Understanding Insurance Plans

Health Insurance plans and options are more complicated than ever.  On the positive side many newer plans do further to empower the consumer to make healthcare choices that can assure them excellent care and at the same time save them money.  In addition a thorough knowledge of all of the benefits of your particular plan allows you to take maximum advantage of classes, support groups or discounts due to participation in wellness programs, etc.

The cost to not understanding your exact health plan can be significant.  Far too often a denial for coverage can be due to a consumer not following required procedures or failing to understand limits of coverage.  Here are some commons problems:

• A patient with an HMO visits a specialist. The health plan denies payment of the visit as the patient needed a referral from his primary care.
• A PPO participant sees a doctor who is not in the PPO network.   The plan might cover 80% of the care if you saw an in –network physician and far less or maybe nothing if you go out of network.
• A patient schedules surgery however the procedure is not authorized by their insurance plan as the criteria for that particular plan has very specific limits.
• A patient receives a denial for a procedure and does not follow the specific appeal process in the timeframe outlined by that plan and automatically loses the appeal.
• A patient has a procedure at one location and has no out of pocket expense.  They then have the same procedure at another facility and end up with a large deductible they must pay out of pocket.

In order to avoid these costly mistakes here is what you can do.

•  Be aware of what kind of plan you have ( HMO, PPO, etc).   Find out in advance who is in network and who is not and if a referral is needed.  Ask your provider if they have the referral on file prior to your visit.  If not, call your PCP and get one in advance.  Many plans will not authorize a retro-active referral.
•  Determine if any procedures require prior authorization and whether your provider’s office will do this on your behalf.   A medical provider’s office can assist you with obtaining the authorization however that is not a guarantee of payment and often only the member can find out how much it will cost them out of pocket and if there are any limitations to that coverage.
• Find out if your plan excludes certain services and if there are any service limits during the calendar year. 
• Many plans now have a “Site of Service” differential meaning some facilities will provide a service at a significantly lower cost.  For example, a spinal injection at your doctor’s office may only result in an office copay ( for example 10.00- 50.00) versus having it done at a hospital or out-patient center might be subject to a deductible and co-insurance.  ( 250.00 to 1,000.00 or more)

Finally, you will receive optimal service and coverage if you do your research in advance.  Advise your doctor's office of any changes in your personal information and be sure to provide them with a copy of your health insurance card.  Since the contractual agreement for your Insurance coverage is between you and that Insurance company there is some information only available to you.   Therefore in some cases only you can determine exactly how your benefits will work and what your out of pocket costs might be.  We will gladly provide you with any information needs ( such as procedure codes,etc) so that you can obtain this information. 

Just as is necessary in optimizing your medical care, we must work as a team to assure you the best medical care and obtaining the most benefit from your health insurance plan.  These concepts are not easy to understand and can be even more challenging when you or a loved one is ill.  At NHNSI we Care about the quality of your life and strive to assist you in anyway we can.  If there is something we can assist with, please do not hesitate to ask.