Patient advocate: In health coverage, the details matter
When it comes to your health insurance, whether private or government-provided, not paying attention to the details can be costly. Patient advocates like me do more than help clients in the hospital. We also spend a lot of time unraveling health insurance mysteries that can leave clients with thousands of dollars in medical bills.
You may have seen a recent article about a Florida woman whose health insurance, which she purchased through the federal exchange, was canceled because she was late with her premiums — a total of five cents.
Yes, for want of a nickel, she lost her insurance and began receiving large medical bills.
Her premium had been $0, but when she dropped her mother from the family policy because she had become eligible for Medicare, the premium became one cent per month. She figured it was a rounding error and didn’t pay much attention to the letters saying she might lose her coverage because premium payments weren’t met.
After five months, her insurer dropped her. Was it legal for them to do that? Yes. Did it make sense? Hardly. Her insurance has been restored now, but she’s still disputing the bills she received while it was inactive. Stay tuned.
I find that a lot of clients, and people in general, don’t really understand the terms of their policies, which leads to insurance denials, insurance appeals or, in this case, loss of coverage.
No matter if your health coverage comes through an employer, an ACA exchange, Medicare or Medicare Advantage, you have to pay attention or risk large medical bills.
What do I mean by paying attention? Here are some tips that may keep you out of hot water.
Read and understand your policy
This means understanding what medical services are (and are not) covered, what premiums are due each month, what your deductibles and copays are, and what your annual out-of-pocket maximums are.
Insurance companies must use “clear and unambiguous” language in their policies, and any ambiguity is typically interpreted in favor of the policyholder. However, insurance policies often contain complex and ambiguous language that can be difficult for you to understand, which may lead to disputes over coverage.
If you have questions about your policy, talk to your human resources department or call the company directly. Keep notes about who you spoke to and when and what they said.
Open the mail!
Pay attention to what your insurance company is sending you, even if you think you know what’s in the envelope. It may be an explanation of benefits (EOB), a bill or even, in the case of the Florida woman, a notice that her premiums weren’t up to date.
There’s a reason the companies print “important insurance information” on the outside of the envelope.
Use the insurance company portal
You don’t have to wait for mail. Your policy is available to read in the customer portal, and claims usually show up pretty quickly. It will tell you if your premiums are up to date, how your claim was paid (or not) and what the appeals process is. Check in with the portal regularly.
Is the doc in your network?
Medicare Advantage plans, which are HMOs, keep a network of approved providers. If your primary doctor is referring you to a specialist, your first stop is the list of network providers on the insurance website.
If the info on the website is wrong or outdated, you’ll be on the hook for payment. Call the doctor’s office to make sure they accept your insurance.
Pay attention to prior authorizations and referrals
Some insurers require a referral from the primary provider if you have to see a specialist. Original Medicare doesn’t have this requirement. Prior authorization may also be required for certain procedures or tests, or for certain medications. Missing a prior authorization is a major reason claims are denied and patients end up with full liability.
If a claim is denied, don’t panic
A claim may be denied because the person who submitted the claim misspelled your name, gave a wrong member ID number or used the incorrect diagnostic code. You won’t be able to review the claim submission, but if you do get a denial or the coverage isn’t what you expected, call the doctor’s office and ask them to review the claim for errors. You can also call on the services of a patient advocate.
A popular phrase since the late 1800s is “the devil is in the details.” And those details can make or break your insurance coverage.
• Teri (Dreher) Frykenberg, R.N., a registered nurse and board-certified patient advocate, is the founder of www.NurseAdvocateEntrepreneur.com, which trains medical professionals to become successful private patient advocates. She is the author of “How to Be a Healthcare Advocate for Yourself & Your Loved Ones” and her new book, “Advocating Well: Strategies for Finding Strength and Understanding in Health Care,” available at Amazon.com. Contact her at Teri@NurseAdvocateEntrepreneur.com to set up a free phone consultation.