Making Your Insurance Make Sense

It’s a new year, a time for new beginnings, new goals and unfortunately, probably a new deductible. Insurance companies have a way of sneaking in new protocols with each new calendar year so it is always a good idea to take the time at the beginning of the year to brush up on your benefits. But don’t worry, it doesn’t have to be daunting and miserable. Here are a few tips for helping find the forest through the trees when it comes to your healthcare coverage.

It is crucial that you know the details of your plan. Start by determining three key components: your deductible, your co-pay, and your co-insurance.

It is crucial that you know the details of your plan. Start by determining three key components: your deductible, your co-pay, and your co-insurance.

Know Your Plan

The details of your plan are usually mailed to you or made available on your healthcare provider’s website. It is crucial that you know the details of your plan, especially if you want to avoid headaches once billing takes place. But to help you get through the minutiae of the paperwork start by determining three key components:

  • What is your deductible?  This is the amount you will owe before your insurance provider will pay a bill. If you have a procedure (a biopsy for example) you will pay 100% of the cost up to your deductible limit. So if you have a $1,000 deductible and have an $800 procedure you will owe the whole $800. Some plans require you to meet your deductible before they will pay for doctor visits as well;  that brings us to the next point.

  • Do you have a co-pay?  This is especially important as you schedule doctor’s appointments. If you have a co-pay then you will simply owe that at your visit and it will be collected at that time.  If you do not have a copay it will be up to your individual health care provider whether they will have you pay before or after they bill the insurance, but you will owe 100% of the negotiated rate until your deductible is met.

  • Do you have co-insurance? Co-insurance is just a fancy way of saying the insurance company will not pay 100% of your medical costs after your deductible is met. Your co-insurance can be anything from 10% to 50% so it is good to know what it is.

In Network vs. Out of Network

It is important to always stay in-network in order to keep your costs down. An in-network provider is simply a physician or hospital that has agreed to accept your insurance companies negotiated rate. Your plan will have an “in-network” and “out-of-network” deductible but they are completely separate, and most out-of-network deductibles are unattainable.

  • When having a procedure done at a hospital be sure to ask if all of those attending to your care are in-network.

  • If one of your providers (doctors, therapists, etc)  is not in network at a hospital that is, be sure when signing all the paperwork you state that you will only pay in-network rates for out-of-network providers.  Speak to your insurance company about this if you are planning to have any procedure done.

  • Pre-approval status usually only covers the facility of a procedure and not necessarily all the doctors attending to your care so it is a good idea to check on pathologists, radiologists etc.  If you are not sure who the doctors are, then ask.

When in Doubt Call Customer Service

Remember, the insurance company works for you. In most cases you are paying them an exorbitant amount of money and it is okay to call them with questions.  As a patient you also have the right to understand the charges from your provider.

  • Do not pay the bill if you do not understand the charges. If you are not sure of the charges you can always ask for an itemized bill from your provider. If you do not understand the negotiated rate or the amount the insurance company paid you should call and ask someone to clarify the charges.

  • Do not be afraid to call and ask a lot of questions. If you feel overwhelmed about your coverage it is always a good idea to just call customer service and ask them the basic questions

    • What is my deductible?

    • Do I have co-insurance?

    • Do I have a co-pay?

    • Are my current physicians in-network?

  • If you are disputing charges be sure to request a bill be put on hold while you clarify                  . the bill. And if payment plans are necessary do not let them bully you into a payment plan that does not fit into your budget. If the first person you talk to says they can’t help you, ask to speak to the next person up. Advocate for yourself and speak to another human being whenever possible. Never underestimate the power of human connection.

As with many things in life, especially the unpleasant things, the key is to be informed and organized. The more you know, the more empowered you will feel to deal with the questions as they arise. As a bonus, while you are doing research on your plan you can also find out if your policy covers a certain number of mental health visits, physical therapists or even a masseuse; often these benefits go unused simply because people don’t know they are available to them. You are your best advocate and the more you know about your policy the more pleasant your medical experiences will be.

*Disclaimer: Please note that the above recommendations are not a substitute for speaking to your insurance company.

Valerie Liao, M.D.Comment