I’m still on my health insurance rant. How many ways can the health insurance system screw you? If you’re a health insurance user, chances are you’ve been scammed, duped, or basically not given the coverage that you paid for because the health insurance system in this country has been intentionally/unintentionally designed to make sure that you won’t know how to use it and getting enough reliable information to avoid costly errors is practically impossible. (Help fight this by choosing the most cost-effective health insurance for you with some of these comparison spreadsheets.)
Here are five things I’ve learned about when dealing with health insurance:
#1 Health insurance representatives and provider office personnel often give wrong, different, or incomplete information
How are you supposed to know what information is correct if you get different information depending on who you talk to? What’s worse is that, you then usually make financial or health decisions based on this incorrect information.
If you ask about coverage benefits, the health insurance representative may forget to tell you that your deductible applies. I have been told over the phone that services from an out-of-network provider are covered 100% (no deductible mentioned). Only to find out after the claim has been denied and 15 phone calls later, that our deductible needed to apply first. Perhaps someone could have told me when I asked the first time? Get a summary of the plan benefits sent to you. Better yet, make them send you the long detailed version and look up the answer to your question. Don’t rely on over the phone answers.
The provider’s office has also on occasion told me that they are out of network, even when I was able to find them in the online in-network provider directory and then confirmed it with a health insurance representative. In those cases, you can now get a confirmation number of the phone call along with a record of the call content. However, you have to ask for it.
# 2 Services performed by in-network providers may need coverage by different types of insurances or may not be covered
Well, I didn’t know this was possible, but after being billed for the refraction portion of a visit to the ophthalmologist office, I discovered that you may need to break down claims to submit different portions of it to medical insurance and vision insurance. However, you have to figure this out in ADVANCE so that YOU can tell the eye care provider’s office which doctor will be allowed to perform which service on you.
These days, many eye care offices house ophthalmologist, optometrists and eye care shops in the same location. We needed to check on the sudden onset of myopia (therefore the need for an ophthalmologist), but checking the eye problem also involved the need to check vision, a refraction service which could be performed by either the ophthalmologist or the optometrist, both of which performed services on my son at the same visit.
However, it turned out that we were only covered if we had the optometrist perform the refraction. So although the optometrist was seeing my son at the visit, the ophthalmologist happened to perform the refraction. Therefore, we had to pay for the refraction out of pocket. Make any sense? Somehow, you really need to do your research before you go to any doctor. I’m sure this happens in many doctors’ offices. However, I bet you the doctor’s office won’t be able or willing to help you much when you ask questions BEFORE a visit. Who’s screwed? You’re screwed.
# 3 Surprise billing
They’re finally doing something about this “surprise billing.” I have an Explanation of Benefits (EOB) that now actually states what to do if you receive a “surprise” bill – they’ll try to help you fight it. In fact, there was even a recent article in the Atlantic about this, stating, “A fifth of U.S. patients get surprise bills from surgery—even if their surgeon and hospital are in-network.”
Surprise billing occurs when you are receiving a medical service from an in-network provider and, unbeknownst to you, part of your service is performed by an out-of-network provider. You will receive a “surprise” bill for that portion of the service. This could be $150 or lots of $$$ depending on the service.
Two examples of situations where this might happen: 1) you’re getting lab work done at your in-network provider, but without notifying you, they send the lab to an out-of-network lab to perform some of the tests. This happened to me. 2) You’re getting surgery and the work has been pre-authorized by your insurance as in-network covered services. However, maybe the anesthesiologist or another doctor who does a little work on you (while you’re out cold) happens to be out-of-network. You get the bill for the out-of-network services.
#4 FSA or HSA – not both
Maybe a lot of you knew this already, but not me. You can only have an FSA or HSA – not both. (However, you can have a limited purpose FSA that’s for vision and dental expenses only and HSA together.) We signed up for an FSA at the beginning of the year. Mid-way through the year, we had a job change and had to change insurance plans. We looked at the HSA and discovered that was a good option for us. BUT guess what, since we already had an FSA for the calendar year, we were not allowed to enroll in the FSA plan. And we were not allowed to cancel the FSA, in order to enroll in the HSA. No double-dipping, but you gotta read to figure this out because no one will point this out to you.
#5 Administrative labyrinth
I’m not sure if NOT getting to enroll in the HSA was actually a blessing in disguise. HSAs (and to some degree FSAs) are for those who are extremely good at keeping receipts, completing paperwork, reading the fine print, following up when claims get denied, resubmitting receipts, making phone calls that last 30 minutes each (at least), and a plethora of time to do these things. The administrative labyrinth also applies any of the problems mentioned above. You know yourself. Are you going to have the time to follow up on all of this (because you will inevitably have to)? Otherwise, it’s $$ to Uncle Sam or cash you can never use.
Or if you don’t care about getting screwed – you can just save yourself time, and know you’re probably getting a bad deal with your insurance. But I say, keep calling them, keep irritating them, send your horror stories to the media, or we’re all going to have to deal with this miserable system forever.
Do you have more to add to my list? Send them over!