In my last post, I talked about talking to your healthcare team. In this week’s post, I wanted to discuss building trust with your health insurance company.

The first thing I suggest when you have a question for your insurance company is to look at your member handbook. The Member Handbook has information on how to use your insurance fully. The handbook can provide information that should answer most of the questions. If you did not get one when you started with your company’s carrier, look at your health insurance company website. You should find a PDF called Member Handbook under the patient information tab. Download a PDF of the handbook and print a copy to read and keep for your records or review it on your computer.

If you still have questions, you can call the number on the back of your health insurance card. Before you call, pick a time when you can devote about an hour or more to the call. Have all your paperwork in front of you with your questions. Have paper and a pen to take notes. You should note the date you are calling, when you place the call when you were connected to a person, and who you talked to. Ask for the person’s name, badge number, and extension if you have the person’s name.

Each insurance company has a system to answer your calls. Listen to the menu to choose the number that gets you to a live person.

When calling your health insurance company, the customer service department is your first stop. The customer service team can answer most questions, but if they can’t give you an answer that helps you understand what you were looking for, you can ask to talk to a supervisor. This request might cause pushback with the customer service person, but be persistent and ask to speak to a supervisor as they have more authority than the customer service person and can escalate an issue as needed.

Depending on what you are calling about, the call can take some time. You may have to wait as the people you talk to check things, so be patient. Also, most insurance companies record all of the calls for educational purposes. The recording can help if you need help getting what you are asking for or prove you followed the directions. Companies can look back through the tapes and find your call to verify your claim, so keep this in mind.

The most important thing you need to remember is that whatever health insurance company you are with, it is a good idea to become familiar with their network of providers and how to access them. Staying within your Insurance Provider Network is very important. The providers within your network have agreed to charge a specific price for treating you with your insurance company. If you go outside your network, your insurance may not pay, so staying within your network is critical.

If you need a provider or have to get a test that your insurance does not have a provider in the network,  they will try to find one in your area and make a single provider agreement with the provider. Keep any paperwork you get on a provider outside your network and the agreement made so you can go back to your health insurance company and dispute the bill if you receive a bill after the service is rendered.

If you have an HMO policy, you must go to your primary doctor for a referral to see a specialist, get a diagnostic test, or go to therapy. Most primary care provider offices will get the referral for you. Ensure you obtain a copy of the referral and bring it to the provider you see. When you register, the registration team might need to keep a copy of the referral, so ask for the original so you have it for your records. Depending on your insurance, you may need to pay a co-pay to see a specialist. Your member handbook will have the co-pay for specialists and tests you get.

If you have a PPO, you only need a referral to see a specialist or get a test if it is a costly test. Again, check this with the insurance company and find out if there is a specific company you need to follow up with. Keep notes on what you were told for your records.

Until recently, if you went into the hospital and saw a specialist, he or she might not be in your insurance network. As a result, you may get a hefty bill for going out of network. Today, there are rules to prevent this as you, as the patient, have no control over who the Hospitalists call in to see you. These rules, called Surprise Billing Rules, protect the patient against excessive charges.

Any medical bills should be reviewed. Reviewing bills takes time but is very important as there can be mistakes in any bill from a provider.

When you get a bill, wait to pay it until you get notice from your insurance company that they paid their portion. You will get notice of this payment so you can match up what your health insurance company paid with the bill you got from the provider. If you get a second notice, call the number on the bill to ensure the bill was sent to your insurance company. The provider will often bill you and not bill your insurance company, so it is up to you to make sure to make sure the provider sends their bill to your health insurance company and pays the bill. You should not have additional costs when you stay within your provider network. The exception to this is if you still need to meet your deductible. Once you meet your deductible, your insurance company should pay 100% of the network costs.

I will cover billing errors and balance billing and provide tips for handling these bills in next week’s post.

In closing this post, know that your insurance company is there to serve you. Most health insurance companies refer to you as members. As a health insurance company member, you should have a relationship with them as they are in place to serve you so you get the best health care to help you stay healthy and provide the resources to meet your needs within their contract. Staying current on new rules and updates from the health insurance company is essential. You will get letters from them if there are changes in your policy, so keep an eye out for them.

Insurance companies are in place to ensure your care is cost-effective by providing a provider network where they negotiate prices on services. They provide preventive services that help you stay well and identify problems early so your healthcare team can develop a plan of care to meet your individual needs.

Your insurance company can help you find doctors and providers in your network when your primary care provider moves or retires or you need services from a specialist. They are there for you, so feel free to call them when you need help.

If there is a time when your insurance company is not helpful or responsive, let your employer know so they can address it with the company. As discussed in last week’s post, you are the most important team member, so identifying and reporting problems with providers or the healthcare insurance company is up to you as you use your policy. Speak up so issues can be addressed.

Let me know your experiences with your Health Insurance Company and how you handled the challenges or when you received good service. Your comments help others understand how to use their voice when thrust into the complex healthcare system.

Have a good week!


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