Things no one thinks about

As we enter the holiday season, many of us have surprises on our minds: How to surprise a loved one with a gift, or perhaps a surprise visit to a friend or relative. These are good surprises. There are also not-so-good surprises. Today’s column is intended to enlighten you to some ideas to help eliminate some of the not-so-good surprises that come along with health insurance.

Deductibles

Most deductibles run according to a calendar year. However, not all insurance plans follow this rule so be sure to check your policy or check with your agent if you are not sure. Years ago, when we all had the “traditional” 80/20 plan with a $200 deductible it was much easier to remember about the deductible. Then, nothing was payable until you met that deductible. Now, in the age of managed care, the products are much more complicated. Deductibles apply to some services, but not others. It can be quite confusing to remember which services require that you meet the deductible first and which do not. And it can be a most unpleasant surprise to receive a medical bill where most or all of the charge went to the deductible if you were expecting that service to be covered.

Anesthesia

Many anesthesiologists do not participate with health insurance plans. Their practices are set up far different from physicians who see patients in their office and establish a rapport with patients. If you are having scheduled surgery in the future, you may wish to inquire who the anesthesiologist will be. If you have health insurance that offers benefits at different levels for using in-network or out-of-network physicians, you may wish to inquire if there is an in-network anesthesiologist who participates in your Plan. Find this out before hand and you will not experience unpleasant surprises when the bills start to arrive.

Pathologists

One of the most frequent comments we hear in our office, from our clients for whom we do claims processing is, “I have no idea who this doctor even is!” The pathologist is the person behind the scenes. He/she analyzes the biopsies. When “something” is removed from us, they study it to determine what the medical problem is. Certainly mistakes can happen in any field. However, it is highly unlikely that you will receive a bill from a physician or provider of medical services who did not render a service to you. You may not have been aware of it, but that does not mean it did not happen.

Well Care or Routine Services

Most policies now available in New Jersey offer a separate benefit for routine care. You may have just co-pay for anything routine, or may have a fixed dollar amount per year for routine services. Keep in mind it is your responsibility to know how your health insurance works, not your doctors office. Your doctors’ office is there to render medical care and the staff to support that goal. If you have separate benefits available for services coded as routine, and you wish for the claim to be processed that way, you should remind the staff or doctor at the time the service is rendered. Coding is what determines how benefits are payable on claims. If the claim is not coded as routine, it will not be paid using the routine benefit. The coding must of course coincide with reality. If you just found a lump in your breast, or are experiencing an unusual symptom of something, do not expect that your doctor’s office can code this as routine. Those are not routine. Likewise, if you have used up your calendar year allotment for routine services and find a claim has been denied entirely, perhaps the inverse occurred: Perhaps something was coded as routine that was not routine. The bottom line here is, know your benefits, and know which services you are having performed as routine and which services are relative to a problem or condition. Then you can ensure that your claims are processed correctly.

And finally, a good surprise! If you or a family member have had an especially medically intensive year, the sop-loss may come into play. The stop loss is that point at which the plan pays benefits at 100% for the remainder of the calendar year. Again, the point at which this kicks in is dependent on the exact policy. Check your benefits booklet.

Referrals and out-of-network

If you have an HMO you may find some very unpleasant surprises if you do not get the proper referrals, or if you go out of network if you do not have out of network benefits.

Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance Claims, Inc. a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, browse our past columns on our web site at www.micinsurance.com.

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