6 Things To Know Before Getting Angry With Your Health Plan

The NYT read the Consumers Union’s, “A Consumer Guide to Handling Disputes With Your Employer or Private Health Plan,” and here’s their distillation of how you can avoid out of pocket expenses and frustration by making sure you know the following:

  • What your deductible is…and if there are different deductibles for different parts of your health care…
  • What your co-payis
  • If your insurance company requires referrals from your primary-care physicians for specialists…or certain procedures…
  • If your insurance requires preauthorization for elective surgeries or other services.
  • If your insurance plan limits the number of visits to certain specialists.
  • …the policy on using a doctor out of your insurance network…

It may sound like common sense but this reporter got worked up after denied payment for stuff she thought was covered, only to find out she hadn’t yet met her deductible for a certain treatment.

Hands to Hold When Health Care Becomes a Maze [NYT]
(Photo: paul>)


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  1. Anonymously says:

    Find out if there’s a prescription drug limit.

    For example, the University of Pittsburgh’s supplemental health insurance claims that it’s a “means of protecting yourself against unexpected, unforeseen medical expenses that could temporarily or permanently interrupt your college career”, yet it has a $500 prescription drug limitation. $500 is hardly enough to cover someone who is diagnosed with a serious medical condition.

  2. cashmerewhore says:

    @Greg P:

    Better or worse, Ohio State’s student health plan is straight 80/20. Meaning the students have a 20% copay for all health services.

    Most people don’t understand the percentage copay is killer if you ever need anything more than a standard exam at the doctor’s office.

  3. uricmu says:

    @Greg P: Probably because the money doesn’t go to UPMC which is supposedly affiliated with the University… Biggest monopoly in the state and yet pays zero city taxes.

    On the bright side, you have four lifetime detox treatment, so you can go and overparty on Atwood St. every year… :(

  4. uricmu says:

    @cashmerewhore: I can only imagine. My fiance just came out of emergency surgery with four days in the hospital and she’s on an 80/20. God knows how much we’ll be slapped with.

    Having any insurance sometimes reduces costs because the insurance is charged less (e.g., 10$ for a blood count with a cent for drawing the blood, compared to 20$ for drawing and 300$ for the test). On the other hand, sometimes they slap in more because of the insurance.

    I’ve got tons of EOBs with overpriced UPMC charges that would have been out of my pocket if I did not have insurance. For example, some testing I recently did cost 4000$, but the insurance only had to pay 200$. Amazing markup and it’s those without insurance who’re screwed.

    We need national single-payer health insurance. This way, prices are negotiated to realistic costs.

  5. DrGirlfriend says:

    I work with health insurance at a large hospital. I cannot stress this enough: get to know your health plan, get to know what all the terms mean, get to know what your coverage is. If you don’t understamd something, call up the customer service line and ask. So many patients come in for potentially expensive surgery, for example, and have no clue what their coverage is. Then when I tell them something they weren’t expecting to hear about their coverage, they become upset at the plan, they become upset at their provider, but they don’t realize that their coverage is not dictated by their provider, or sometimes even by their insurance company: it’s dictated by what coverage your employer chose to purchase. I am often amazed at how little thought people give to something so important.

    For anything more than a routine dr’s visit, call your insurance company and ask “What needs to happen for this to be covered?” They will tell you if you need referrals, if you need authorizations, if you need to pay a deductible or copay, etc. Then you can verify with them that everything that has to be done, has been done.

  6. uricmu says:

    @DrGirlfriend: I thought that for anything larger than a routine visit that is not an emergency the hospital always seeks pre-approval from the insurance company first ?

    By the way, any idea how much a typical hospital inpatient runs per night? I’ve never managed to find a reliable estimate guide online. I realize it’s market to market, but I am guessing that the insurance companies have all some standard rate they’re paying in network

  7. bohemian says:

    I had our health plan send me on a serious of fools errands. My ortho said I needed this minor medical device. Insurance says it is covered but only if I get it at one of their two home medical stores, both located in the middle of nowhere.

    I drive to one, they don’t have it. Go to the next one on the opposite side of town. They tell me it isn’t covered. I call me insurance who has no idea why they told me it was covered the first time cause its not.

    If you ever get an issue of your insurance company constantly losing claims submissions and they happen to be in the same town as you do this. Get a copy from the clinic. Take two copies to the insurance company claims office. Insist they send someone from that department down. Give them one copy and require them to sign and date your copy showing it was received by them on that date.

