Professional Patient

Never Never : Self-Pay When You Have Insurance

I have learned the hard way to never, never self-pay when you have insurance. Last April, my husband started a new job and got new insurance, but it took a few weeks for us to be entered into the system and receive our insurance cards. So for a few weeks, I could not prove that I had insurance to doctors' offices that needed to know. And I happened to have a very expensive appointment to keep with a neurologist to do nerve testing. When I say very expensive, I mean it: $4,000. And of course, the doctors' office insisted that I pay up front for everything because they could not verify that I had insurance.

I should never have blithely put that $4,000 on my credit card! Almost 14 months later, they still haven't given all of my money back to me. I did eventually get an insurance card that proved that I was covered by health insurance the day of the tests. And the doctor's office did eventually bill the insurance for the charges related to that appointment. But it has been like pulling teeth to get them to give me my original $4,000 deposit back. First, the doctors (this was a hospital visit, so there were people from multiple departments involved) had to bill the charges to my account. Which took up to 6 months! Crazy. Then the billing office had to ask my insurance to cover the billed charges. Which took many more months. Then the billing department had to process the payment from my insurance and post it to my account. Then they had to release my original payment in bits and pieces as "credits" to my account. Which I then had to call and specifically ask to get paid back to me! And because of some billing/accounting issue, they have to process repayments to me as checks... which takes several more weeks. 

Almost 9 months into this game, I had recuperated about $3,000 of the $4,000. But there was $900 or so that seemed to have disappeared altogether. After driving the billing coordinator crazy with calls about it, she mailed me a 50-page ledger of billing activity for my account. After weeks of staring at it, I figured out that $900 of charges were never sent to insurance... so I would have no chance of getting that money back until they did so. After convincing the doctor's office that they needed to bill those charges to insurance (they thought they had, and that my insurance had denied the claim altogether, but I had no explanation of benefits showing that, so I knew they were incorrect), I've been waiting a few more months. And finally, last week, they agreed to send me my last $800. I say $800, because along the way, about $100 has disappeared. And I'm too worn out to go find it!

Of course, I'm still waiting to actually receive the money back. Wish me luck!

What can you do if you find yourself needing medical care at a time when you have insurance, but can't prove it (because you don't have a card yet and aren't listed in the health insurance company's system)? Just DON'T do it. Don't pay for the appointment. Wait if you can. I could have waited a few more weeks for my neuro testing. And should have. Or you can work out some kind of payment plan with the doctor - pay 20% up front and 20% for each month thereafter. (In the amount of time you will need to pay off the bill, you will get the insurance card in the mail and can have the doctor bill your insurance instead. So you will be fighting with them to get your original 20% back, but probably nothing more than that.)

And please do go to the ER for emergency care if you need it. Your life is that important! And ERs won't ask you to pay up front if you're in dire need of care.

Hidden Treasure on Carefirst.com: Full Policy Manual, Including Medical Basis for Coverages

In doing health-insurance related research online today, I stumbled across an amazing resource: a full, in-depth "policy reference manual" for CareFirst insurance plans. The manual is so complete that it explains the rationale for approving/denying coverage for any and every medical treatment you might possibly want. It also cites medical evidence that guides the policy's stance on covering or not covering a particular item/service. And the manual is searchable by keyword! You don't even have to wade through the entire file to find the one line of text you are interested in.

Oddly, this policy manual is NOT where patients like me would normally look for it. No, instead, it is shoved in the "Providers/Physicians" area of the CareFirst.com website. (View the online Medical Policy Reference Manual for CareFirst health insurance policies.) The manual is a really interesting way to see the rationale for coverage. Looking at the manual would help you understand how hard you might have to fight to get a particular treatment approved as being "medically necessary."

Do not, however, rely on these "policy reference manuals" to determine whether your health insurance plan covers a specific medical treatment or service. These "policy reference manuals" state the health insurance company's general opinion on the medical validity of certain treatments and services. You cannot be 100% sure that the information given in these online manuals matches what your specific health plan will cover. Your specific health plan may still choose to cheap out and not pay for certain treatments that the policy manual considers medically valid. For example, a CareFirst PPO plan that costs a fortune might offer the highest level of service, paying for routine physicals because they are a medically valid way of preventing later disease (diabetes, heart disease, etc.). A less expensive CareFirst HMO plan that offers a lower level of service might not cover routine physicals because they are just cheap bastards. If you want to know if a treatment or service is offered by your specific health insurance plan, you always want to check with the customer service team for your health insurance plan. And you might also want to to get a copy of the Summary Plan Document for your specific health insurance plan.

Can you find your insurance company's overarching policy manual online? You won't know unless you try. Go to the insurance company's website and look in the Physician/Providers section. Or try using the site's search box to hunt for "medical policy manual". You can also Google the phrase "medical policy reference manual" or "medical policy manual" and see if your insurance company's policy manual is on the Google results list. Using this Google tactic, I immediately found the medical policy manual for Blue Cross/Blue Shield of Tennessee, and policy manual for the Arizona Health Care Cost Containment System.

Happy hunting!

Making Sure Your Doctor Accepts Your Insurance and Is "In Network"

Last week, I got caught in a terrible snafu about whether one of my doctors is really "in network" for my health insurance plan. It's going to cost me $300. Expensive mistake.

I have a managed care health plan and dental plan, which means I can't see just any doctor. I have to see one who is "in network" for my insurance. If I stay in network, I pay a small copay for the doctor's visit. If I don't, the insurance pays a little money to the doctor, and the doctor bills me for the rest.

The secret to success, then, is to find doctors who are in network. How?

1. Call the doctor's office and ask their billing person if they accept your health insurance plan.
2. Call the insurance company (or use their website) to determine if the doctor is "in network". The CareFirst insurance company, for example has a "find a doctor" feature on their website that will tell you which doctors are in network for CareFirst insurance plans.

To be absolutely sure, you should do both step #1 and step #2. It sounds simple. In fact, it should be simple. But sometimes things get messed up!

Case in point: my problems last week.

In my expensive mistake, I called my new dentist and asked if they accept my insurance (step #1, above). They said yes. Then a few weeks later, I got an explanation of benefits from my insurance company showing that the dentist is actually not in network. (Learn more about explanation of benefit statements in my earlier post "What's An Explanation of Benefits?")

Fudge! I called my dentist to ask about it, and they changed their tune and said "Oh gosh, I guess we don't take that plan." So asking if a doctor "accepts" your insurance is different from asking whether they are "in network". Don't make my mistake.

I also failed to do step #2 (above) and check with the insurance company to confirm that the dentist was in network. If I had done that before the appointment, I would have in fact learned that the dentist was not in network. Damn.

Some caveats to my advice: Calling your doctor to ask if they are in network is risky because the person who answers the phone may give you incorrect information. Contacting your insurance company to ask if your doctor is in network is risky because the insurance company's listing may not be up to date. Doctors drop out of plans (and thus become out of network) all the time, and the insurance company representatives and/or website may not have current information.

So yes, it is a little bit of "damned if you do, damned if you don't". You may get hit with bad information once in a while. And unfortunately, it may cost you money.

In my case, it is breaking my heart that my dentist is not in network. I really liked him! But he is gonna get one heck of a complaint letter from me... his people have got to learn which insurance plans they are "in network" for, so they can give new patients accurate information!

Managing Referrals and the Billing Process to Prevent Unpleasant Surprises

In HMO/POS style health plans, "referrals" are the golden ticket you must have before you can see a specialist. They are also the main reason for billing errors that can cost you hundreds or thousands of dollars in out-of-pocket expenses each year. (In 2006 alone, I was asked to pay more than $1200 extra, out of my own pocket, because of referral errors.) Here are some tips and tools for managing referrals and nipping referral-related billing problems in the bud. Before the medical bills even make it to your mailbox.

What is a Referral, Anyway?

Referrals are just special pieces of paper used by your health insurance plan. When your primary care physician decides that you need to see a specialist (any non-primary-care doctor who is "in network" for your health plan), he/she writes a "referral" to that doctor. View sample: Maryland Uniform Consultation Referral Form. These referrals authorize you to see an in-network doctor, beginning on a specific date, for a certain number of appointments or certain amount of calendar time. Once you use the allotted number of visits or go past the expiration date on the referral, you must call your primary care physician and request a brand new referral to the same specialist.

How Do Referral Problems Cost Me Money?

Referrals can easily become a source of billing problems. Your primary care doctor (PCP) sends a referral to your specialist, who then sends it to the health insurance plan. Problems arise when the referral gets lost along the way and never makes it to the health insurance plan. If the referral doesn't make it, your health insurance may bill you for an "out of network" visit. For many of us, this means the difference between paying between $5 and $25 for an appointment and paying between 20% and 50% of the entire cost of the appointment. Sometimes, the insurance plan will even bill you for 100% of the cost of the appointment (it shouldn't happen, but it does anyway).

How to Manage the Referral and Billing Process

Getting the Referral

1. Your PCP will tell you he/she wants you to see a specialist and give you that doctor's name and phone number.

2. Call the specialist's office to schedule the appointment. During the call, confirm that the doc still is "in network" for your health plan. If he/she is not, do not make an appointment. Head back to your PCP and get the name of a doctor who is in network.

3. Call your PCP's office and request a referral to the specialist, asking the referral to start on the day of your appointment with the specialist. Make sure your PCP has everything he/she needs for the referral... the specialist doctor's name and address, phone and fax, date of your appt. with him/her, and the reason/condition for the referral.

Ensuring that the Specialist Receives the Referral

1. When you request the referral, ask your PCP if he/she will fax it to the specialist's office or mail it to the specialist.

2. A day or two before the appointment, call the specialist and confirm that they have the referral.

3. At the appointment, while you are checking in, confirm (again) that the referral is already in your file. If it isn't there, explain when/how the referral was sent, and ask where it might have been misplaced in the office. If they can't find it, call your PCP and ask them to fax it to the specialist right away.

After the Appointment: Monitoring the Billing Process

1. Two to three weeks after your appointment, check the status of the claim. Call your health insurance plan's customer service number and ask about the status of the claim (you will need to give the customer service rep a date of service, i.e., the date of your appointment). Or go online (if that's an option) and check the status of the claim.

2. If the claim is denied, ask why. Typically, the answer will be that they (your health insurance plan) did not receive the referral from your doctor. Ask who you can send the referral to (get a name and specific fax number or mailing address). Then call your PCP and ask him/her to re-send the referral. **

3. Two to three weeks after re-sending the referral, check the status of the claim. If necessary, repeat the previous step. Keep at it until you get the claim correctly paid or your insurance company tells you the REAL reason they won't pay the claim (sometimes, we as patients make errors). It can take two, three, four, or more rounds of re-sending the referral to get the claim paid correctly. Don't give up.

**Sometimes, someone in your specialist's billing department will be able to call the insurance company and re-send the referral for you.

Miscellaneous Referral Tips

• Sometimes, primary care doctors will hand you the referral and ask you to physically take it to the doctor on the day of your appointment. In this situation, you may want to make a photocopy of the referral for your own records. You never know when you might need it again.
• Consider having your PCP mail you a copy of each referral. That way, you can send and re-send the referral without bugging your PCP.
• Referrals are good for a limited number of months or visits, starting on a specific date. Ask your PCP for the info. you need (start date, number of visits, end date) to track your use of the referral. You can use something like my Referral Tracker form to stay on top of the details. You can view a sample use of the form in my Referral Tracker Sample document.
• If you are dealing with a large hospital in which you are treated by a student (a graduate fellow) who is overseen by an attending physician, consider writing the referral to the general department (e.g., Hopkins Dept. of Rheumatology). If your health insurance plan requires that the referral include a specific doctor's name, call the hospital a few days before the appointment. and ask who the "attending physician" (i.e., the real doctor in charge) will be on the day of your appointment. Then have your PCP modify the referral (if necessary) to include the attending's name.

What's an Explanation of Benefits (EOB)?

Your health insurance company has probably sent you an explanation of benefits (EOB) at some time. You might have thought it was a bill, but it's actually a vital tool for tracking your health care expenses.

EOBs explain why and how the fee for a doctor appointment was paid or not paid. They provide an important record that you can use to

• claim reimbursement from your flexible spending account, and/or
• claim health costs as an itemized deduction on your annual tax bill.

EOBs are byproducts of the whole health-plan-billing mess. How it works:

• Your doctor charges you a certain fee for an appointment.
• You pay a copay--part of that fee amount.
• Your doctor asks your health insurance company for reimbursement of the rest of the fee. His office will do this by filing a formal claim.
• The insurance company agrees to pay a certain portion of that fee.
• The doctor/health insurance company agree to write off any remaining portion of the fee, or in some cases, to bill you for that remaining amount.

An EOB is the piece of paper that tracks all of this who-pays-what action. The EOB is a record of the fee the doctor requests, the copay you pay, the amount the insurance company agrees to pay to the doctor, and any remaining amount to be written off or billed to you, the patient. An EOB looks a lot like a bill, because it is a detailed account of the billing process.

The EOB also includes information about why a claim was paid (or not), and how to dispute a denied claim. The State of New York has a great Web page that outlines the basic pieces of information that must appear in an EOB.  

No matter who you are and what health insurance plan you have, the insurance company will create an EOB for every doctor visit you make. Whether you get to see the EOB is another matter.

Different Plans Have Different EOB Processes

Health insurance plans may or may not show you the EOBs for every doctor visit you make.

Some plans let you view EOBs for every appointment. UnitedHealthCare, for example, mails paper EOBs to you, and/or lets you view them online. A few plans, like Alaska's AlaskaCare plan, send you a monthly summary EOB. (Read more at http://www.state.ak.us/drb/ghlb/eobs.shtml).

Other plans only send you EOBs in special situations. For example, Cigna sends you an EOB only for doctor visits for which you will pay extra money (beyond your up-front copay). View Cigna's Explanation of Benefits information page.

Still other plans keep electronic EOBs that you do not see. For example, New Mexico's Presbyterian Health Care will only send you hard copies of the EOBs if you call and request them. They will mail the printed EOBs to you, but they will charge you a per-page processing/printing fee.

Know Your Coverage: SPD, not SPF

With sunscreen, you can look at the bottle and know what kind of coverage it offers. With health insurance, it's not so easy. Every time you have a chance to sign up for a health insurance plan (when you start a job, or experience a life event, like getting married or having a baby), you have to weigh the choices and pick the best possible plan for you.

Health insurance companies, like United Health Care, Cigna, Blue Cross,  and Aetna, often produce slick brochures that give very vague details about what exactly is covered under a certain plan. But you need to know more. Before you sign up!  What can you do?

Every health plan has what is called a Summary Plan Document or a Summary Plan Description, referred to as an SPD. An SPD  provides a comprehensive list of everything that is and is not covered under a given health plan. SPDs  can be hundreds of pages long. (In fact, there are professional writers who produce these things for a living.) When you read an SPD, you may feel like you are wading through a bunch of legal mumbo-jumbo. Hang in there and don't give up. In  an SPD,  somewhere, you can find the minute details about which services are covered.

SPDs are difficult to get your hands on (most health plans and employers don't tell you that SPDs exist). To get the SPD for a health plan you are considering,  you may have to call the insurance company and request it. Or, you may have to go to your job's benefits office and request it. You never know which route to take, so try one, then the other.

Insurance plans are so complex and expensive that you should not pick one blindly. Get the SPD. Read it. Know your coverage--before you sign up.