Buckle Up: It’s Time To Navigate Health Insurance

On top of the physical pain, the added challenge of navigating your health insurance company can feel daunting.

I’m not in the insurance field but my health journey did catapult me into the world of EOB’s, deductibles, and self-advocacy. Here’s a quick guide to help you ask the right questions and cover your bases. 

Every insurance company is different so I encourage you to read the fine lines of your coverage.

Scheduling Appointments

In-Network: 

• When you schedule doctor appointments, confirm that the provider participates in-network with your plan. Don’t ask if they accept your health insurance. Providers typically “accept” most insurances, however, there may be little-to-no coverage when it comes time for the bill. Sometimes they’ll ask you to call your insurance company for confirmation of network status. Usually there’s a number on the back of your card that you can call. 
• Once you’ve confirmed that the provider is in-network, ask if all providers and services are in-network. For example, the physician or facility could be in-network but the phlebotomist might not be. When this happens to me, I ask for the order and seek another in-network provider to perform the service. That facility will then send the results to the original provider.

Out-of-Network:

• When a provider is out-of-network, don’t be intimidated. You just need the to ask the right questions. When my back issues started, I went to the best spinal center in my area. Unfortunately, it was out-of-network. On my consultation call, I asked how it worked. Note: It’s okay to have a lot of questions. Here’s a few that I asked:
  • What does the billing look like as an out-of-network patient? She informed me that they would submit a bill to my insurance company. Whatever amount not covered would be awarded a patient discount.
  • What does the patient discount look like? She gave me an outline of maximum costs to expect. They had a max cost for patient expenses per service. For example, let’s say they billed insurance company $5,000 for a service and my insurance only paid $2,000. If the patient discount would be $2,250 for the service, I would only have to pay $250 for the service. 
  • Does the insurance company pay you directly? She informed me that my plan did not pay the facility directly when out-of-network. Instead, I would receive an Explanation of Benefits (EOB) with an outline of coverage and a check. I would then deposit the check and submit it to the facility.
  • If I can’t pay a bill immediately, are there payment plans? She informed me that they had a billing department that would work out payment plans (with 0% interest) if the situation occurred. Spoiler: It didn’t! All of the expenses were exactly as outlined.
  • Can you send me this information via email? Get. It. In. Writing. He-said-she-said doesn’t matter when it comes to bills due. 
• Some out-of-network facilities can be money-hungry. You still don’t need to be intimidated, this just reinforces why it’s so important to ask questions and get those answers on a recorded line or in writing. I asked those questions to one of my out-of-network specialists, however, I did not get it in writing. A bill came and I was not expecting all those zeros. This can happen, and it’s okay. I called the billing department and luckily, they worked with me to honor the original quote. Don’t be a rookie like me though (that was early-on in the journey); get all billing information in writing. If they won’t do that, don’t use the facility. Most reputable offices are transparent about their costs.

Understanding Deductibles

If I’m honest, deductibles are still confusing to me. I’ve had my health insurance company spell it out at least 5 times and I still wouldn’t ace a test on it. It’s critical to at least attempt to find out how your deductibles work so that you can strategically schedule appointments to avoid unnecessary costs. Here’s a high-level overview for beginners: 

• In-Network
• In-Network out-of-pocket
• Out-of-Network
• Out-of-Network out-of-pocket 

Some of these expenses can overlap. For example, if your in-network deductible is $2,500 and your in-network out of pocket deductible is $3,000 – there could technically be an overlap in those costs. So, if you’ve spent $3,000 in-network, some of those costs can count toward the out-of-pocket cost (AKA you don’t always need to spend $2,500 + $3,000 = $5,500 to meet both deductibles). However, in-network deductibles don’t always overlap. And, typically those don’t count toward the out-of-network deductibles.

It’s important to note that typically the individual in-network and out-of-network deductibles do not apply to other family members.

Planning for Surgery

Scheduling surgeries adds a whole new level of health insurance confusion. Personally, I scheduled my surgeries in-network. I created a mini check-list of questions and asked my insurance company on a recorded line to ease my billing worries (no one wants to have to think about the bill while recovering from surgery!):

• Is the surgeon in-network? Provider coverage status can change. It’s important to confirm that they are still in-network prior to a surgery.
• Is the facility in-network? Although the surgeon is in-network, some facilities are not. Determine which facilities are available (i.e.: If the surgeon performs at two hospitals, the other one is likely in-network).
• If there are complications, does my coverage status change? My total hip replacements were both outpatient surgeries. This required a separate approval process than inpatient surgeries would. I learned the steps my provider would have to take to receive a STAT authorization, with no penalty to me, in case my surgery became inpatient due to complications.
• Is the anesthesiologist in-network? Most of the time they’re not. And it’s even more likely that you won’t know until the day of surgery. I communicated to my surgical team in advance that I’d prefer an in-network anesthesiologist. They couldn’t guarantee in-network personnel but they did communicate an agreement with the hospital. The agreement outlined an affordable minimum cost when not covered by insurance. Fortunately, mine were in-network for both surgeries so I didn’t have to pay any added cost.

Learning nuances of insurance can be confusing. With this guide, you’ll be one step ahead. 

Now that you know the basics, click here to learn more about EOB’s. 

Do you have other recommendations that should be added to this guide? Comment them below!