A doctor’s advice for navigating your health insurance

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I am a physician, chair of a medical school department, and faculty member of a family medicine residency. I have a blood disorder that requires periodic visits to a specialist in New York and recently suffered a kidney stone attack, surgery and brief hospitalization locally in Connecticut.

I work in Connecticut and get my employer health insurance from an insurance company in California. The insurance company partners with a “Third Party Administrator” (TPA) – a company that handles insurance claims for the insurance company. The insurance company is part of a much larger insurance organization with separate branches located in many states. Enough said.

Howard Selinger, MD

BEFORE you get sick, receive health services and have to make sure they are paid for, I recommend the following;

Always try to have your health care provided by an “in-network” “provider” (an MD/DO physician), hospital, health care facility (i.e. outpatient emergency care, X-ray imaging, physiotherapy , counseling center, etc.)

Be proactive. Call the number on the back of your insurance card (customer service). Ask them to explain to you what happens when they receive a bill from a provider (whoever it is) who has provided you with health care services. This is important regardless of your type of insurance – traditional Medicare, Medicare “advantage” (Medicare administered by a national health insurance company), state Medicaid, and employer-based (called commercial) health insurance.

Where does the bill go first, what is their role? So after that and their role? How many “hands” are touching the ticket? What if it’s a doctor’s or hospital bill? Inpatient or outpatient? Or a “paramedical health professional (physiotherapy, mental health counselling). Let’s not forget the cost of medication and even durable medical equipment (crutches, wheelchair, walker etc.)

Understand what it means to have a franchise (money that you/the patient/legal guardian must pay up front), when it applies and when it does not apply (wellness physical exam, wellness screening mammogram, colonoscopy, etc. ). What is coinsurance, a co-payment? Most insurers will have a website that offers a “grid” describing all of these different situations.

Always make sure you receive and understand the “EOB” (explanation of benefits) for each invoice submitted and processed by your health insurance “system” for a specific date of service (DOS).

Here is my brief and disconcerting story. I received outpatient care on a particular summer service date in New York. The care included a visit to the doctor, a series of blood tests, all directed to different laboratories in the same hospital system. Some could go through a machine and others required the interpretation of a clinician.

I didn’t understand it at the time, but my healthcare costs are reviewed both by my health insurer in California and their partner TPA. However, the actual check is cut by the branch of my insurer based in the state where I receive my care, in this case New York. Now here’s what you better get used to, my bill had 20 separate lines and a total charge of $10,000!

The saga begins with the insurer’s approval of $11,800 – $1,800 more than the total expenses!

This was paid for and then recalled.

The care provider then received a new approval for $14,000!

The EOB insurer says $9,800 was paid, but the supplier says it was never received.

The supplier then received $5,580 from the New York State insurer.

Since the approval was for $14,000 ($4,000 more … than the fee and the $5,580 the supplier received, the supplier charged me $14,000 minus $5,580…or $8,420 even though, remember, the original fee was $10,000!

How is an individual patient supposed to untangle such a mess?

A rep from the supplier said we could have a three way phone call to sort out the issues, but another rep from the supplier said they never contact the insurer directly! So, I, as a patient, ended up receiving a patient account statement for DOS from the provider and emailed it to a representative from the insurer. The saga continues to this day and is still unresolved.

My purpose in sharing this is to emphasize that as a patient embroiled in insurance issues, you should never pay a bill to the provider until you fully understand and accept the grounds for the charges. You have the right to dispute the charges.

Also, don’t just pay the fees received from a vendor. Often, payments from your insurer to the provider will be “mailed through” with an invoice from the provider to you. Always check with your insurer or TPA to understand how your insurer handles the supplier claim and when/if some/all is due. I frequently discover an insurer payment to a provider who just billed me directly for the same service date and amount.

In summary, our American health insurance system is filled with convoluted workflows that can frustrate even the most sophisticated and knowledgeable patients. This in turn creates enormous stress which can further complicate a patient’s health issues and needs at a particularly vulnerable time.

Resilience, perseverance, and the determination to advocate for yourself with all parties involved will help you successfully navigate this system and promote your well-being.

Howard A. Selinger MD is chair of the Department of Family Medicine at the Frank H. Netter MD School of Medicine at Quinnipiac University. He is also a faculty member of the ECHN Family Medicine Residency in Manchester.

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