Avoiding Health Insurance Pitfalls - 5 Simple Steps to Get Your Insurance Claim Paid


While many clients and friends have now signed up for coverage for 2015 many more are still dealing with the idea that their Blue Cross or Aetna coverage was terminated and they haven't found replacement coverage.  We can help you review the universe of health insurance options and determine which plans would be best for your family.  Contact Us today for quotes and analysis.

For years, Texas Health Design has educated clients to ensure that when they need coverage, they know exactly what to expect and what steps to take to ensure that they don't run into problems getting claims paid.  We often hear from new clients that their past experiences with health insurance companies have been terrible and we feel strongly that many of their issues result from a lack of understanding of their specific policy and a broader knowledge of "how things work" with insurance.  After working with insurance companies for more than a decade, we've seen random, crazy, and illogical denials, but more often, we see issues where clients fail to take simple steps to avoid problems.  The goal of this brief post is to ensure that we know basic steps to get the most out of our coverage.

#5 - Check the Insurance Company's Doctor List - Never Go Out of Network!

The number one complaint that clients have had in the past is that clients they have seen a doctor that is out of network.  There are several reasons this may happen.  First, a patient simply doesn't check their insurance company's provider or doctor finder and schedules an appointment.  The result is that the office visit charges are high and any tests or examinations are also unpaid by the insurance company.  This problem has been reduced in the last several years as many physicans' offices call for pre-authorization of benefits and determine that they are not in-network.   The biggest take away for clients is that they cannot purposefully go out of network.  Some clients think this isn't a big deal, but in our mind you must stick to in-network providers only.  Many HMO networks like Blue Cross' Advantage HMO now do not offer any benefits if you venture out of their provider list. 

We've reported problems recently with the Cigna Local Plus network where clients have found providers in-network on the provider directory, called their physician to confirm the doctor takes their plan and is in-network.  The offices have pre-authorized coverage, but after the visit, have reported to clients that they are "out-of-network".  In this case the client must scream and fight with the doctor as we feel strongly that they are simply deciding not to take Cigna and their new lower reimbursements in the Local-Plus network.  We've had mixed success where physician's offices have waived all charges except for the co-pay that was collected at the door.  This is truly frustrating and has been a big reason we have significantly reduced the use of Cigna plans for our clients in 2015.  When we can't trust that a plan will be accepted by a provider, we cannot recommend the insurance!  In summary, you need to check the provider list and find your doctor.  Follow up with a phone call to ensure they take your specific plan.

#4 - Drug Formulary Lists are Important

Several times a year we'll get phone calls from clients that are frustrated that their medications are so expensive.  Many of these issues revolve around the fact that clients are taking very expensive brand name drugs that you might see on television in advertisements.  Many of these "push marketing" drugs are either not on insurer's formulary lists or are non-preferred.  Make sure to speak with your doctor about alternative prescriptions that are generic or made by another manufacturer.  Also make sure to take the time to communicate with the doctor or their nurse to go through the formulary list in the physician's office to find drugs that will be more affordable.  You might also consider changing health plans if you have a very expensive medication that could be covered by a co-pay if you were to improve your plan.  We see this many times with drugs like Humira and Vyvanse which could cost as much as $1,500 a month or $225 a month.  If clients were to transition from those high deductible plans to a more expensive plan that offered drugs with co-pays we often see considerable savings.  Call us at 713-422-2935 and we'll review your plan and medications to ensure we optimize the plan you have based on the way you use your coverage.

#3 - Pre-Authorize

I typically feel like falling out of my chair when I hear a client has had a problem with an insurance provider because the carrier didn't pay for a scheduled surgery.  First we ask, "Was the doctor in network?"  Next, we ask if the facility was also in network?  Once we've asked those questions we get to the big one, "Did you and your doctor get approval for the surgery and confirm a claim would be paid?"  Unfortunately, the answer is often, "No".  This situation is entirely avoidable and always a result of the patient assuming that having an insurance policy equates to a blank check.  We all know that policies have lots of exclusions and limitations, so it is important to make sure that you call your insurance well before the scheduled procedure and also make sure that the physician gets pre-approval prior to moving forward.  Personally I had a situation where our insurance carrier declined my scheduled surgery and it took my doctor's office more than 3 conference calls and many hours of documentation to get an approval.  I would not have had the surgery without the approval since it would have cost $30,000.  You cannot assume that a prescribed surgery or service is approved just because a doctor orders it.  You must engage with your insurance company to avoid paying costs out of your pocket.  Why risk it? 

#2 - Don't Clam Up - Talk To Your Doctor

I personally have experienced this many times in my life.  I sell health insurance for a living, talk about claims and the insurance process all day, and then go to the doctor and act like a sheep and say very little when I'm at the office or the hospital.  Admit it, you do the same!  I want to challenge you to stop your docile behavior and begin managing your own care when you go to the doctor.  Gone are the low co-pay, low deductible days where we could see a physician or have a surgery and pay a few hundred dollars for a procedure.  Current health plans require us to pay thousands if we have an event or have any significant procedure.  Because we are now paying more, we must be more vocal and direct the doctors and their staff on how to handle your claims.  I know, you are stunned that I'm challenging you to tell your doctor how to handle your affairs, but the truth is, you must!  Doctors are good at treating your illness and also possibly running their business, they don't necessarily have the knowledge, time, or skill to help you reduce your costs when you receive services.  I have identified several areas where we must gather our courage and tell the doctor's office how to handle our claims.

