Posts Tagged: HMO

Why Did my Health Insurance Deny My Claim!?

No! You expected your health insurance to cover a service, and then you get the dreaded letter that it’s been denied. Why do claims get denied and when does it actually matter (that’s right, sometimes it doesn’t matter)?

Your health plan might refuse to pay for a service or treatment you received for many reasons. It’s good to know whether it was denied because of the services themselves OR because of how your provider submitted it. Why is this important? Because in the first case, you’ll probably be responsible for paying the claim. In the second, you won’t be.

Here are some common reasons claims get denied where you could be responsible:

  • You didn’t get a referral or prior authorization when it was required
  • The service isn’t covered by your plan
  • You already used up your benefits for the service (like a cap on the number of physical therapy visits per year)
  • You went out of network when you have an HMO
  • Your insurance wasn’t effective at the time of the service

Don’t confuse these situations with those where a claim (or a portion of a claim) was denied because of how your provider submitted it to your insurance. This happens surprisingly frequently.  It might be that:

  • Your doctor didn’t submit the right billing code to your insurance plan
  • Your doctor didn’t submit the claim in the timeframe your insurance required
  • The service was actually covered as part of another claim or set of services
  • The claim is a duplicate that was already paid

You might see these things show up on your EoBs, or Explanation of Benefits–the statements you get from your health plan just informing you about your coverage (the ones that say “This is Not a Bill”). Just know that if your provider made a mistake submitting a claim, or your insurer found that it had already been paid for, you’re not responsible!

So before you panic, look into the reason for the denial. And if you believe you were billed unfairly for the cost, you can always appeal the decision. All health plans have to honor a process of reviewing claim appeals from their members.


How to Start a New Health Plan Off on the Right Foot

Welcome to a new year, with new health benefits. You just chose a new health plan and now it’s in full effect. But most people don’t have a full understanding of how their benefits work. This means that many of them end up losing money in their spending accounts, paying more for care, or getting claims denied.

Follow these tips to make sure you start off 2013 right.

Plan for your Deductible
Guess what–deductibles have gone through the roof over the years, so that often means more cash out of your pocket. If you are one of the 65% of people who have a high deductible health plan, it’s especially important for you to plan your spending. High deductible health plans (HDHPs) come paired with Health Savings Accounts (HSAs), or accounts where you can save money just for medical expenses free from taxes. To be best prepared, you should plan to save at least the amount of your deductible in your HSA as soon as possible.

Network It
Most health plans have some restrictions on what providers you can see or they cover much more on visits to in-network providers. Find out the type of plan you have and whether you have a provider network. HMO plans are the most restrictive–don’t even think about going to a non-network provider unless you want to pay the full cost. PPOs have some more flexibility, but services in-network will be less expensive. POS plans give you more freedom, but often involve more paperwork for out-of-network visits. And finally, FFS plans allow you go to any provider you want, but few companies offer this option anymore.

Get Spent
Did you sign up for an FSA or HRA? Don’t forget about the money in your account. These funds disappear if you do not spend it by the end of the year. Do some planning now by finding what eligible expenses you expect this year so that when they come up, you’ll know to pay with your FSA or HRA, insteading of other funds. If you have an HSA, the same “Use it or lose it” rule does not apply. Your savings will roll into the next year.

Practice Prevention
All health plans must cover a list of dozens of preventive care services, all free of cost. Get your money’s worth by checking out the list and asking your physician what they recommend. Even if you have a high deductible plan and you have not met your deductible, you can still get these services completely covered, as long as you don’t have a pre-existing condition that already required one of these tests or screenings. Learn more about preventive care here.

Have a Non-Emergency Plan

What do you do on the weekend or in the middle of the night when you’re not sure if a medical condition is serious enough for the ER or can wait for a doctor’s appointment?  Most health plans have a variety of options for these uncertain situations such as nurse advice lines or extended-hours urgent care. Know your options so that if you’re caught in the situation, you can choose to avoid an expensive ER visit. Of course, always go to the ER if you are having a life-threatening emergency.


5 Mistakes To Avoid During Open Enrollment

 This post originally appeared on the blog. 

The last few months of the year usually mean time to think about choosing new health benefits. Some people think about Open Enrollment as an opportunity—it’s your chance to switch plans! But for most, it’s a looming headache: time to stress about choosing the right benefits.

It could be that there are just so many more options today than ever before. Several years ago, most employers just gave you a choice between a low-cost HMO and a more expensive PPO. Now the options have multiplied into an extended family of acronyms. To make things worse, employers and health insurance companies are pushing more costs onto consumers, so it’s even more important to make sure you’re getting your money’s worth.

As you approach your Open Enrollment period, here are 5 common mistakes, and how to avoid them.

1)   Doing nothing

Almost 9 out of 10 of us just keep the same benefits we had last year. That’s not necessarily a problem, especially if you’ve done your research and your needs haven’t changed. Just make sure nothing substantial has changed about the plan either. Sometimes premiums increase or  benefits get cut, and over time, the plan that was once a good deal may not be the best one for you anymore.

2)   Shopping only by the premium

It’s easy to focus on how much health insurance will cost you each month because it’s a clear, predictable expense. But don’t overlook what you’re paying for or you may find yourself facing big costs later on, such as high deductibles or co-insurance.

3)   Over-insuring

It’s possible to have more insurance than you need. While good-for-you from a health perspective, this might not be that great from a financial perspective.

This doesn’t necessarily mean choosing the cheapest plan if you are a healthy individual—because we are all at risk for those unexpected medical events. But it might mean choosing a plan that has a more limited network, like an HMO if you are not seeing any specialists. Or choosing a high-deductible plan if most of your visits are routine preventive care.

