Because health insurance does not always protect the patient, customers must be aware of their rights.
Many individuals assume their health insurance provider is on their side, but this is not always the case. It may be difficult to understand the facts of health insurance, especially when large corporations conceal the truth about the prices of care or coverage specifics.
Not reading the tiny print might cost you a lot of money, so be sure you understand what your insurance should cover and how to save as much money as possible while seeking medical treatments. It is your responsibility to be an informed customer; here are nine facts your insurance company does not want you to know.
1. Full coverage does not necessarily imply that all of your expenses are covered
Some insurers sell their policies as “complete coverage.” However, this does not imply that you will get reimbursed for every single expense you may spend.
If you visit an out-of-network provider (one who has not consented to engage with your insurance), you may have restricted or no coverage. Some services may be completely excluded. Even for insured services, there will normally be copays and coinsurance to pay.
Check the coverage details carefully, including any potential exclusions and your out-of-pocket spending limit, to ensure you understand how much of your healthcare bills you may be liable for.
2. Billing errors happen all the time
One of the most startling things patients discover is that medical invoices might contain mistakes or overcharges more frequently than they believe. These mistakes can include:
- Billing the incorrect code, which results in you being charged for the incorrect services
- Unbundling codes, which indicate that instead of billing for a single worldwide service, they split it down into all of its components, causing you to pay extra.
- Updating (charging for a more expensive service)
When these mistakes occur, you may wind up paying extra money because you are normally liable for covering at least a portion of the expenses of your treatment. To avoid this, thoroughly study your invoices and ask questions about the services you were charged for if you don’t understand.
3. Balance billing can be expensive
Balance billing is a typical occurrence. It happens when an out-of-network provider costs you for the difference between what your insurance pays and what the provider charges for a service.
Frequently, suppliers — particularly hospitals — demand exorbitant charges for modest items like as bandages or Tylenol. The insurer only covers a fraction of this, leaving you with the remainder of the inflated bill. To avoid this, get an itemized copy of your account, thoroughly analyze it, and dispute any charges that appear excessively inflated.
4. Even at in-network institutions, not all caregivers are covered
As an insured patient, it stands to reason that if you visit a hospital or doctor’s office inside your insurance network, all of the services you get will be in-network, right?
Unfortunately, this is not always the case. Some office or hospital providers, including as radiologists, anesthesiologists, pathologists, and surgeons, may be out-of-network even though they deliver services at an in-network institution. Because out-of-network treatment is often significantly more expensive and frequently not completely covered, you might find up owing a fortune for the services they give.
To avoid this, make sure to check with your doctor’s office or the hospital to see if everyone you’re working with is in-network. If the problem is an emergency, this may not be possible; nonetheless, your insurance should pay the expenses of emergency treatment, even if it is provided by non-network providers.
5. Insurance companies sometimes dismiss genuine claims
Insurers are in the business of earning money, and paying out large claims gets in the way of that. As a result, insurers frequently refuse genuine claims to see whether they can get away with it. In fact, in one study of Medicare Advantage Organizations, insurers overturned up to 75% of denials after patients or providers challenged them.
Make sure you understand exactly what your insurance covers, and engage with your physician to challenge a claim denial or a pre-authorization request if you believe the services should be covered.
6. Insurance companies might be slow to respond in emergency situations
Sometimes insurers take too long to approve a claim for a medicine that a doctor has recommended. They may do this in the expectation that patients would simply pay out of pocket for a potentially life-saving drug. Insurance companies may also force you to attempt less expensive options first, even if they are less likely to succeed.
In these cases, working with your provider to try to show medical necessity may be your best option.
7. Prescription medications may be less expensive if purchased outside of insurance
In certain situations, using your insurance to pay for prescription medicines may wind up costing you more than paying for the drug out of pocket. This is especially true because many health insurance policies only cover medicines once you’ve reached your deductible, and plans may not cover less expensive generic alternatives.
To avoid overpaying for medicine, shop around for coverage using sites like GoodRx or contact your pharmacist before using insurance to pay for it.
8. You have the option of requesting a review or filing an appeal
You have the right to seek a manual review of your invoices, as well as to appeal any insurance claim denial that your insurer refuses to pay. You can seek both an internal appeal and an external review, which means that an impartial third party will make the ultimate decision on whether or not the insurer must pay your claim.
9. Patient advocates aren’t always on your side
Patient advocates are frequently appointed by hospitals and insurance to assist patients who have billing problems. It is critical to remember that these advocates work for the insurance company or hospital.
In conclusion
Understanding the tactics used by health insurers is critical for all consumers in order to preserve their rights and guarantee they receive the coverage they require and deserve. By avoiding overpaying for health care, you might wind up saving money that you can use towards other goals, such as debt repayment or future savings.
