The dreaded “I” word. Insurance. A relationship that you love to hate. A necessary part of healthcare. That being said, it begs the question...why does it have to be so complicated and frustrating? The answer: it is actually designed by insurance to be difficult. With his years of experience, Dr. Ryan offers this checklist to help you know how to manage your own insurance.
The Big Picture
Insurance naturally wants to limit their payments since this is how they make a profit. They do this by making the process more difficult and cumbersome for patients and providers by:
- Passing on the cost to the patient (deductible, copays, co-insurance) so they are less likely to use services. Patients usually pay 100% until the deductible is met, then they pay a percentage of charges (the co-insurance) until the max out-of-pocket expense is met, then insurance pays 100%.
- Restricting services by requiring pre-approval and denying payments after services are complete
- Restricting access to providers or hospitals by limiting which are in-network vs out-of-network.
Before Treatment
It’s important to gather correct information prior to your office visit. You can do this in a variety of ways and ask for a summary of coverage (take a picture and leave it on your smartphone):
- Talk to your employer’s human resources or benefits manager - that person is your company's advocate for getting the most out of your insurance company.
- Call your insurance company - Call the customer service number on the back of your insurance card and have your card handy.
- Login to your insurance company’s online portal - Your insurance plan should be able to help. From this site, you’ll have access to all the information you’ll need.
What to Know
Prior to any treatment, you need to know how much you’ll be responsible for. Here’s a list to know...and it’s worth writing down:
- Copay amounts. Know your copay amounts for office visits, urgent care, walk-in clinics, and the ER. Specialty doctors and different clinic types may have differing amounts, as do in-network providers versus out-of-network providers.
- What services are covered and how much? Specific procedures, lab tests, and ambulance or emergency fees are often covered at differing rates.
- In-network vs out-of-network coverage rates. There is usually a difference, so ask ahead of time if your provider is 'in' or 'out' of network and what the cost will be.
- Deductible amounts. A deductible is an amount you pay before the insurance kicks in. You need to know your plan’s total deductible amount and how much you have already paid so you have an idea of what you would still owe. The amount varies by plan and whether it's an individual or family deductible. After paying the full deductible amount, you’re not off the hook yet since you often begin paying a percentage of charges - the coinsurance.
- Coinsurance. This is the percentage you will pay after paying the full deductible until you reach the Max Out-of-Pocket Expense.
- Max Out-of-Pocket Expense. This is the maximum you will pay including deductibles, coinsurance, and copays. After this, the insurance covers 100%.
- Referrals - Many plans require a referral from your primary health care provider (PHCP) to see a specialist or you will be denied coverage. If so, you’ll need to request your PHCP to make the referral - don’t be surprised if this requires a visit to your PHCP.
- Pre-approval - Some insurance plans require pre-approval BEFORE a treatment is started or they will deny payment. You have to ask your plan if it will cover the desired treatment. The provider’s office will usually help with this.
- Services not covered - Every plan has its limits, so be sure to read them in your plan. Even something as simple as eye care is often a separate plan. Never assume that your desired doctor or treatment is covered just because you have insurance.
The bottom line is to be an advocate for yourself. Keep a file of insurance documents especially the plan summary, and when in doubt...ask to avoid a surprise bill. Your employer should be able to assist you, as should your insurance plan's customer helpline and the insurance/billing department of your provider.
Furthermore, the Missouri Department of Insurance will also answer questions and act as an advocate if there are issues.
Your healthcare is important. Insurance is complex and frustrating. Knowing what to know and where to go for help puts you back in control.