    I had every claim doctors filed for months go missing, the insurance company claimed they never got it. One of the clinics tipped me off that this insurance does this all the time to avoid or delay paying claims. After my in person submission they quit “losing” my claims submissions.

  8. melmoitzen says:

    Let’s say you work for Company ABC, your health plan coverage through work is through Insurer DEF.

    With larger employers nowadays, the insurance rates you pay typically reflect premiums collected by DEF from ABC, adjusted for claims made by ABC employees. Which essentially makes ABC self-insured, and usually gives them the power to make (and bend) the rules DEF is putting in front of you.

    When you feel you’ve exhausted your appeals with DEF, work your way up the ladder with the benefits folks at ABC. We were able to get coverage for something major that DEF said we’d never get approved by going through ABC.

  9. sassypizzazz says:


    Sorry, there’s no standard. I worked for a health insurance company as a claims adjustor. As far as inpatient goes, the cost depends upon why you are there. For example, many hospitals charge a different inpatient rate for labor and delivery versus heart surgery. And another different rate for knee surgery, etc. Again, it just all depends on why you’re an inpatient. So, I think that’s part of the problem. No two hospital contracts (and by contract I mean the reimbursement contract between the hospital and the health insurance company) are the same.

  10. cashmerewhore says:

    [Ohio hospital services rates]. Google your state plus hospital pricing. Many states are posting them. You’d be surprised how pricing can vary from public to private hospital, educational or non. This way, if you’re on an 80/20 plan you can see an average for standard services (like birth, cesearian vs. vaginal), but please don’t bitch when you have complications and your bill is more than average.

    This list includes many common procedures, both inpatient & outpatient.

    It’s hard to provide an average cost of hospital stay because some people with organ transplants can get out relatively quickly, and rack up hundreds of thousands of dollars in medical bills. Certain hemophilia drugs are expensive.

  11. cashmerewhore says:


    I don’t know what financial situation you’re in, but many hospitals provide free or discounted care. Ask any finanical counselor/customer service rep at the hospital for an application. Worst case is you can set it up on a payment plan, most do not charge interest for non “bad debt” collections.

  12. Anonymous says:

    I fully agree with these points. Let me add one more: confirm the network participation of everyone you deal with.

    Let me preface this story with stating that I’m an insurance professor teaching in a college setting that formerly did employee benefits consulting. They still almost got me.

    We are in a BC/BS HMO plan.

    My wife needed an MRI, which we knew needed prior approval. So we got a referral to the network hospital along with the pre-approval for the procedure. She got the MRI, which was covered for $5300 or some amount. However, I got an EOB and a bill for $710, because the radiologist, associated with the in-network hospital, was out of the network. Since we are in the HMO, there is no out of network benefit. Not good. After much kicking and screaming, the radiology firm and/or the hospital ate the charge.

    More research led me to understand that non-network specialists working in network hospitals is not uncommon among radiologists, anesthesiologists and emergency room physicians. Or, exactly those people who deal with you during times you are most likely to not confirm their network status.

  13. uricmu says:

    Speaking of health insurance companies, make sure to review your denials and the denial code.

    One time I had a routine x-ray, and I got a rejection because I was from “the wrong gender”. Turned out that they typed in the wrong procedure code for some female-only thing (a pelvic or a pap, don’t remember). The insurance claim reviewer, rather than look again and fix the mistake, simply figured out that I was trying to get a free pelvic (yay) even though I’m a guy, and rejected the claim.

  14. Indecision says:

    @Greg P: “$500 is hardly enough to cover someone who is diagnosed with a serious medical condition.”

    Heh, you’re tellin’ me. I was diagnosed with cancer recently, and underwent radiation therapy. I was prescribed pills to treat the nausea that radiation therapy causes. (Note the pills didn’t treat anything directly related to the cancer, they just stop the radiation sickness.)

    I needed three pills a day, 5 days a week, for three weeks. The pills were billed to my insurance at $70 each. That’s $3,150 worth of pills. Just to keep me from constantly feeling like I was going to throw up. I would have blown through that $500 limit in about 2 days.

  15. @uricmu: “I thought that for anything larger than a routine visit that is not an emergency the hospital always seeks pre-approval from the insurance company first ?”

    It depends. You might have to tell the hospital to seek approval or not. The hospital sort-of doesn’t care because it gets to bill you either way.

    My insurance doesn’t give a rat’s ass if I get things pre-approved. The only thing they require pre-approval for is psychiatric admissions, although they prefer that if you’re pregnant, you call them at some point in the 9 months before you give birth … but even that’s not a deal-breaker. (Not that my insurance isn’t a bunch of rat bastards about not covering anything, but they don’t require pre-approval to not cover it!)

