You don’t like getting a surprise healthcare bill in the mail, right? If you have health insurance, you want the services to be paid.
And, when an unexpected bill arrives, tempers flare. (Or, at least mine does.)
So how can you get the most value from health insurance?
By knowing exactly what parts to read in your health plan benefit book.
I used to have a job working with the medical director of a health plan where I prepared clinical documents for people who were appealing their previously denied claims.
I also had the responsibility of calling the people to tell them whether their appeal was approved or denied.
Um, that was not always a fun job!
But I was able to speak directly to the people who had appealed, so I heard them explain what their understanding (or misunderstanding) was initially.
This experience helped me see the most common places where misunderstandings, misuses, and mistakes interfered with getting the most value from health insurance.
Without a doubt, the health insurance lingo, healthcare vernacular, and the legal terms are significant barriers to lay people clearly understanding how to use their plan. But, it usually isn’t the cause of denied claims.
One of the most common issues is knowing if and how services are covered. This can be found easily if you start reading in the right place.
But, STARTING in the wrong place can lead to HUGE misunderstandings or possibly even cause some awful financial situations.
WHAT PEOPLE MISUNDERSTAND: Where to Start
Most people want to start by looking for the deductible, co-insurance and co-pay amounts (on the summary of benefits and coverage page).
And, that makes sense right?
For example, after I find out I have to have X procedure, and it will cost $$ dollars, what I really want to know is – what will it cost ME in the end?
The summary of benefits and coverage page is the correct page to find that answer UNLESS it is a non-covered service.
If that service isn’t a covered service, your out-of-pocket expense will be ALL of it.
100% of the total billed charges (which is higher than what the provider would bill your insurance company!).
WHAT PEOPLE SHOULD DO: Start with the Benefit Exclusions List
Check the benefit exclusions list FIRST.
More than likely, the service will NOT be on this list. But, if you don’t check it before starting services, and it is, you could be responsible for hundreds or thousands of dollars.
It is worth the 1 minute to check the list. (That minute could be a savings $500 or $5000 or $50,000!)
The benefit exclusions list should always be your first place to review.
No matter what the circumstance or situation, if it is a non-covered service, it will be denied on the first submission. And, in my experience, the decision is RARELY overturned.
The benefit exclusions list is the guide that the health plan uses to deny non-medical services, unproven treatment, experimental treatment, or anything else they do not want to cover. And, they tend to stick to this list so it is important to check.
Knowing this information provides:
The opportunity to decide if you should seek an alternative treatment option or pay source.
Notice ahead of time if YOU will be FULLY responsible for the expenses.
And lastly, if desired, the opportunity to submit a pre-certification or pre-approval request BEFORE the services are rendered to see if it could be covered (although it is rarely approved).
And by the way, if the service is not on the benefit exclusions list, THEN looking at the summary of benefits and coverage page to see your deductible, co-insurance and co-pay is the next step for what and how it will be covered.
Unless you have to pay attention to a network.
WHAT PEOPLE MISUNDERSTAND: How to stay in-network
People are either unaware or ignore networks.
And, people assume they have complete coverage for all emergent services whether in or out-of-network.
No, it’s not always true!
WHAT PEOPLE SHOULD DO: Pay attention to whether providers are in their network
Know your network. You should receive a paper list or a web address for an online directory. Review it before using services.
People buy health plans with either ONLY in-network coverage or HIGHER coverage by staying in a specific network (a specified group of providers). But if you do not seek network providers or know which health systems are considered ‘in-network’, this will not work well for you.
I understand this can be a total hassle. And if you feel this way, do something different if you can.
Buy a plan of coverage that has both in-network and non-network (also called out-of-network) coverage if you do not want to worry about the network. You will pay more for the health services, but it becomes less of an issue.
But, if you don’t have that option, ask the provider whether they are in your health plan’s network BEFORE receiving services.
Next, do not to assume emergent services will be covered (more and more plans are denying or excluding this).
Look on the back of your health insurance card to see if there is a 24-hour nurse hotline.
You can call this number for guidance if you have an urgent/emergent (but not life-threatening) need.
Nurse hotlines typically follow physician-approved guides to triage your need and provide you with options.
Write down the time, date and name of the person you spoke with, what they said, AND WHERE THEY SENT YOU. Save this note someplace safe until you know if your claim gets paid. If not, include this information in an appeal.
If you do not have access to a nurse hotline and your need is not life-threatening, you can call the member services department (some only open during business hours – the number is on the back of your health insurance card) for close in-network provider options. It is best to obtain this information before it is needed.
WHAT PEOPLE MISUNDERSTAND: The value of preventative services
The summary of benefits and coverage lists covered preventative services (many are at 100% if they are a covered benefit).
A Fee Schedule is a shorted version of the summary of benefits and coverage. If it is provided by your health plan, it is a nice quick reference guide. Sometimes it even has a section dedicated to preventative services.
Many people miss these valuable benefits.
WHAT PEOPLE SHOULD DO: Take advantage of preventative services/benefit
Schedule preventative service appointments
ANNUALLY obtaining preventative services (which are not on the non-covered list and in-network) is one of the best ways to get the most value from health insurance because it is at low or no cost to you.
Mammograms, screenings, wellness exams, etc. will fall into this category. Make a note of all preventative services available for each of the covered members of your family, and schedule appointments for these services.
Yes, you invest your time, but you invest time in YOU and your family’s health.
Finding small problems EARLY is the optimal time to find health problems because the health problems generally require less intensive treatment options, which are typically at a lower cost.
Sometimes these services can be life-saving.
Finding health problems as early as possible also increases your opportunity to reverse or minimize the health problem (and costs) in your future.
A preventative service is a benefit that provides value TWO ways. Early detection and treatment now, and a possibility for fewer health costs later.
In closing, there is a lot to filter through to get the best value from your health benefits. But now you won’t get overwhelmed because you know where to start. Three ways to get the most value from your health insurance include: checking the benefit exclusions list FIRST, understanding your network, and using your preventative services annually.
Please take a few minutes to see how you can take advantage of your preventative benefits. Schedule that important appointment today!
Was this article helpful? Would you like more health plan benefit information? Email me and let me know!
Have a great day!
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