Understand how your insurance works

[disneysteve]

This may sound like an odd piece of advice, but my experience after 25 years in healthcare is that most people simply don't know how their health insurance works. They don't know what is and isn't covered. They don't know what is and isn't in the network. They don't know which labs, radiology sites, pharmacies, and other facilities are or are not participating. But it is very important to know all of that. Getting your lab work done at Quest instead of LabCorp or filling your prescription at CVS instead of Walgreen's could cost you hundreds of dollars unnecessarily.

When you get your insurance, they typically send a big guide to benefits that most people promptly toss. If you have it, take time to read through it. If not, go to the website and review the info there. If you have questions, ask at your doctor's office BEFORE having anything done. Don't wait until you have a bill to find out that you went to the wrong place.

It is the patient's responsibility to know what is covered. Your primary doctor may refer you to a specialist but you need to verify that that doctor is participating with your plan. If your plan requires referrals, make sure you get one in advance. Don't expect your primary to issue a backdated referral for a visit that has already happened.

Also be aware that sometimes it can be cheaper to do something without using your insurance. For example, if your copay for generic drugs is $10, that's what the pharmacy is going to charge you, even if their cash price is only $6. Be sure to ask first before they put the claim in.

[TexasHusker]

All really good points.

I will add this:

Just because Dr. Jones is in your provider directory, do not automatically assume that he (s)he is still a participating provider. He might have quit that insurance last week. Go online to make sure - and for your protection take a screen shot and file. And also confirm with Dr. Jones' office.

[disneysteve]

Just because Dr. Jones is in your provider directory, do not automatically assume that he (s)he is still a participating provider. He might have quit that insurance last week. Go online to make sure - and for your protection take a screen shot and file. And also confirm with Dr. Jones' office.

Very true. Even the online guide can be out of date. The only way to know for sure is to call the office and verify it. When you call, be sure you have your insurance information in hand. Don't just call and say, "I have Aetna. Do you take that?" Aetna is just the name of a large insurance company but they offer dozens of different plans. A particular doctor may take some of their plans but not others.

[Thrif-t]

I call and ask about everything because 9 times out of 10 the online site is wrong and who gets books anymore with info? Not me. Anytime I ask about it I'm directed to look stuff up on line.

Oh, and just because I've been burned so many times in the past, I've been known to call multiple times asking the same question to make sure I get the SAME answer. Never take the 1st person's word for it, more times than not they are wrong. It's really a shame how much leg work you have to do now a days to make sure you are given accurate information!

[disneysteve]

It's really a shame how much leg work you have to do now a days to make sure you are given accurate information!

Agreed. I think this is really a symptom of how ridiculously complex our healthcare system has gotten. I'm on the inside and I can't tell you how many times we struggle to get the right answer to a question, especially when it comes to billing issues.

[TexasHusker]

Healthcare finance is an incredibly complex, and regulated, industry. It is indeed filled with confusion and contradictions. Whether or not you are a proponent of heavy government intervention in health care, I think most would acknowledge that the government's involvement in this industry - or any other for that matter - ramps up the complexity considerably.

[disneysteve]

I think most would acknowledge that the government's involvement in this industry - or any other for that matter - ramps up the complexity considerably.

As far as healthcare, I'd tend to disagree. The easiest one to deal with is Medicare. They have one set of rules that applies across the board nationwide. The problems arise with all of the private insurance companies - Aetna, United, Cigna, Blue Cross, etc. Not only does each company have different rules and policies but even within one company, they have different policies for each of the different plans that they sell. And the rules vary by state, even within the same company, so how we handle a patient insured with Aetna in NJ is different than how we handle a patient insured with Aetna in PA.

Having a one-payer system would be phenomenally simpler. If the whole country had Medicare, most of our billing problems would go away.

[TexasHusker]

As far as healthcare, I'd tend to disagree. The easiest one to deal with is Medicare. They have one set of rules that applies across the board nationwide. The problems arise with all of the private insurance companies - Aetna, United, Cigna, Blue Cross, etc. Not only does each company have different rules and policies but even within one company, they have different policies for each of the different plans that they sell. And the rules vary by state, even within the same company, so how we handle a patient insured with Aetna in NJ is different than how we handle a patient insured with Aetna in PA.

Having a one-payer system would be phenomenally simpler. If the whole country had Medicare, most of our billing problems would go away.

One payer has its pros, and it also has its cons. One con is that it would immediately limit the number of provider choices, as many providers - hospitals and doctors - cannot or will not survive on government reimbursements.

Canada seems to be a popular example of single payer:

Canada ranks 26th out of 28 developed nations in physician-to-population ratio.

