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Health insurance has become increasingly complicated over the last couple decades. Information is out there, but the wording is confusing, it can be difficult to find, and, if we’re being perfectly honest, it is not particularly interesting.
Many folks know a bare minimum about their plan- who the insurance company is and what they pay for their plan. We see this disparity as an opportunity; we’d like to share the basics of health insurance with our families and friends in an effort to promote understanding of the complicated world of health insurance.
Knowledge is power, right?

Know the Process

  • After a provider provides a service to the patient, a claim is created and sent to the insurance company on file for the patient. The insurance company runs claims through a mostly-automated system (with exceptions, of course), then sends the provider the payment or denial information. The amount the insurance company says is owed by the patient is then billed by the provider.

Know the Terminology

  • Find out what your deductible is, how much you have spent for the year, and when the amount is ‘re-set’
  • Cost-Sharing – beyond paying until the deductible is met, patients are usually responsible for either a copay or for coinsurance:
    • Find out what your copay is; this is a flat fee often listed on the front of your insurance card. It may vary based on the age of the patient, and whether you are seeking care at your PCP’s office, or a specialist’s office.
    • Find out what your share of the coinsurance is; this is usually a percentage-based cost. Many high-deductible plans (HDHP) have a coinsurance that the patient is responsible for after the deductible has been met.
  • Often, plans with lower premiums have a higher deductible and/or more cost-sharing, and plans with higher premiums have a lower deductible (or none!) and less cost-sharing.
  • Find out who is in-network. Networks change frequently, and providers are not always notified of their status (whether they are in- or out-of-network).
    • Choosing to seek care with an out-of-network provider usually means you have to pay more or potentially have to pay for the full service.
  • Most health plans cover preventive services (well checks, shots, screenings, etc.) at no cost to you, regardless of whether your deductible is met or not.
  • Certain health services require a prior authorization (or pre-certification) be submitted to you insurance company before they can be approved as medically necessary. Except in the case of an emergency, you could be liable for covering the full payment if you receive these services without a prior authorization.

Know the Type of Plan

  • That 3 letter acronym can tell us so much!
    • Health Maintenance Organizations (HMOs) & Exclusive Provider Organizations (EPOs) often limit coverage to in-network providers, require selection of a primary care provider (PCP), and generally have lower premiums than PPO and POS plans. HMOs require a referral to see a specialist.
    • Preferred Provider Organizations (PPOs) & Point-of-Service plans (POS) offer coverage for in- or out-of-network care (with a higher copay for out-of-network care). Referrals are not required for PPOs, and are only required for out-of-network care with POS plans.
  • High Deductible Health Plans (HDHP) offer low premiums in exchange for higher deductibles. Many HDHPs offer a health spending account (HSA) to pay for qualified out-of-pocket costs.
  • Catastrophic Health Insurance plans have very high deductibles, and offer minimal to no coverage for prescription drugs or shots.
  • Your ‘metal’ tier determines about how much coverage you’ll have:
    • A bronze plan will give you about 60% coverage (leaving you responsible for the other 40% essentially)
    • Silver plans cover about 70%
    • Gold plans cover about 80%
    • Platinum plans cover about 90%

Read the EOB

  • Human error is always possible, as is error from the automated systems insurance companies use while processing claims. It is a great idea to read the explanation of benefits (EOB) from your insurance company thoroughly.
  • If a service is denied, call your insurance company; they can give you the reason for the denial. If it is inappropriate or you suspect an error was made, call the practice’s billing department.

Document Communication

  • Document your calls with the insurance company. Note the representative’s name, the reference number for the call, and the date and time of the call.
  • If you are attempting to appeal a decision, it is a good idea to send a letter to the insurance company (and save a copy for yourself). It takes a while longer to get a response, but this written record of communication is preferable to the sometimes unreliable notes the representatives at the call center take.
Become familiar with your plan. Most carriers offer websites full of information and resources. Many carriers now have apps which are handy and easy to use. If all else fails, there’s always the number listed on the back of your insurance card! You never know, you might end up speaking to someone who is as passionate about insurance as we are about medicine!

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