  • When having diagnostic tests, tell them they must send it to an in-network lab.  How many times has a nurse taken a blood sample or a dermatologist cut something off you for a biopsy and sent it off to some place?  Unfortunately, I've seen many instances where the "someplace" is an out-of-network lab.  When doctors use an out of network lab you are at the mercy of that lab and their schedule of charges.  In today's environment, you could have a plan that won't pay for out-of-network services.  When your physician orders labs, speak up and demand that they send it to an in-network lab facility.  If not, you could be writing expensive checks!
  • We've had good success over the years coaching clients to remind them that they must tell their doctor that they have a high deductible plan and thus are paying most of the bill out of their own pocket.  Why is this successful?  Many doctors are so busy seeing patients that they never consider the impact of all those marks they are putting in your file.  For each "mark" there is frequently a corresponding charge for services he is performing.  We had one client years ago that went to a dermatologist to have several moles or warts removed.  Luckily, we had visited with the client prior to the procedure and we asked him to share with his doctor that he had a very high deductible plan.  After the procedures were performed our client bravely told the doctor that he was paying for much of this out of pocket because he had a high deductible.  Immediately, the physician removed 4 of the removals and billed the client for only one wart.  Communicating to the doctor what you want and what you need can only help you reduce your costs!

#1 - Don't Assume Everyone and Every Location Is In Network (Balanced Billing)

The scariest thing about the health insurance system is that we just don't have control as patients.  We can do everything right and make every effort to confirm that doctors and surgeons are all in-network and still be shocked to receive staggering bills that are from providers we've never met and are not in our insurance network.  Texas newspapers have been reporting the problem of balance billing for several years and hopefully the Texas legislature will actually write and pass some useful laws that protect Texans from this terrible practice.  "Balanced Billing" is a process where a patient has a visit to the ER, a surgery, or other service and is seen by out-of-network providers.  The out-of-network charges can be hundreds or even hundreds of thousands of dollars.  Most of the time these out of network providers are seeing you in an in-network facility like a hospital. 

Here is an excerpt from the Texas Department of Insurance website - Balance Billing 

What is balance billing?

Balance billing occurs when physicians or other providers and hospitals or facilities who are not contracted with your HMO or preferred provider benefit plan (often referred to as a "PPO") bill you for the difference between the amount your health plan pays them and the amount the provider or facility believes to be adequate reimbursement.

For example, assume you visit the emergency room at a hospital that is contracted with your health plan, but the emergency room physician involved in your care is not contracted with your health plan. The emergency room physician and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The hospital, which is contracted with your health plan, may only bill you for your appropriate copayments, deductibles, and coinsurance amounts under your plan. It may not bill you for the additional amount not paid by your health plan. However, the emergency room physician, who is not contracted with your health plan, can bill you for the appropriate copayments, deductibles, and coinsurance amounts and for the remaining $600.

What can you do about balance billing?

Make sure your health care providers and facilities are contracted with your plan.
The most important thing you can do to prevent being balance billed is to find out in advance whether your health care providers, including hospitals, clinics, and other facilities, are contracted with your health plan. This is important because contracted providers are prohibited from balance billing you for anything over their contracted reimbursement rate for covered services and for anything other than copayments, deductibles, and coinsurance on covered services.

This is especially significant in the case of facility-based physicians who may become involved in your treatment, such as radiologists, anesthesiologists, pathologists, emergency room physicians, and neonatologists. Remember that even if a facility is in your health plan's network, some physicians who provide services there may not be. You may be able to prevent balance billing by asking that a contracted provider be assigned to your care. In certain circumstances, this option may not be available to you. For example, a hospital might contract with a group of doctors who are not in your network to provide emergency room care.

Additionally, find out whether the services you will be receiving are covered under your health plan. If the services are not covered, you will be responsible for all charges.

Here is another story related to the problem of balance billing.

High Medical Bills - Houston Chronicle

Clearly you can see the problem as a patient may do everything in their power to get to the right facility and pre-authorize services only to have an out of network anesthesiologist sit in your surgery and charge thousands of dollars above and beyond the negotiated rates of the insurance provider.  I've had clients that have used sleep-study centers that were in network only to find that the attending physicians contracted by the facility were out of network!  You also need to be concerned anytime your physician wants you to have a surgery or colonoscopy done at a location other than their office.  Recently I had a client ask me about having a colonoscopy done at a surgical center.  I shouted "No way, don't do it!"  First we determined that the facility was out of network, but second we found out that the physician was part owner of the center.  Talk about a conflict of interest! 

Once again, the prescription to deal with balance billing is that you and your family must be your own biggest vocal advocates.  You must try to demand that all providers must be in-network.  I suggest that you write those words all over your in-take documentation at the hospital or facility.  It may not help, but will certainly bolster your case if you try to fight with them later. 

I'm not overly political, but we need more protections in Texas and you need to contact your local lawmakers to change the laws here in Texas and requires in-network facilities contracts to include and encompass every professional that performs services and has privileges in that location.  Otherwise, hospitals will continue to have contract ER doctors that can change anything they want while the hospital shrugs and refuse to own the issue since they don't employ the doctor.  It is time to force hospitals to get in the middle of the balanced billing issue rather than deny that it is a problem of their own creation.  The hospital can hire a contract physician for an hourly rate and then charge you based on their own charge master.  Allowing the hospital to simply stand aside giving contract doctors an unchecked hand in a helpless patient's wallet is unacceptable.  You can find your Texas Representatives by clicking "Find Your Rep".  Reach out to them and demand a solution to balance billing now!

Contact Us to examine your plan and ensure you have the best coverage to fit your budget.  Call us today at 713-422-2935!

Jason Bohmann
Texas Health Design