When I tell people that I am patient advocate, everyone has a story. Probably the most common stories are insurance problems from cost to reimbursement issues. I was picking up a rental care yesterday and after I told the agent about my business, he started talking about the cost of his insurance and his billing reimbursement issue. He told me the story and how he resolved it which included multiple phone calls to the insurance company and long waits on the phone.
In today’s healthcare market, insurance premiums are rising and the consumer is paying more for each doctor and hospital visit. Beside high monthly premiums, consumers are being strapped with high deductibles and coinsurance percentages. It is not uncommon for a family to pay $1,000 per month, have a deductible of $3500 or more, a copay of $10-40 per office visit, coinsurance of 10-30%, and an out of pocket family limit of of $16,000 and higher. Add the cost of prescriptions which frequently has it own copay and coinsurance.
It would seem if you had to pay this much money, there would be an effort by the insurance companies to provide correct billing and customer service. I continue to experience quite the opposite. I advise all my clients to be constantly vigilant of any explanation of benefits received from the insurance company. It is not unusual for there to be a mistake . I have seen everything from denials due to the wrong policy number to in network being placed out of network to stating a child was not on the policy. These are just a few. It is so important to scrutinize a bill.
Much of the problem comes from not understanding the policy. My first task is always reading the insurance explanation of coverage. It gives every detail of the policy from what your responsibility is to what aspects of health care is/isn’t covered. It is the Constitution for your health insurance. For instance, a common error on insurance reimbursement is ambulance coverage. Most policies state if you are transported by ambulance (air or Ground) in an emergency by an out of network provider, it is considered in network. Without a doubt, the insurance company will initially reimburse it as out of network. Unless you are able to understand the explanation, it would be easy to think you had to pay the out of network price. If you know your policy and this benefit, you can call make a call and get the bill resubmitted for full reimbursement.
I recently had a family who had a newborn in the neonatal intensive care for 21 days. The insurance policy had a $3500 deductible and 30% coinsurance. When the insurance explanation of benefits started arriving, I noticed two things that the family had not. First, the baby’s hospitalization was being billed under the mother. Secondly, the insurance company used a code that stated the child was not on the policy. These two mistakes created a cost to the family of over $25,000. It took multiple phone calls to get the customer service representatives to make sure all the bills were resubmitted and put under the baby’s name.
One of the most powerful tools for an empowered patient to know your insurance policy. By knowing the policy, you can question the explanation of benefits and not give an inch when speaking with a customer representative. Once the customer representative knows you understand your benefits, there will be no argument. Having this knowledge will reduce the stress associated with calling your insurance.