    This is a pretty popular plan around here, so our hospital really doesn’t bother with pre-approval. If you need pre-approval, it’s your problem.

  16. bigvince1981 says:

    I’ve come up with a pretty accurate way of predicting my medical expenses. I just take whatever I’m *told* I’ll be charged and double or triple it. That way, I’m at least emotionally (if not financially) prepared when the bill comes.

    I’ve been doing this ever since my wife was pregnant and both our doctor and our insurance company told us that out of pocket expenses for *the entire pregnancy* (including anesthesiologist, hospital fees, doctors fees, etc.) would be around $1500. My son is now 5 months old and we’ve forked out about $5000.

    The hidden bonus is that occasionally someone in the healthcare/insurance industry tells you the truth and you are pleasantly surprised when you get the bill.

    It’s totally jacked up that one visit to the hospital or doctor’s office can generate 5 or 6 bills, all from different people. The provider should be solely responsible for collecting on anything that occurs in his/her office. Let the labs, technicians, and other nameless medical goons bill the provider and let the provider sort out all that paperwork.

  17. Consumerist Moderator - ACAMBRAS says:

    The insurance claim reviewer, rather than look again and fix the mistake, simply figured out that I was trying to get a free pelvic (yay) even though I’m a guy, and rejected the claim.

    As a woman, I can tell you that you didn’t miss anything awesome.

  18. Anonymous says:

    It is very difficult to know what your insurance covers and does not cover. There are so many exceptions, and odd situations where things apply and do not apply. Its almost impossible to know it all. The best plan is simply to call EVERYTIME you are not sure. Thats what I have had to do.

  19. uricmu says:

    @Consumerist Moderator – ACAMBRAS

    I’ll take your word for it :)

    Admittedly, as part of my first checkup my new GP told me he would like to do a “digital prostate exam”. Being a computer person and having never had said exam I was foolish to assume that “digital” meant some cool high-tech device. Turned out it was slightly more analogue, if you’ll excuse the pun.

  20. uricmu says:

    @Indecision: And the sad part is that the real cost to the provider is probably like 3$ a pop.

  21. uricmu says:

    @bigvince1981: I agree.
    What’s worse is that sometimes you’ll do something at an in network provider (hospital, doctor, etc.), but somewhere down the chain (E.g., the guy reading your xrays) there’s somebody who’s out of network.

  22. Consumerist Moderator - ACAMBRAS says:

    LOL — yeah, “digital” is not necessarily high-tech, especially if it involves latex-gloved digits.

    That makes me think of all those prescription drug commercials on TV that warn of all the complications that can be brought about by an enlarged prostate. The hypochondriac in me starts to worry if my prostate is enlarged. Then I realize I don’t have one. ;-)

  23. juri squared says:

    Keep these in mind when signing up at work, too, should you have that luxury. We found out the hard way that the mental healt segment of our health care plan had wildly different rates than the main plan.

    Also, I don’t know if this is common or underreported or what: the hospital where I recently gave birth has a Patient Advocate Program. It’s mostly for the uninsured, but we were told they could help us out with our insurance mess (due to very unfortunate timing, my insurance coverage switched while I was in the hospital).

  24. Notorius_VMG says:

    When I talk to the insurance company in advance to find out if certain procedures will be covered, I have to sit through a recorded message that basically says that “there is no guarantee of payment.” It sounds like I shouldn’t believe anything they might tell me. When I speak to a rep, even if you have a list of codes, they are not very patient in looking them up for you. I have been told that “everything is covered,” only to find out later that certain procedures were not. Then, when you begin the appeals process for denial of claims, you go through another round of “even though we are granting the appeal, this notice does not guarantee payment” I have had 2 appeals granted, but getting reimbursed for them was like pulling teeth.

  25. mconfoy says:

    @Indecision: And to think pot, I mean medical marijuana, would have been cheaper and worked better. Glad we let the DEA make medical decisions in this country.

  26. Agent Cow3.14 says:

    I work at as a tech at a pharmacy, you wouldn’t believe how many people don’t know what’s on their formulary or even what a formulary is. It’s a list presented to you by your insurance company listing your drugs in categories of preferred, non-preferred, and non-covered drugs. So before you blow up in the face of the poor pharmacy worker in front of you, may be ask your insurance to send you a formulary before you find out you have to pay $300 on that single prescription, please.