There are waiting lists to get accepted by a family doctor in many provinces, with some waiting for years to get accepted.

There is a median wait time throughout Canada of 20 weeks for medically necessary services.

In New Brunswick, its almost 39 weeks.

National wait times for medically necessary neurosurgery average almost 1 year - 46.9 weeks

Single payer will come at great price.

[disneysteve]

One payer has its pros, and it also has its cons.

Absolutely. I don't disagree with any of your points. I was strictly speaking about the complexity issue. One payer is FAR less complex than hundreds or thousands of payers.

[msomnipotent]

This may sound like an odd piece of advice, but my experience after 25 years in healthcare is that most people simply don't know how their health insurance works. They don't know what is and isn't covered. They don't know what is and isn't in the network. They don't know which labs, radiology sites, pharmacies, and other facilities are or are not participating. But it is very important to know all of that. Getting your lab work done at Quest instead of LabCorp or filling your prescription at CVS instead of Walgreen's could cost you hundreds of dollars unnecessarily.

When you get your insurance, they typically send a big guide to benefits that most people promptly toss. If you have it, take time to read through it. If not, go to the website and review the info there. If you have questions, ask at your doctor's office BEFORE having anything done. Don't wait until you have a bill to find out that you went to the wrong place.

It is the patient's responsibility to know what is covered. Your primary doctor may refer you to a specialist but you need to verify that that doctor is participating with your plan. If your plan requires referrals, make sure you get one in advance. Don't expect your primary to issue a backdated referral for a visit that has already happened.

Also be aware that sometimes it can be cheaper to do something without using your insurance. For example, if your copay for generic drugs is $10, that's what the pharmacy is going to charge you, even if their cash price is only $6. Be sure to ask first before they put the claim in.

The only thing I would correct is to ask your insurance carrier and not your doctor before you get anything done. I was on the hook for $300 worth of xrays when my doctor directed me to the wrong facility. He even wrote up what I thought was a referral, but they said it was just orders and not a referral. My insurance didn't care that I was new to the plan and that I was in a lot of pain, or that the Dr told me that my knee was broken and needed to be set ASAP. So when it turned out it wasn't broken and I needed an MRI, you can bet I had the name of the person, date, and time from the insurance co stating where I could get the MRI done.

I would add to bring your formulary with you if you are getting a prescription. As an example, I brought my formulary with me when I knew I was getting birth control pills. We chose one that was in the cheapest tier and I saved $50 every month.

[disneysteve]

The only thing I would correct is to ask your insurance carrier and not your doctor before you get anything done. I was on the hook for $300 worth of xrays when my doctor directed me to the wrong facility.

This goes back to the complexity issue. It is virtually impossible for us to know with certainty exactly what every plan covers. Plus, sometimes things change and they don't notify us until weeks or even months after the change goes into effect. Drives us nuts when they do that.

I would add to bring your formulary with you if you are getting a prescription. As an example, I brought my formulary with me when I knew I was getting birth control pills. We chose one that was in the cheapest tier and I saved $50 every month.

And make sure the formulary is up to date. Formularies change regularly. It used to be that they generally changed on January 1 but anymore, they can change at any time throughout the year.

[LivingAlmostLarge]

You have to call about everything. A dentist office recently told me that my night guard wasn't covered. So I called Delta Dental and asked what could be done with my insurance. They told me I was covered, I called my dental insurance and they said "oh we checked, I guess it changed." I was like I was about to pay OOP for everything and you couldn't get off your behind and figure it out? Okay fine. don't do your job I'll do it.

Anyway they cover 50% of it saving me $150 and I still pay a share. All for the time of calling 20 minutes.

Arrgh. I hate to say this but seriously I think that most medical offices have no idea what is covered and what isn't. The US is by far the worse with navigating the healthcare system. And I bet most people have no idea how to call and ask what's covered and work the system properly. Most people stare at a bill and just throw their hands up.

An interesting article recently about a woman who took a year to get her kidney stone removed in the UK. She was diagnosed in US and American married to a British person and moved there. They summed it up.

In the US if you have health insurance and money you are GREAT. If you don't then it sucks. And yes you wait a long time in UK potentially, she would have had the surgery faster in 3 months if she didn't have a positive pregnancy test by the way. But the emergency room visit in the US cost them $6k. But she said they wouldn't have gone to the ER if they had known it would cost that much and sucked it up and done something different.

So you tell me how the US can continue down the path of affordability? I agree transparancy, but if most people can't even manage a CC you think they could manage to pay medical bills and shop around? Even worse.