3 Important Health Insurance Facts You Need To Know!

My recent experiences with health insurance plans have been a big eye opener. I’m not a novice at this, having worked in upper management of corporate behavioral health benefits. Any time you deal with insurance, you are not on a level playing field.   Insurance companies have armies of actuaries and legal staff to ensure that their taking on your risk is profitable.  That’s okay, as we get benefit in return, a benefit we hope never to use beyond routine health maintenance.

But when you need to use it, as I recently did, there are a few important areas to fully understand.  Three major ones can make a significant financial impact on your use of services:

1.The deductible and out-of-pocket costs are not straightforward.

If you choose to go with a provider or facility that is out-of-network, the out-of- pocket expenses applied to your deductible are subject to limitations placed by your insurance company under the “reasonable and customary” stipulations. The hospital or health care provider may be billing you for service at rates your insurance deems too high for customary reasonable fees.  It will limit the amount it will apply to your deductible.  This means that an X-ray read by a Radiologist may be billed at $250.00, but you only get $150.00 applied to your deductible under the reasonable and customary rule.   You still have to pay the full amount as billed. The only way around that is to negotiate the rate for Provider and facility fees before the procedure. Most will be willing to work with you if you offer to pay cash or credit card at the same rate their insurance contracts reimburse. The advantage to them is the fast turn-around and no need to file claims or wait for a check in the mail.  Your insurance company can give you the in-network rate for services as a guideline, or consult online resources such as The Patient Advocate Foundation. www.patientadvocate.org

2. Not all providers may be covered or participate in your insurance.

When you arrange for a test that involves several activities of care such as a colonoscopy, your PCP is just the first step. The GI specialist will see you and refer you to a Surgi-center for the test. That center may be on your health plan. However, the anesthesiologist may not. It’s important to clarify with the Surgi-center that you want an in-network provider for all services or get in writing that it will accept the in-network rate for the service.  That will ensure that you don’t wind up with extra payments. Remember, most practices use a billing system and collections agency, so the billing churns through the system based on what response comes electronically from the insurance company. Unless you have an agreement up front, you may be in for a surprise or unnecessary hassle.  

3. Coverage during an emergency.

Lastly, in an emergency, whenever you can, clarify with your insurance regarding an in-network provider or facility. If you are unable to do so before receiving treatment, do so as soon as possible afterwards. It could require a transfer to a different facility. In the best of circumstances, it would result in your insurance agreeing to cover your care as if you were at an in-network facility and provider. That could lower your cost for services. It also puts the insurance company at the negotiating table with the hospital about how they will get paid.  Most people don’t know that if an in- network provider is not available within a reasonable distance, your insurance must cover the care as if in-network or make arrangements to transfer you at their expense. Again, hidden charges can happen, such as X-Ray or ECG readings from your ER visit that are billed separately from the ER visit itself.  All those papers you sign on entering the ER commit you to paying the bills received if not covered by insurance. Balance billing is also possible if it’s not in-network.  It’s hard to negotiate when you are on your back in pain. You are at a disadvantage, but that does give you a little more flexibility with those billing offices once insurance does its thing on the coverage. Again, “money now”, at the reimbursement rate for their local reasonable, customary fee is better than no, slow or collection pay. Most healthcare facilities and providers take some form of insurance and discount their fees to be in the network. In return, they get more patients with a payment attached to them. Don’t think you don’t have any leverage. Your ability to pay immediately with cash or credit card allows the process of “cash flow,” which often trumps the slower flow of billing insurance.