Health Insurance Deciphered...Part 1

I've been snowed in today, which means I am home alone without any plans. I remember a time in my life when that was a recipe for destruction, fo' sho. Those days are long gone, though, and I find myself in full-on task-accomplishment mode. The dog is hardly a distraction, minus her snores, and with the dulcet sounds of "Funkytown" playing in the background, I'm going to knock out something that's been on my to-do list for over a year: The Insurance Blog--Part 1
At some point, I'll be editing this and making it uber-professional, to send out to patients on the mailing list for the office. Since this is my personal blog, I'm going to be as honest as I can, without fear of retribution--it's MY BLOG, darn it, and I'll say what I want!!! :) The more I think about insurance companies, the more I realize I couldn't possibly write all of this in one blog, so at least, on this snow day, I will handle the first part.
For a background, (because credentials are always nice), I do not have a degree in health care. I am not a nurse, a licensed medical assistant, or a doctor. I am not a certified biller or coder, and I do not (nor have I ever) worked for an insurance company. I am not issuing legal or technical advice, and I am not guaranteeing benefits. So, on paper, I don't know anything, and I am not responsible for what you do with this information.
Practical experience, however, trumps credentialing. I have worked in health care for 10 years, starting as a chiropractic assistant/communications coordinator for a chiropractor in Franklin County. From there, I worked briefly as an unlicensed Medical Assistant/Federally-Certified Drug Tester, and then to my current position, as an Office Manager for a chiropractor in St. Louis. My specialty is chiropractic billing and coding.
Numerous personal health conditions have taught me extensively about handling insurance companies as a patient; my job has taught me extensively about handling insurance companies as a provider. I've seen both sides of a very ugly industry, and needless to say, I have opinions, tips, and tricks to make dealing with said companies much smoother than most would know.
Here are a few things I've learned along the way, in dealing with insurance companies. Remember that this is Part 1--if you have questions, I can try to address them in the next part.
1. Always review your Explanation of Benefits (EOB).
People get statements from their insurance company all of the time, and usually barely glance at them. In the office, I've heard the following phrase that truly disturbs me: "I barely look at the statements. I trust you guys." REALLY??? That's incredibly brave--you barely know me. Billing and coding is intentionally confusing (and it's about to get a lot worse). Some insurance companies don't even put the procedure codes or explanations on the statement, which I wholeheartedly disagree with. I recently received a statement from United Healthcare (my insurance company) for $1100 worth of lab work, that they said I was responsible for, that the lab would be billing me for. It stated the lab, and the cost, but not the codes or description of what the charges were actually for. Had I not known what the doctor had ordered, or what the lab was called, I'd have no idea what that $1100 charge was for, and would promptly freak out. The EOB is NOT a bill--it merely shows what your insurance company covered, and what your responsibility should be. You don't have to pay anything until the provider (the doctor,lab, or hospital you were seen at) bills you directly. Should you need to negotiate that bill, you'll do it with the provider, NOT with the insurance company.
Reviewing the EOB not only prepares you for the billed amount; it also alerts you, should someone have committed insurance fraud on your account. If you see a provider you've never heard of on your EOB, you need to call your insurance company and find out who it is. Don't forget, though, that labs/radiology usually has a third-party handler that bills for interpreting your tests, and you may not know their name. For example, say I go to St. Luke's for a chest x-ray. I am billed at least 2 different ways--1. The hospital bills me for the x-ray. 2. The radiologist bills me for his interpretation of the x-ray--we've never met, so when I see a charge from a Dr. I-can't-pronounce-this on my EOB, and I call, someone has to tell me that he's the radiologist who read my film. In a private office, they could bill 1. for the x-ray; 2. for an outside consultation of the x-ray; 3. for the doctor/patient follow-up consult on the x-ray. Keep in mind that EOBs do contain the date of service for the charges. If you keep track of when you've had doctor's visits/lab work, and compare it to the charges on the EOB, it really does help clarify.
2. Verify your benefits before you make an appointment. No one likes to do this--if I had a nickle for every time someone asked me if they had coverage, I'd be rich. It is not my job to find out what your benefits are, and even if it was, I can't do it unless I have your card in my hand. And, even if I have your card in my hand, whatever information I get from the insurance company clearly states that it is NOT A GUARANTEE OF BENEFITS. I can only find out so much; usually, it's not until a claim actually goes through, that I see the full insurance coverage for service. BE PROACTIVE. Go online or call the Member Services number on the back of your insurance card before you see a physician to make sure they're in-network. Look at your card to estimate your co-pay. Know what your deductible is. This is all part of being a responsible patient--if you know what your benefits are before you go into a doctor's office, there are fewer surprises when you get that EOB.
3. Things aren't always what they seem. I realize that may come as a shock, when dealing with an insurance company. Services can mistakenly be denied; software issues can cause claims to process incorrectly. *()*( happens. If you get a statement or a denial, and you feel that the charges are not correct, call the insurance company. Ask them to reprocess the claim. I once sat in a physical therapist's office where they told me I didn't have the necessary coverage to pay for a $400 custom wrist brace. I asked them to hand me the phone, and I spoke with the insurance representative. Within 2 minutes, I had the brace paid for in full. What made the change? Besides the fact that I'm a self-proclaimed insurance badass, logic was on my side. Deny a $400 brace, or pay $10000 for surgery. EVERYTHING IS NEGOTIABLE (except for deductibles and copays). If a service is denied, talk to the insurance company first, then file an appeal. When you file the appeal, (which usually, your doctor's office knows about before you do), contact your physician to get the necessary documentation to support your claim.
4. Repeat it again: EVERYTHING IS NEGOTIABLE except for deductibles and copays.
Deductible = The amount of money you pay out of pocket, before your insurance pays anything. This amount varies; David and I currently have a $1500 deductible, per person. This does not mean that we pay $1500, dollar-for-dollar, before the insurance company kicks in--the deductible is subject to the contractual agreement your provider has with your insurance company. Deductibles are perhaps the most confusing part of the insurance process, and this is why. Your provider agrees to take a significant reduction in fees, in order to be in-network with (and advertised by) a set insurance company. For example, Dr. R., a chiropractor, would like to have access to the number of patients who have United HealthCare for an insurance company. In order to get into that network of people, she agrees to accept a discounted rate for her chiropractic adjustments--instead of the $45 she normally gets for the adjustment, she agrees to accept a contractual rate of $30 for the adjustment. If I have a deductible of $500, and I want to go see her, I will pay her $30/visit (not $45) until my deductible is met. I get the United HealthCare discount, but United HealthCare doesn't pay anything until I've met that $500 deductible, $30 at a time (even though $45/visit is billed, only the $30 contractually allowed amount applies to the $500). Then, after the $500 deductible is met, United HealthCare will pay Dr. R. the $30 (minus whatever my copay is-if my copay is $15, then United HealthCare will only pay Dr. R. an additional $15) per visit until my visit limit is reached.
YOU AGREE TO THE AMOUNT OF THE DEDUCTIBLE AT THE TIME YOU CHOOSE YOUR HEALTHCARE PLAN (ENROLLMENT). IT IS NOT NEGOTIABLE, AS YOU ARE RESPONSIBLE TO BE INFORMED ABOUT THE DECISION THAT YOU MAKE. I stress this--just last week, I got a phone call from a patient who was totally distraught. During Open Enrollment at her company, she chose the wrong plan and will now have a significant decrease in her coverage. DURING OPEN ENROLLMENT, YOU CHOOSE YOUR PLAN, YOUR HEALTH INSURANCE PROVIDER, YOUR DEDUCTIBLES, etc. MAKE THIS DECISION VERY CAREFULLY, as it will have a huge affect on you in the following year. You might laugh, but I sat on the floor and highlighted key issues in each plan offered. It was a detailed decision, and not easy to make. Consider yourself, your spouse, and your family; don't base the decision strictly on the cost/month.
Copays and coinsurance are generally not negotiable, either, unless you're able to prove financial hardship. Copays are clearly defined on your insurance card, i.e., $20 Office Visit (OV), $35 Specialist, $50 Emergency Room. This amount is generally due at the time of service. Coinsurance, however, is a little different. Most plans with coinsurance have a deductible, and after that deductible is met, you're responsible for a percentage of the contractually allowed fees. For example, after I meet my $1500 deductible, I only pay 20% of any medical charges I might have. Most practices will bill for coinsurance, as it's nearly impossible to know the percentage of the contractually allowed amounts before it's processed through the insurance company.
Deductibles, coinsurances, and copays are not usually negotiable because they're something you agree to when you choose your plan during open enrollment. If you can prove financial hardship, though, most hospitals are willing to work with you (I speak from experience--David was unemployed while I was hospitalized for almost 3 weeks in 2006 and while Hannah was hospitalized for 2 weeks and 5 days--and life-flighted; we were also down to one income while I was hospitalized back in April for surgery, for 3 days). Never be afraid or ashamed to ask a hospital to work with you, financially.
Individual health care providers vary, as far as financial flexibility goes. I've never met one who wouldn't set up a payment plan, and few charge finance charges. People do need to understand that failure to pay health care bills will be reported to the Credit Bureau. You can get thrown into collections, so don't take their willingness to work with you, as a reason to blow off those doctor's bills. If you call the provider, they'll work with you. Don't ruin your credit over something as flexible as a doctor's bill.
I know this is long, and that it's only Part 1...this is a tangled industry, and there's a lot of information out there. I'll periodically add more to this, and if you have questions, I can try to answer them or find out more, to help you. Just know that YOU are not a helpless patient against the GIANT insurance companies. David felled Goliath--you can take these guys on, and come out ahead (or at least, with understanding).