Dealing With Health Insurance

So many aspects of health insurance can be confusing

  • figuring out what type to get
  • knowing how to use it once you have it
  • learning what to do if your claims are denied

FAIR Health, a national, independent, nonprofit that aims to bring transparency and clarity to healthcare costs and health insurance information, provides a comprehensive series of guides and videos to explain health insurance. They have information on health plans from employers, an exchange/marketplace or a union, or one that you bought directly from an insurer.

Their website explains many common insurance questions, including:

  • What do the terms in my Explanation of Benefits (EOB) mean?
  • How are in-network and out-of-network care different? How do they affect my costs?
  • What are co-pays, co-insurance and deductibles?
  • What should I think about before I choose a medical or dental insurance plan?
  • I saw an in-network doctor. Why did I get a bill?
  • What do I do if my claim was denied?
  • How can I use my Flexible Spending Plan to pay for my healthcare costs?

What to Do When Your Insurance Company Says No

Insurance denials come in many forms. The Alliance for the Adoption of Innovations in Medicine has identified four of the most common insurance roadblocks:

  • Adverse Tiering: a method used to discourage patients with certain conditions from enrolling in a health plan by placing newer drugs for diseases like cancer and HIV on the highest copayment tier. A 2015 study in The New England Journal of Medicine found that some insurers participating in the state health exchanges placed all HIV therapies on the highest tier, meaning enrollees in these plans paid more than twice as much for their drugs as those in other plans.
  • Non-medical Switching: a practice where the health plan switches patients who are stable on a medication to different treatment for non-medical reasons by refusing to cover the therapy any longer or significantly increasing the copay. While insurers use this practice to control costs, patients may experience negative side effects of the new treatment regimen or become less responsive to treatment even if returned to their original medication.
  • Prior Authorization: a process requiring physicians and other health care providers to obtain advance approval from a health plan before a procedure, service, device, or medication is given to a patient and qualifies for payment coverage. Prior authorization can lead to delays in treatment. In a 2010 American Medical Association survey of 2,400 physicians, two-thirds reported waiting several days to receive authorization for drugs, while 10 percent waited more than a week.
  • Step Therapy: a policy sometimes referred to as “fail first” that requires the individual to try one or more less-expensive treatments first and “fail” on them before the health plan will cover the one prescribed by the provider. Step therapy not only delays effective treatment, but multiple studies show the practice increases the costs to the healthcare system, particularly for hospital and emergency-room care.

There is also:

  • Co-Insurance
  • High Deductible Plan
  • Out-of-Network Charges

If your insurance company denies your claim, you have rights to fight back.

Know Your Rights

Aimed Alliance has launched “Know Your Health Insurance Rights”—a website that offers specifics steps to take if your insurer improperly delays or denies your coverage. That can include: filing an appeal directly with the insurance company, requesting an outside review by an independent third party, or filing a complaint with the insurance commissioner or attorney general in your state.

Your odds of reversing your insurance company’s decision are better than you think. That goes for internal appeals directly with your insurance company and external appeals with an outside government agency.

According to a 2011 report by the Government Accounting Office, patients who fled internal appeals directly with their insurance company saw insurance companies reverse their initial denial 39 to 59 percent of the time. In 2009, 54 percent of patients in California succeeded in reversing or revising an insurance denial through the external appeal process.

In other words, it pays to fight your insurance company and file an appeal.

Health Insurance: How to Request an Internal Appeal

If your insurer denies your claim, you have the right to an internal appeal. This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
  • Collect information. In addition to the determination letter, collect all documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
  • Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
  • Call your health care provider’s office. Contact your healthcare provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
  • Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
  • Request an expedited internal appeal, if applicable. If your case is urgent, you should contact your insurer and ask for instructions on how to apply for an expedited internal appeal. Your situation is urgent if it jeopardizes your health, life, or ability to regain function.
  • Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

The Patient Advocate Foundation also provides extensive information on appealing insurance denials, including a booklet called “Navigating the Insurance Appeals Process.”

Keep Track of Your Medical Bills

There’s no one best way to keep track of your medical bills. Some people are more comfortable with paper files, while others prefer keeping electronic records. Once you decide the way you want to keep track of your medical bills, you can find many tools to help you. has put together an essential list of all the information you should keep track of to help you manage payment of medical bills:

  • Records of each appointment, including the date and any lab work, tests, or procedures that took place
  • The name and dose of each drug prescribed and the name of the doctor
  • Copies of checks and credit card receipts for co-pays and other health care costs
  • A current copy of your health insurance coverage
  • Bills and invoices from health care providers, such as doctor’s offices, hospitals, or labs
  • Insurance claims filed by you, your doctor, or your hospital
  • Explanation of benefits statements from your insurance company for processed claims
  • Insurance reimbursements you’ve received
  • Insurance claim rejections you’ve received and appeal letters you’ve written

You are allowed to deduct from your taxes the amount of your total medical expenses that are more than 7.5% of your adjusted gross income. If you think your medical expenses will reach or exceed Internal Revenue Service minimums, keep track of travel, meal and telephone expenses related to your medical care.

Tools for Tracking Medical Bills

Calendar: Using either a paper or electronic calendar, record all your medical appointments, tests, procedures and prescription drug purchases the day they occur so you don’t forget. You can refer to the calendar for insurance claims and tax purposes.

Paper Tracking: You can use a pad of paper to record the payment status for medical services. Add columns for the date of the appointment, the doctor’s name, the amount paid (with the date), the insurance claim status and other notes.

Electronic Tracking: You can use spreadsheet software to track this information. There is software available that provides a template to view and manage medical data, as well as templates for writing letters to dispute rejected insurance claims. Or you can create your own spreadsheet. Update the list or spreadsheet every time you receive a bill or insurance statement, or pay a bill.

There are websites that will save your insurance information and help you manage medical bills. Examine them closely—some may charge a fee, and others may not have adequate security to protect your data and privacy.

Going Over Insurance Statements

You may get several bills for the same care. If you had surgery, you may get bills from the surgeon, the anesthesiologist and the hospital. If you had an X-ray, you may get separate bills from the imaging facility and the radiologist who read the image.

When you get the medical bill, compare it with the insurance statement. Make both have the correct date, provider and type of medical care. Make sure you understand how much of the bill you are expected to pay (the amount your insurer says you owe). If the medical bill is incorrect or unclear, call the provider’s billing office. Call your insurer if you have any questions about your health insurance statement. If the insurance company won’t cover a service your policy says should be covered, file an appeal (see section above).

Filing Your Documents

You can set up a paper filing system with separate files for insurance statements, bills and receipts of payment, or you can scan these documents and save them on your computer. Organize bills by date of service. An insurance statement can be about more than one medical bill. Make a copy of the statement and match it with each separate bill it mentions. Include any payment receipts and updated statements about those bills. Medicare has an online tool for storing and accessing personal information: here.

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