How To Get The Most Out of Your Insurer

Even if you have terrific health care insurance from your company, you know this: Your out of pocket costs are rising. In just six years, the average annual amount you pay for health care has risen from about $2,000 to $3,400. Have a family? You’re looking at even more money. And, the prospects are getting worse, not better, as Obamacare is phased in.  One major insurer recently revealed that consumers buying their own plans could see prices rise 116 percent from current rates. Small business rates, they said, will go up 25 percent to 50 percent. These days, whether you’re buying your own policy or getting coverage from your employer, it’s clear that more and more of your take home pay will be sucked up by medical bills.

Behind the scenes, doctors say they struggle to get reimbursed by insurers to cover their costs of care. Dr. Pamela Gallin, a pediatric ophthalmologist at Columbia Presbyterian, says the excuses she receives from insurers run from “We didn’t receive your paperwork” to “You didn’t fill out the paperwork correctly.” Or simply, “You’re not covered anyway.”

In fact, there is a war on between insurers and doctors. Behind the scenes, an entire industry has grown up to advise medical offices on how to apply for reimbursement. Gallin says doctors spend hours learning about the complicated coding required insurers to successfully file a claim. There are seminars, books and even newsletters describing these codes, which she compares to SKU numbers on products in stores.  File too aggressively and ask for too big a reimbursement, called “coding up,”  and the doctor’s office is subject to fraud charges. Ask for too little and the doctor’s costs aren’t reimbursed.

Hospital groups are putting the pressure on too for savings using “big data” to monitor doctor’s work. The move is possible because of Obamacare requirements that patient data be made electronic.

The upshot of these trends is that consumers are stuck in the middle, and often stuck with bigger bills.

“The insurers don’t want to pay and hospitals and doctors do want to be paid and the patients would like to have their services covered,” says Gallin.

Getting the best outcome, then, can be tricky:

• Read your insurance policy. Okay, so you may need some Sominex, but reading the policy is the only way you’ll know what you’re covered for and can manage your care.
• Check for grandfathered exemptions. Obamacare requires insurers to cover some procedures and tests that some private plans don’t.  Changes to coverage won’t happen immediately. Don’t assume your plan automatically expands coverage.
• Be aware of changes. Not only in your insurance coverage, but also your own health needs. Benefits change overtime, so make sure you’re continually reviewing your health insurance plan. Along with the policy changing, your needs change over time, too. Take into account starting a family, or having kids out grow your insurance plan. Make sure your plan will cover what you need through life.
• Seek help. If you are lucky enough to have your coverage provided by an employer, use their leverage to help get your bill paid. Your human resources department can run interference. If you aren’t in a corporate plan, hire an advocate to take up your case.  Health care advocates exist across the country and usually take a percentage of any settlement they get for you.
• Understand deductibles. The amount you pay out of pocket before your insurer starts picking up the tab can be confusing. Understand this, the tab you get from a doctor for a service or test may not be applied to your deductible in its entirety. An insurer will credit you for less – say, the costs that Medicare would reimburse plus 10 percent. As an example, let’s say you run up a $250 bill getting an exam from your primary care physician. An insurer may credit you for the amount Medicare would reimburse the doctor for a similar service, say $80, plus another 10 percent. Not $250. Plus, you may have multiple deductibles, one for medications, another for your provider’s treatments and yet another for hospital treatments.
• Stay in network. There’s only one source of funds for doctors that are not in your insurance network and that’s your pocketbook. Before opting out for an out of network specialist, carefully consider the costs.