Some helpful information regarding medical insurance – based on 25 years experience
I worked for a Blue Cross affiliate for nearly three decades and frequently see questions here about medical insurance. I wanted to share some helpful tips about some common roadblocks people run into.
Firstly, medical insurance has many, many policies in place, but you have to ask for them.
You visit the ER and are seen by an out of network doctor. You are shocked when the statement comes in and you have to pay much more than you expect. Similarly, you have surgery with an in-network surgeon, but surprise surprise, the anesthesia doctor is out of network and the claim gets applied to your much larger, out of network doctor. This is known by many names – surprise billing, RAPs (Radiologist/Anesthesiologist/Pathologists). If this happens do you, don’t panic. Call the number on your insurance card and explain to the rep that this particular scenario was out of your control and you are requesting that they process the claim under your in-network benefits. 99/100 times, they will agree and your share will hopefully be reduced significantly
An offshoot of the above – if you are treated by a “surprise” provider, and your insurance does process the claim under your in-network benefits, you may find that the doctor bills you more than expected. For example – radiologist bills Cigna $1000. They “approve” $500, pay 80% of that $500, and state that you share is 20% of that $500 ($100). But the bill comes and they are billing you your $100 share, plus the other $500 that the insurance “ignored’. This is called “balance bill”. And again, if you call your insurance and explain that this was out of your control ,and the doctor is not kind enough to accept the reduced rate that insurance calculated, 99/100 times they will recalculate the claim to approve the full $1000, and then assign the 20% as your share (or whatever your benefits happen to be).
A big complaint around here is having some test, service or procedure that ends up not being covered by the plan. It could be because the plan simply does not cover it (cosmetic procedure), or perhaps they deem it experimental. So how are you supposed to know? Every single blood test, scan, surgery, poke, and prod is assigned a unique five digit code known as a CPT code. They bill that code, along with other codes that describe your medical state. Those are known as diagnosis codes. 99/100 times, a decide to either pay or deny a claim is based on a policy that involves looking at the combination of CPT and diagnosis code to determine if that is a covered service. That means that before you have anything done, you can ask the provider for those codes, then contact your insurance by email to get confirmation that those codes, when billed together, are covered. I say by email, so that you have it in writing if there is a problem down the road. There are some CPT codes that have very rare coverage, so even with a diagnosis code, they may not be able to definitively say yes or no. In those cases, the doctor can send them your full medical records and ask for a pre-determination. Basically saying, if we were to bill you a claim with these codes, and this medical history, would you pay or deny. They will send a response letter letting you know.
Pricing is all over the place. If you are lucky to have a plan that just charges copays for everything, this does not really apply to you. But if you are like most people and have a large deductible, the negotiated rate for a specific service can make a huge difference. If you need an MRI, there could be 5 in-network facilities in your area and the range of negotiated rates can run from $450 for a private, MRI facility, to $4500 for large university hospital. You can call your insurance with the CPT code for the test you are having and ask them to supply you with the negotiated rates for a few facilities in your area. Many insurers now offer this pricing tool when you log into your insurers website.
Many insurers are recognizing that keeping customers happy is good for business. They are starting to create programs to erase the old image that insurance companies just want to deny everything. For example, Aetna has a program that (IF you ask,) will reprocess a claim to an out of network provider, to your in-network benefits, once per year. See this link for a full description of the program: https://www.crnstone.com/news/service-without-borders/
You have appeal rights. Depending on your plan, you can have 2-3 attempts to appeal, so even if you are not lucky the first time around, you can try again. After you have used up all attempts, many plans let you ask for an external review, where a 3rd party reviews everything and makes a non biased decision. By the way, since you have a fixed number of appeal rights, usually 1-3, make sure each one counts. Don’t call up Cigna and say “I dont agree with this copay, i want to appeal”. You just wasted an appeal because what exactly did you give them to review other than your dissatisfaction?
I will try to answer any other questions that pop up regarding medical insurance so feel free to post here.