Hi everyone. My description says "newbie", but I've been hanging around the forum for years, mainly when I'm having one of my infrequent episodes. Over the years, I've seen a lot of questions posed about dealing with health insurance, and wondered if a brief primer of sorts would be helpful. Since 1992, I've worked in the health insurance industry, either at an insurance company or as a broker hired by employers to negotiate their employee benefit plans with the insurers. So, I know the back roads. I do a lot of public speaking about health insurance. I often tell audiences to think about health insurance the same way they would about car insurance. Really, the principals are the same. Really! Here's also some other information to keep in mind: 1) Every insurance company pays claims differently and has different policies. Also, Blue Cross Blue Shield is an organization, not a company. Each Blue Cross and/or Blue Shield plan is independently owned and operated. In many states, BS and BC compete against each other. 2) In the majority of cases, your employer has the option to pick & choose many benefits they cover. If your plan doesn't cover hearing aids, it may be that your employer chose not to cover them to save money. Talk to whoever in your company decides your benefits. Ask them why they aren't covered. It might make an impact. The larger your employer, the more options they have on what to cover. Very small employers are more limited. VERY large employers, like Boeing and GM, are their own insurance companies. They choose what benefits to cover and don't pay premium but rather what the actual claims cost. They generally hire insurance companies or other administrators to do the day-to-day administration. 3) There is a federal law called HIPAA that guarantees any condition for which you were seen, treated or diagnosed by under a prior plan won't be considered pre-existing as long as there is not a break in coverage of more than 63 days. You can read more about it here: http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html 4) Remember that the insurance company doesn't know what transpired between you & your doc other than what is submitted to them on the claim form. Sometimes it will take more information, such as the doctor's chart notes or a letter to show them why a specific treatment plan should be approved. We had that situation come up recently when the insurer wanted my husband to take a more established drug before they'd approve a newer one. Once the doctor wrote to them telling why the established drug wasn't an option (my husband had kidney cancer 2 years ago and the drug carries an unacceptable risk of tumors), they agreed to pay for the treatment we'd requested. 5) Appealing a denied benefit takes effort, time and help from your doctor. Your success in appealing depends on many things. Think again about car insurance. Let's say you decided not to purchase towing insurance. During the year, your car broke down and you needed a tow. The insurance company denies the claim because you didn't buy towing coverage. Very few people would argue with the car insurance company about that, right? The principal is exactly the same with health insurance. Now think of hearing aids. If your employers plan specifically chose to exclude them, you'll be in for a fight. I'm not saying don't fight it, but I am saying you have to have an argument better than "I need them". Work with your doctor on this one. Call the Insurance Commissioner of your state if it isn't required coverage in your state. It might not get it covered that year, but it might have an impact down the road. 6) ALWAYS take responsibility for your own insurance and your own benefits. Doctors are not insurance professionals. They deal with hundreds of patients with hundreds of benefit plans -- always check to see what is covered or what isn't on your own. If you don't understand something, call the insurance company and don't hang up until they've helped you to understand. Ask whoever in your company handles your benefits to help you, if needed. I hope this is helpful and not too high level. If anyone has questions about what deductibles or out-of-pocket limits are, or how to choose a health plan during open enrollment, let me know and I'll be happy to help.
NurseMom, you made a great point. COBRA is the best option, but it IS expensive. If you choose to get an individual plan while between jobs, make sure the coverage you're getting is creditable. Many high deductible plans aren't, especially ones with limited benefits (like no maternity). This is very important. Why? Under HIPAA, coverage under a plan that isn't creditable is treated as if you had no insurance. So, you may have to re-meet your preexisting conditions. You need to ask the person selling you the policy specifically if it will be creditable. Better still, call the insurance company directly (if you're using an agent) to ask and write down who you talked to and when. My own mother-in-law ran into this problem when the joke of an agent I referred her to didn't know to check.
Nice post. Another thing I ran into as a Benefit Administrator: Whenever our employees needed an xray (or labwork) - they'd go to a covered hospital, but they'd end up getting a bill from the Radiology Co. The insurance company's system would automatically deny the Radiology bill (separate from the hospital bill). It always took a phone call to remind them that this was considered an ancillary service - ordered by a covered, in-network physician. The insurance company would then resubmit the claim, and it would be paid. But you'd be surprised how many people just paid the bill automatically, and never bothered to call. As an addendum to that - once you've called the insurance company and had them resubmit the claim - go ahead and call the Radiology office. Let them know what steps you've taken, and that the insurance company has resubmitted the claim. Sometimes these things take a little time, and if it takes to long the matter can go for collection - and that's a major pain. If you let the Radiology Co. know what's going on - they'll make a note in your file and you can avoid the mess of a collection agency.
