I have health insurance, it will be fine. That is, until it’s time to go to the doctor and confusion runs through our mind about what to do next. Do I have a co-pay? What does it mean to be in-network? Where do I even start?
I recently attended a Young Professionals Ellevate luncheon in Arlington, VA. After making the “classic” D.C. round of asking about each person’s profession, my job title sparked some conversation.
“Healthcare Consultant? Wait, you sell us our health insurance? Can you tell us how to use it?”
I like to see myself as a healthcare strategist for employers, but realistically, the most important thing I do is educate employees on how to use their insurance.
Healthcare has become so confusing that we feel uneasy throughout the entire process. Hesitation sets in from the moment we make an appointment, and continues with the opening of the explanation of benefits (EOB) from the carrier. It’s the only invoice we receive in which we do not understand what is said or whether it is correct, but still never raise an objection.
The hard truth in receiving care: You have to put your guard up and take control. For any treatment beyond a preventative exam, I recommend bringing backup, such as a friend or family member, to act as your advocate and ensure each medical decision is made prudently.
Every year at open enrollment, you receive a document stating your Summary of Benefits and Coverage (SBC). SBCs are a product of the ACA, meant to explain your coverage in an easy-to-read format — though we can all agree, it has not made health insurance easier to use.
The reality is: You have to be a quick-thinking, inquisitive consumer each time you seek care. Though it’s not simple, there is a process you can utilize to get through each appointment without unexpected costs. The steps listed below might seem excessive, but I am confident each person reading this has missed one of the steps and had it cost them anywhere from $100 to thousands of dollars.
Look at your network.
Look at your carrier’s (UHC, BCBS, Cigna, etc.) website and search for an in-network physician. Once you find your physician, call their office and double-check they accept your insurance. We often find miscommunication between a carrier’s listed network and the physician.
Take note that I say “physician,” not hospital or facility. Often, two physicians in the same facility can differ on whether they are in- or out-of-network. Tricky, I know.
Go on to your carrier’s website and check to see whether the visit is covered by your insurance. This is a great time to look at your deductible. You will likely have to meet your deductible before the insurance kicks in, unless it’s preventative care, which is covered 100% under the ACA.
Most carriers have a price check tool on their site, which allows you to estimate how much you will be responsible for. Let me stress this: it is simply an estimate. I would go a step further and call the physician’s office to see how much treatment will cost. Do not be surprised if they refuse to give you an answer. Sadly, they may not even know what they charge — another thing we would never put up with in any other financial transaction.
Be an investigator during the appointment.
Read over the paperwork carefully and ask for copies. During the appointment, do not accept additional tests without asking if they’re covered under your plan. If you are getting a lab test, ask if the lab is covered under your insurance. Do not accept care from another physician during the appointment without asking if it will be covered — you cannot trust that they are in-network.
If you receive a referral for a specialist or an additional test, start at step one again. If you receive a prescription for medication, price hunt before picking a pharmacy. The convenience of going to CVS could cost you. Check to see if it’s covered under Walmart or Costco’s $4 prescription program.
Scam alert: Your co-pay could actually be higher than the $4 prescription cost. Go to GoodRx to see where you can get the best price and generics, along with any available coupons. Consider a 90-day, mail-order prescription to save on additional co-pays. Use your HSA to pay for the prescription with tax-free money.
Analyze your bill.
Eight out of ten medical bills include errors, whether they’re overcharging or incorrectly coded. Either way, it will not be in your favor. If you owe money, ask for an itemized bill so that you can look up the CPT (common procedural technology) codes. If you feel the bill is incorrect, or you would like further explanation, call the physician and your carrier. Do not be surprised if you do not receive even sub-par customer service — they are used to being the bully.
It’s your right to ask questions. It’s your right to receive transparent healthcare. It’s your right to feel as if you own the insurance you pay for. The way in which we experience healthcare is changing. It already has for some employers who accept more forward-thinking methods of contracting healthcare for their employees.
I strongly believe that changes in healthcare start at the employer and employee level, not through policy and lawmakers. Collectively, we have the power to make a ruckus large enough to demand a response from carriers, physicians, and drug manufacturers.