The information below applies to both the Best Doctors and WEA insurance plans:
Unlike the U.S., most doctors here do not accept insurance. They are not proficient in filling out the required insurance forms and are small independent physicians that do not have access to a "Billing Office" as our physicians do in the U.S. Unbeknownst to you, most doctors in the U.S. subscribe to a "Billing Service" to assist with their insurance filings and/or are affiliated in some way with a larger "group" of medical professionals that provide the billing service as a benefit of belonging to that particular medical group.
Additionally, a licensed doctor in Mexico has hospital privileges at almost any hospital in their area. In the U.S., physicians have authorization to practice only at one or two licensed hospitals.
To offer you worldwide coverage, the insurance company agrees that they will reimburse you. You must still follow their specific insurance guideline protocols regarding notification of the insurance company for emergency situations and pre-authorization Protocol for planned medical treatments/surgeries.
Following the guidelines of your insurance carrier, you then pay the doctor and fill out a Claim Form for reimbursement. Reimbursement into your account normally is within 30 days from the date you submit a fully-documented Claim. Fully-documented means that you have taken the necessary steps to insure that you have everything the insurance company requires to substantiate your claim.
Especially in the case of our catastrophic policy, most often hospitalization is required. It is the hospital that has the direct pay relationship with the insurance company, not the physician. Consequently, the hospital is responsible for collecting all the costs related to your stay (doctor, operating room, anesthesiologist, hospital charges, etc).
If you choose a direct-pay hospital, the hospital will verify your coverage and review your insurance pre-authorization papers. You pay them your deductible and they will then settle with the insurance company for charges incurred over the amount of your deductible.
If you utilize the services of another hospital, outside of the direct pay network, you are responsible for paying the incurred charges to the hospital upon your discharge. Then you must complete a Claim Form to the insurance company. All of your receipts must be explained and show evidence that the 16.9% Mexican IVA tax was paid, to be legally reimbursable. YOU MUST ALWAYS REQUEST AND SUBMIT A FACTURA FROM YOUR MEDICAL PROVIDERS. Be assured, this is the ONLY acceptable receipt for services the insurance company can accept as legal payment for the services you received. This is not a negotiable option. It is illegal for a medical provider to deny issuing you a Factura if you request one. If you are denied a Factura, you may report the offender to the SAT (Mexican equivalent of our IRS).
The normal time for reimbursement from the insurance company is 30 days from the date that the Claim Form is submitted with all the appropriate documentation.
Factura, Factura, Factura ...
We cannot emphasize this enough! It is somewhat customary in Mexico for the small, independent physicians to not report all of their income to the Government. So, while you are provided with a receipt for the medical services, if it does not have the word FACTURA printed on your receipt, it is not considered a legal, reimbursable receipt by insurance standards. The receipt will also show that the Mexican IVA tax is being collected and paid.
While the above warning may seem a bit trivial, when it comes to paying a sizable amount to a physician for his services, if you are remiss in getting the Factura Receipt, you may be left "holding the bag" and a non-reimbursable receipt from your physician.