February 23, 2019

Get the Most from Your Health Insurance

by Nancy Metcalf  

As many people have learned the hard way, even if you have comprehensive health insurance, using it smartly—that is, maximizing the amount of care your insurer covers and minimizing your out-of-pocket expenses—involves more than picking up the phone and making an appointment with a doctor. Here are six ways to avoid getting hit with higher bills than necessary.

1. Understand the benefit structure. Except for Medicare itself, the United States has no such thing as a “standard” way to design a health plan. Insurers can include any combination they want of deductibles, copays (fixed dollar amounts for a given service, such as a doctor visit), and coinsurance (the percentage of the bill you’re responsible for paying). Every health plan, whether from an exchange or an employer, comes with a standardized form called the Summary of Benefits and Coverage that has complete details and a helpful glossary.

2. Go for the most affordable treatment option if you have a choice. Say you wake up on a Saturday morning with a sore throat and fever. A trip to the emergency room may set you back a $150 deductible plus 30 percent of the balance, an urgent care clinic a $70 copay, and a visit to your doctor’s after-hours office a $30 copay. Your Summary of Benefits and Coverage can guide you.

3. Register on your health plan’s website. At a minimum, this will get you access to your plan details, replacement cards, and records of past claims. Many insurers are now starting to post some price information on their sites, customized to your plan. So, for instance, if you need a MRI of your sore knee, you can look up the actual prices the plan has negotiated with different providers in your area. You may be surprised at how much they vary.

4. Don’t pay any doctor or hospitals bills until the insurance company has sent you an Explanation of Benefits. The provider may send you a bill for the full list price of the procedure, rather than the discounted price negotiated with your insurer, which is all you’re responsible for paying. The EOB will tell you exactly how much the insurer has paid towards the claim, and how much is your responsibility. If there’s a discrepancy, contact your insurer for more information.

5. Don’t go out of network if you can possibly avoid it. Depending on your plan, it may pay nothing or very little towards the bills (often very, very large) of nonparticipating doctors and hospitals. Most health plans have plenty of qualified specialists and providers. Use them for standard medical needs, and try to use out-of-network providers only for special or unusual situations—you have a very rare disease for which there are only a handful of superspecialists, for instance (in which case your plan will likely pay for out-of-network treatment anyway), or you have an established relationship with a mental health provider who stops taking insurance.

6. Fight back if your insurer denies services you think you should have received. First, though, check with both the insurance company and doctor to make sure the denial isn’t the result of a typo, the use of the wrong procedure code, or mishandled paperwork. Such errors are relatively common. If it’s a real denial, you have the right to appeal not only to the insurance company itself, but also to an impartial third party. Your Summary of Benefits and Coverage will have information on where to start.