Secrets health insurers are keeping from you

Few things irritate us more than having to haggle with health insurers. Nevertheless, it is hard to avoid having to do so, especially when we have to figure out what our insurance will cover. Even if we did figure it out, we still have to watch out for insurers who say our bills are suspects or invalid. We only want to be charged properly and fairly, is that too much to ask?

As far as surprise billing goes, your charge might be false

According to health care advocacy experts Families USA, surprise billing happens because a family has received “out-of-network care due to no fault of their own.” This can often catch people unprepared, especially if the patient is being treated at a hospital within their vicinity but remains unaware that all the services within that hospital do not necessarily operate under one system. Scrutinizing each professional we come across is not always a feasible task.

How can patients guard against this problem? Well, there are shrewd approaches to adopt but, as Cheryl Fish-Parcham, Families USA director of access and initiatives, points out, understanding the nuances of your state’s legislature is essential. So, there is no one-answer-fits-all solution.

As Fish Parcham comments: “It would certainly be advisable for any consumer who has a surprise bill to talk to their state insurance department and find out what’s the remedy in their state.” Safety nets may have been passed through legislature that you are unaware of, with Families USA reporting this year that certain states are working on solutions to surprise billing. One example was passed in New Mexico, in April, which comes into force as soon as we hit 2020 – SB 337; the Surprise Billing Protections Act.

Find out whether a doctor can advocate for you

Sometimes health professionals can prove a weapon in instances when insurers attempt to save money by leaving you stranded. There are many examples of insurers claiming health care is not “medically necessary” so they are not required to pay up, but doctors can help here, providing a powerful advocate to compel these insurers to put their hands in their pockets.

For further advice, Fish-Parcham advises looking into the appeal process via the health care provider of a certain treatment. Communication is often moving back and forth between health professionals and health insurers, so we never know what kind of pressure they have come under to support certain treatments. For example, James Moss, MD, although retired, continues to make his presence known at his state insurance board, knowing that insurance providers do take the will of the board seriously, even if they are not swayed by patients’ needs.

If uncertain, speak to a professional

Regarding my own health care, I’ve had to look at alternative medicines my doctor recommended in instances where the insurance company refused to support his initial prescriptions. In this respect, the public will find a varying response depending on which insurance company and doctor they are with. If you are fortunate to have a doctor who, like mine, has a shrewd understanding of how insurance works, then your doctor can prove a great asset.

In some cases, it might be feasible to ask insurance companies to name their preference – if they happen to favour a version of a particular medication. Nevertheless, often there is a need for patients to remain specific, meaning that meeting them halfway isn’t good enough.

For advice, Fish-Parcham comments: “You might consider an appeal about their formulary and whether they can make an exception for you.”

Take records seriously

Keeping all your paperwork in order is incredibly useful when it comes to dealing with insurance companies. They are much more likely to feel responsible when faced with the details in writing. Nevertheless, sometimes drawing a representative in to help by contacting them in person also speeds matters along.

“(Patients) should then follow up by either keeping notes of who they talked to and what they said,” Fish-Parcham says. “Then sending an email or a letter saying, ‘This is what I understood from our conversation.’”

Such an approach is useful if an insurance company has changed their approach, because you may have their previous position in writing and be able to use it against them.

A certain level of protection is assured…

Since Obamacare – or rather the Affordable Care Act – was launched in 2010, insurers have been required to adhere to particular safeguards and coverage standards. Examples of such safeguards include the capacity to be insured in spite of previous conditions, mental health and substance abuse history.

In cases where an insurer isn’t meeting these criteria, a state insurance board can now be drawn in to make them answerable.

… except if you purchase a short-term, limited-duration health plan

“If you’re buying a policy that complies with the Affordable Care Act, you can be guaranteed of certain benefits,” says Fish-Parcham. “If you buy a policy with the short-term, limited-duration plans, you’re not guaranteed those benefits.”

It is now acceptable for insurers to offer lengthier short-term health packages, since the government made it legal to do so in August 2018. Beforehand, such temporary packages expired after three months, but now they can last a year with a three-year renewal option.

Not everyone is in favour of this development, with some labelling these packages as “junk insurance.” This is because the cost-effective nature of these plans is only achieved because typical ACA protections do not apply.

Don’t give in when faced with difficulty

There are ways of dealing with health insurance giants as an individual. Doing so can appear overwhelming but that does not mean the situation is hopeless. Consider many of the options presented here and do not overlook the benefits of including a health care advocate for the advantages they can bring. Sometimes all we need is outside assistance!