by: Lindsey VanDyke DO, FACOI, FEAA
Introduction:
I’ve had enough.
I entered medical school in 2009. I’ve been dealing with insurance on a daily basis for the last 10 years. It sucks the life out of every one of us, day in, day out.
Navigating the complexities of insurance is overwhelming, and if you’re not experienced in dealing with it, you don’t stand a chance.
And that is exactly how they want it.
I’m going to spend the next few months–however long it takes, really–dissecting the details about insurance and provide a basic guide about how to navigate it.
Insurance 101: Key Terms and Concepts
Before we delve into the specifics, let’s familiarize ourselves with some key insurance terms:
1. Deductible: The amount you must pay out-of-pocket before your insurance will pay anything.
2. Premium: The monthly fee you pay to maintain your insurance coverage. Usually this number is cripplingly high.
3. Copayment: A fixed amount you pay for specific services, such as a doctor’s visit or prescription medication. Sometimes this number is $0.
4. Coinsurance: A percentage of the cost you share with your insurance provider after–that’s right, AFTER–meeting your deductible.
5. Out-of-pocket maximum: The maximum amount you’ll pay in a year, after which your insurance covers 100% of “eligible” expenses (they will make it hard to figure out what “eligible” means).
Understanding Coverage Options:
Insurance plans come in various forms, each with its own benefits and considerations. Here are a few common coverage options to be aware of:
1. Health Maintenance Organization (HMO): HMO plans often require you to choose a primary care physician (PCP) who acts as the gatekeeper for any specialty care.
2. Preferred Provider Organization (PPO): PPO plans provide more flexibility in choosing healthcare providers, allowing you to see specialists without referrals.
3. Exclusive Provider Organization (EPO): EPO plans combine aspects of both HMOs and PPOs, offering a network of preferred providers without requiring referrals.
4. Medicare: This can exist in either of two forms. The original, or Traditional Medicare, or the more modern forms of “Medicare Advantage Plans” that are managed by companies like United Healthcare, Blue Cross, and others. I like to call these “Medicare DISadvantage Plans.”
Maximizing Your Benefits:
To make the most of your insurance coverage, keep the following tips in mind:
1. Understand your plan: Read through your policy documents or contact your insurance provider to understand the specifics of your coverage, including network providers, covered services, and any limitations. Don’t be afraid to throw this in their face when they try to deny or delay your care.
2. Choose Carefully When to Stay In or Go Out of Network: When appropriate, choose healthcare options within your plan’s network to avoid higher out-of-pocket costs. Keep in mind that sometimes the best place for a surgery/test/appointment is at an Out Of Network site.
3. Utilize preventive care: Many insurance plans cover preventive services, such as vaccinations and annual check-ups, at no additional cost. Take advantage of these offerings to maintain your health and catch potential issues early on.
4. Keep track of expenses: Maintain records of medical bills, receipts, and explanations of benefits (EOBs) to ensure accurate billing and easily track your out-of-pocket spending.
5. Ask questions: If you’re unsure about a billing statement, coverage details, or any aspect of your insurance, don’t hesitate to reach out to your insurer’s customer service for clarification. Be aggressive and annoying, because that’s how they do business.
Conclusion:
Remember, it’s far easier to rip off the public when the public feels powerless about how their insurance works. This is hard-baked into their business strategies. It’s not your fault, but you are not powerless against them.
NEXT TIME: Why does insurance keep getting more expensive?
Check out these videos for an amusing take on modern medicine and the insurance industry: