Strategies for navigating complex health-care system
Even if your health insurance premiums are on the rise, there are things you can do to control the cost and the quality of your care.
Watch out for common errors: Billing errors are common, especially for complex medical procedures and hospital stays, so get an itemized bill that breaks down each cost. Make sure you haven’t been charged for procedures or items you didn’t receive. Don’t pay a bill for care you thought was covered until you receive an explanation of benefits from your insurer explaining why your claim was denied. It may be that the provider’s office simply input the wrong code.
Seek help from an expert: A claims specialist can organize medical bills, spot errors and work with your doctor to build your case if you need to appeal a denial. The cost is $75 to $95 per hour. Find a claims specialist at www.claims.org.
Read the emergency care rules: Rather than going to an out-of-network hospital in an emergency and getting unwelcome out-of-network bills, find out which hospitals and urgent-care centers are covered by your plan and how much you’ll have to pay, as well as any requirements for prior authorization. Get the right paperwork for prescriptions: Coverage for pricey drugs is often denied because a doctor doesn’t complete the required paperwork. Many insurers now require you to get prior authorization (a form your doctor must complete) or use step therapy (in which you must use a less-expensive drug first, if possible) before they’ll cover your drug.
Understand the deductible calendar: Consider scheduling procedures near the end of the plan year, after you’ve met your deductible, rather than waiting until the new year.
Get approved for out-of-network coverage up front: If your doctor recommends a specialist who isn’t covered by your health plan, ask your insurer what you can do to avoid out-of-network charges before you visit that doctor (your insurer may have a care coordinator to help). You may find an in-network provider with similar expertise, or you may be able to work with the doctor or hospital to make the case that you need to use a particular specialist. In that case, the insurer may provide a network adequacy exception to cover the doctor for you at in-network prices.
Find out where you can get worldclass care: More than 80 percent of employer plans offer centers of excellence, which give you access to wellknown hospitals outside of your area for certain kinds of care, such as transplants, bariatric surgery, orthopedics, and cardiac and cancer care. For example, some of United Healthcare’s policies have a national network that includes major cancer centers, such as MD Anderson and Memorial Sloan Kettering.
Kimberly Lankford is a contributing editor to Kiplinger’s Personal Finance magazine. Send your questions and comments to moneypower@kiplinger.com.