Great point, Fcclimber -- Remember -- you can only count on your primary care doc or ENT to forward medical information to outside labs or radiologists -- NOT insurance information. The radiologist who reviews the MRI ordered by your ENT may not know you have coverage. If you get a bill and it doesn't say that your insurance has been billed, call your insurer to make sure they got a claim. If they didn't, call the provider who sent the bill to make sure they know you have insurance.
Thank you Seatlegirl, fcclimber and Nursemom. Excellent information. I will throw out one experience I had. For background I have a policy with a $500 deductible and then 20% responsibility on many services. When the hydrops came on suddenly I was sent for an mri to make sure it wasn't another acoustic neuroma. When I got the bill, the cost of the service was $3600 for 2 mri's. I was there an hour, thought it was 1 mri and called to see if there was a mistake. The person who answered transferred me to the billing dept. I said I was just calling because I thought it might be an accidental double billing, $3600 seemed kind of high for 1 hour's work. The person first responded I would only have to pay a nominal amount. I said, no, I might end up owing $800 under my policy. She said, well then she would credit me the amount of my deductible which was $500. I ended up owing the other $300 but getting credit with my insurance company for the $500 deductible as being met. I did not ask for this, I just questioned the bill. This was IRG. It seems like that should have been against the rules with the insurance company but those rules are never spelled out to me the customer. I do not know if they over billed in the beginning. I do know there are many things that get crossed off the bill if you make a phone call. It has happened to me before. It's always worth one phone call.
I work for an insurance company as well. One of the Blues that you were referrring to. I know that alot of people appeal decisions and some even get overturned-- so if you are denied any services, please try the appeal process - - you never know. Good luck to all Hugs Kitty
Deductible for health insurance works the same as it does for car insurance. The deductible is just the amount every year that the insurance company makes you pay directly to your doctor or provider. The insurer will not pay for the first (in this case) $500 of whatever claim comes in the door first. So, beware of providers who ask you to pay your deductible up front. Let's say you have an MRI on January 2 and a CAT scan on January 3. You'd think the MRI would apply to the deductible because it was the earlier service, but the insurer looks at when the claim was filed, not when the service was rendered. Remember, you don't pay the insurance company the deductible, you pay the provider who submitted the claim that got applied to the deductible. It's perfectly fine for a providers office to agree to discount a fee or reduce a charge. June, if the claim you're talking about did get applied to the deductible, and the provider says they won't make you pay it, great! You don't owe the insurance company the deductible, you owe it to the provider!
Thanks for that clarification. I was feeling a little guilty about the whole affair. I also didn't realize the deductible applies to when billed. Now I can read my statements with some intelligence. Another surprise was that my deductible year begins in March or April when I switched from Cobra to Direct Pay not with the calendar year (when my rates go up). Is there any way to know what the usual and customary is or how they determine medically necessary. The cs rep refused to give me the usual and customary - she said it wasn't written down anywhere ( how do they say such crazy things). I was going to pursue it but didn't. But as a customer I would like to know what I am buying and take into account some things before I purchase medical insurance and or medical services. Actually I have no other choice in purchasing medical insurance, no one else will take me and bc/bs is obligated with HIPPA. I have actually found the state insurance commissioner's office in PA very helpful in understanding my rights and the insurance companies responsibilities.
Thanks for posting this is most informative. I have a feeling I will be reading this again when I find out what BCBS insurance plan I will have. I agree with So Cal Cyclist this would be great to have on the data base. Thanks everyone for such great and helpful information.
Usual & Customary (UCR), aka Allowed Amount, is the fee the insurer negotiates with providers for anything they'll get billed for. It's more of a formula than a list, though. The CSR's aren't lying -- there's isn't a published list made available to them. But it is in their building somewhere! While it's after the fact, I know, an easy way to find it is to look at your Explanation of Benefits (EOB). It'll show the provider's charge and the allowed amount on it. For an office visit -- the most common claim -- the UCR will vary depending on how long it was, how complicated it was, and who the provider is. So, a 15 minute office visit with your family doctor for a cold will have lower UCR than a 30 minute visit to your ENT for an acute Meniere's episode. An hour long office visit to an oncologist to go over biopsy results and plan ongoing treatment will pay even more. Imagine how complicated it gets for surgeries and hospitalizations! If you see providers who have a contract with your insurer, you won't have the pay the difference between the billed charge and UCR. Providers sometimes will try to bill you for that, so always check your EOB or call your insurer to double-check before you pay up!! Every diagnosis and procedure has it's own code used for billing. For laughs, you can look up the Meniere's related diagnosis codes here: http://www.icd9data.com/2008/Volume1/320-389/380-389/386/default.htm
