB will generally indicate how much of your annual deductible and out-of-pocket maximum have been met. If you’re receiving ongoing medical treatment, this can help you plan ahead and determine when you’re likely to hit your out-of-pocket maximum. At that point, your insurance company will pay for any covered in-network services you need for the remainder of the year.
Filing an insurance appeal
If your insurance company denies a claim for treatment, you have the right to appeal. The policy holder or guardian can write a letter supporting your case and provide documentation, such as journal articles, list of symptoms, to support why a certain procedure or treatment was medically necessary.
You can file an appeal up to 180 days after you are notified of a denial. The explanation of benefits (EOB) you get from your insurance company will have information about how to file. If you do, your insurer must do what the U.S. Department of Health and Human Services calls a “full and fair review” of its initial rejection. If you lose here, you can request an “external review” by an independent organization accredited to review health care decisions.
The Patient Advocate Foundation has a downloadable guide with detailed advice on navigating this process, including sample appeal letters and a checklist of evidence to gather.https://www.patientadvocate.org/
- Get the itemized bill: Our facility sends a bill that summarizes the services you received and lists payments for each service as well as a total amount.
- To spot problems, ask for an itemized statement, this is just a more detailed explanation of the services provided.
- Take notes/Gather evidence: Starting with your first phone call, write down the date and time, the name of every person you talk to and the information they share. If you hit a brick wall request to speak to a supervisor.
- Check to see if you are being charged for services you didn’t receive, medications you didn’t take or facilities you didn’t use.
- Compare the bill with the explanation of benefits (EOB) sent by your insurance company.
- CALL US: Ask our facility about any charges you don’t understand, point out any obvious errors and request that they review your bill.
- Contact your insurance company: If your health plan isn’t covering something you thought would be covered, call the customer service line and ask directly, “What needs to happen for this to be covered? ”Sometimes, it’s just a matter of the medical provider entering the wrong code when it submitted your claim.
Affordable Care Act
Prudent Layperson Standard
One of the most important principles supporting the medical safety net is the “prudent layperson” standard for defining an emergency, which requires health insurance plans to base reimbursement on a patient’s presenting complaint rather than the final diagnosis.
This means insurers must cover emergency department care, for example, when a patient’s severe chest pain turns out to be heartburn rather than a heart attack. Such a determination often takes hours, multiple diagnostic tests, and the considered judgment of an experienced emergency physician. Under the prudent layperson standard, insurers cannot use the final diagnosis as an excuse to deny coverage.
Affordable Care Act
What is the Affordable Care Act? The “Affordable Care Act” (ACA) is the name for the comprehensive health care reform law and its amendments. This law addresses health insurance coverage, health care costs, and preventive care.
Rights & protections
The health care law offers rights and protections that make coverage more fair and easy to understand.
- Requires insurance plans to cover people with pre-existing health conditions, including pregnancy, without charging more
- Provides free preventive care
- Gives young adults more coverage options
- Ends lifetime and yearly dollar limits on coverage of essential health benefits
- Helps you understand the coverage you’re getting
- Holds insurance companies accountable for rate increases
- Makes it illegal for health insurance companies to cancel your health insurance just because you get sick
- Protects your choice of doctors
- Protects you from employer retaliation
Additional rights and benefits:
We would like to thank the AMAZING Nurses that work at GTEC- Orange and tell you a little about each of them.
Casey Daigle our Employee of the year 2021. Pictured with his beautiful wife Wendy and three children. One of the many reasons we appreciate Casey is when Hurricane Harvey made its landfall, GTEC was impacted like many other homes and facilities in our area. When we needed help getting back to working conditions, Casey volunteered himself and his time. He was first on the scene prepared with his own personal equipment to help rebuild our ER. He worked, without complaint, in 100 degree weather and always stayed in contact with management to make sure our facility was okay. Casey is also a veteran from the US Navy and Graduate from McNeese and has been a nurse for 13 years.
John Hennessy is our charge nurse and employee of the year in 2019. John is a father of two beautiful children, Kortlyn and Jase, married for 17 years to his wife Maegan and dad to their dog Cash. He loves LSU, golf, cars, music and traveling. He graduated from Vidor High School and graduated from Excelsior college. He’s a big foodie. A has been a nurse for 11 years and in the ER for almost 20.
Brandon & Aubrey Welch have been married for 5 years this year and are parents to 2 hairless cats (Ollie and Opie) and 1 dog (Odus). They both love to travel the world and have adventures. Aubrey is a native of Orange, graduated from Lamar Orange and went to Bridge City high school. Her husband Brandon had been a nurse for 11 years.
Blake Shute has been a nurse for 11 years. He and his wife had a Halloween party last year and surprised everyone by having a wedding! Father to Jolie and Lily as well as their great dane Rufio. Jack of all trades and loves to read auto biographies and listening to classic rock as well as a huge fan of the Green Bay Packers. Blake graduated from Orangefield high school and Lamar Orange.
Sherry Jones has been a nurse for 24 years. Mom to three kids (Christian, Josh and Jeremy) and loves to spend time at her property in Silsbee with her horse. Sherry has an amazing personality and a joy to work with. Married to her late husband for more than 20 years.
Jordan Read has been a nurse for 11 years. Pictured with his girlfriend Paola (Pao) (also a nurse) and a native of Orange. He graduated from Lamar Orange and went to LCM high school.
Finally our Director of Nurses Annie Kovatch. Annie moved to southeast Texas when she was in 4th grade. She later married her high school sweetheart and now resides in Orangefield where they are raising their two children Annalise and Maverick. Annie has worked as an Emergency Room Nurse since 2008 and has special training in the CVICU, is a member of Emergency Nurses Association, and Texas Nurses Association. Annie is bi-lingual and has worked closely with clubs in our community like the Lions Club and the America Red Cross. She has been able to grow with the company originally PRN, to full time nurse, to Charge Nurse, then the Director of Nurses and help open a new facility.
To receive this distinguished award we look for an employee who goes above and beyond their job requirements. Someone who is always looking for a way to better themselves, the people around them and this company. This individual has done just that.
We would like to congratulate Sheala Vice on being the employee of the quarter. She is a staff radiology technologist for GTEC Port Arthur and has been with the company since its inception 5 years ago. She graduated from Orange Memorial High School and has over 47 years of experience in her field. She helped create the protocols and techniques used at GTEC today for the CT machine. Her job entails: quality patient care, Quality Control of the CT machine, X-Ray patients, help with labs and run tests. She goes above and beyond for this company to make other employees and patients happy and taken care of. Sheala is always helping with event and continuing to find ways to improve Golden Triangle Emergency Center.
Sheala is mom to three daughters, 4 grandsons and 1 granddaughter, and she has two cats Ash and Bibbity (like Cinderella). She loves to read books- preferably crime novels (she could take us all out), garden, shop, admire jewelry, food and to travel! She loves her grandchildren and is always attending their events in Bridge City. She just recently returned from a trip to Russia and Rome and will be heading to London by the end of this month. So, if you see her be sure to tell her congratulations!
Upon receiving this award, the employee will receive a certificate of recognition, their picture hung on the “Wall of Fame”, their own parking space for 90 days, 12 hours of paid time off, and their name is considered for employee of the year. Congratulations again Sheala Vice!
Each fall and spring semester, Golden Triangle Emergency Center in Orange awards a $250, and $500 scholarship to students enrolled in the LVN and RN program at Lamar State College-Orange, respectively.
Golden Triangle Emergency Center staffs its facilities with top-tier professionals and recognizes the value of investing in the future generations of healthcare providers in our local community. The scholarship recipients must demonstrate passion for the profession in an 800 word essay, have a 3.0 GPA, and submit a resume illustrating a history of excellence.
This year’s LVN scholarship was awarded to Parker Kidder of Orange, Texas. Parker is a nursing student at LSCO and has a GPA of 3.75. Passionate about providing high-quality healthcare with an emphasis on compassion and patient education, Parker stood out as the kind of future healthcare professional that would enrich the workforce. Parker plans to continue his education and pursue a Bachelor’s of Science in Nursing upon completion of the LVN program.
Landon Procella of Orange, Texas, is this spring’s RN scholarship recipient. Landon is an LVN who graduated from LSC-O in 2016. Upon graduation, Landon worked as a Medical Surgical Nurse at The Medical Center of SETX. He currently works full-time as a floor nurse and part-time in case management at Post Acute Medical Rehab Hospital of Beaumont while enrolled in the RN program at LSC-O. Landon’s dedication to providing meaningful care to his patients while studying to expand his skill-set in healthcare set his application apart. He plans to apply to a Nurse Practitioner program sometime after graduation.
Golden Triangle Emergency Center would like to congratulate both these men on their accomplishments and wish them luck with their future endeavors. If you are an LVN or RN nursing student at Lamar State College-Orange, or know a student who meets the qualifications, keep an eye on Golden Triangle Emergency Centers Facebook page to see when we will be accepting applications for the fall 2019 scholarship. Golden Triangle Emergency Center is here 24/7/365 for all your emergency needs.
Written by: Christina Segura
Golden Triangle Emergency Center is offering a Scholarship to an LVN and RN student from both Lamar State College Port Arthur and Lamar State College Orange.
To apply you must be enrolled in the Registered Nursing Program or the Licensed Vocational Nursing program, have at least a 3.0 GPA, submit a transcript, resume, and 800 word essay describing why you should be chosen for this award, why you chose nursing for your career and your plans for the future upon graduation.
Application deadline is April 24th for Orange and April 26th for Port Arthur. The LVN winners will receive $250 and the RN winners will receive $500. Good Luck