4)   Under-insuring 

Of course, you don’t want to go too far in the other direction choosing too minimal of a plan either. If you choose a high deductible plan, you should be able to pay the deductible at any time if needed. In an ideal world, you’d have lots of time to save up cash to cover your deductible in an HSA linked to the plan. But if you enroll in a high deductible plan, and suddenly have some medical bills before you’ve accumulated enough in your HSA, you could be in trouble.

5)   Ignoring the savings accounts

FSAs (Flexible spending accounts) and HRAs (Health reimbursement accounts) pretty much mean free money on the table. But there are estimates that as few as 20% of people set up an FSA when it’s offered.

If you’re turned off by the idea of keeping receipts and faxing photocopies, give these savings accounts another chance. Now, most issue debit-like cards and many merchants are set up to automatically recognize FSA or HRA eligible expenses—so you can spend easily. You should still keep receipts as proof, and you might still need them for certain expenses. But the tax savings are well worth the work.


Why Understanding Your Health Plan Just Got a Bit Easier

Wouldn’t it be great if overnight, understanding health insurance magically became easier?

That was the aim September 23, 2012, but whether it actually happened is still in question.

On the 23rd, a new benefit from Health Reform kicked in, aimed at making it easier for consumers to understand insurance and compare plans.

It’s called the Uniform Summary of Benefits and Coverage (SBC). Right now, health plans already send you long, complicated SBCs. But the problem is, every one is different (ever tried to compare two of these?).

But now, every plan will be required to present their information in a standardized way, using the same definitions, so you can compare apples to apples.

Think of nutrition labeling—we can see instantly exactly how much more sodium is in one bag of chips versus another. That’s the goal behind the Uniform SBCs. And the “labels” actually don’t look that different from what’s on your food…

Even better, the new document also include “coverage examples,” or a theoretical breakdown of costs for some common medical conditions. See example SBCs here.

It’s a step forward, but here at Simplee, we know it’s not enough to make shopping for health insurance as easy as shopping for sweet potato chips. For example, it’s still difficult to compare 70% and 80% co-insurance when you don’t know the full cost of a service.

Basically, the new SBC will make is easier for consumers to choose between health plans, but after that, it’s still a challenge to understand claims and bills once you start using the plan.

Everyone with a private health plan will see this benefit. Look for it when you receive your plan documents each year or on your health plan’s website.



How to Choose the Cheapest Health Plan that Still Meets your Needs

This post appeared earlier on 

Maybe it’s Open Enrollment time or maybe you’re starting a new job that offers health benefits.  What’s the key behind all the terms – HMO, PPO, HDHP—and what can they tell you about how much that plan will really cost you?

The two most common terms, HMO and PPO, have to do with physician choice. And a HDHP is about the deductibles. As a general rule? HMOs will offer greater savings than PPOs, but at the cost of less choice and control. And HDHPs can save you even more money if you are healthy and don’t get frequent medical care.

So which plan fits you?

People with an HMO

  • Pay lower monthly premiums
  • Have to go through a primary care physician for everything
  • Have to get a referral for specialty care

People with a PPO

  • Pay higher monthly premiums
  • Can generally go directly to specialists
  • Will usually pay more for specialty care when they do get it

People with a HDHP (High deductible health plan)

  • Pay lower monthly premiums
  • Have a high deductible—you’ll be responsible for at least $1,200 out-of-pocket before your plan pays anything
  • Can open an HSA (health savings account) to save money specifically for health care costs with big tax advantages
  • Are usually younger and healthier

Some things are consistent across HMOs and PPOs – both have to cover preventive care at no cost to you (and that’s even if it’s an HDHP, and you haven’t met the deductible yet!), emergency care at out-of-network hospitals at the same level of coverage as in-network hospitals, and both have the same annual and lifetime out-of-pocket maximums.

Prescription coverage will vary by the plan.

If you’re overwhelmed about choosing the best plan for you, try focusing on two things: Physician choice and how often you need health care. Are willing to pay more to get easier access to specialty care when you want it? And are you willing to chance having to pay a higher deductible to have lower monthly premiums?

For many people, simplifying it to these two preferences will help lead you to the right plan.


Accessing Specialty Care: Are you Covered?

It’s time to see a specialist. Will your health plan cover it? And how much will they pay? These questions are pretty familiar to most of us. Many people end up either getting care they thought was covered and then getting hit with a big bill, or spending so much time getting the right referrals and authorizations that they give up.

How can you avoid these two situations? A little bit of homework and a few phone calls may be all you need.

Step One is finding out what type of plan you have: HMO, PPO, or POS? This will tell you how to navigate physician networks and referrals.

-    If you have an HMO, you’ll need to get a referral from your Primary Care Physician (PCP) before you can get care from any specialist.

-    If you have a PPO, you can go to any specialist you like without a referral. However, if you see an in-network provider, your plan will pay a bigger portion of the bill. For example, your share might be 20% for an in-network specialist but 50% out-of-network.

-    If you have a POS plan, you do not have to have a PCP, but if you do, he or she can refer you to both in-network and out-of-network providers. You do have the option to go out-of-network without a referral, but you would pay more. POS plans are basically a hybrid between HMOs and PPOs.


Step Two is finding a provider. Now that you know what type of plan you have, you know whether you need a referral to see any kind of specialist. Your PCP might be able to give you referrals, but it’s your job to make sure that the physician is part of the plan’s network.

Asking the question “What providers are covered?” will usually get you farther than the question “What type of specialist is covered?” This gets back to the importance of your plan’s network. Let’s say you need to see an allergist. Your plan can’t say whether it always or never covers allergy testing, only whether it covers a certain allergist.

If you don’t already have a specialist in mind, start with the plan’s website, where you can usually filter your provider search by specialty. If you don’t see what you need, find out what Physician Groups or Medical Groups the plan works with. This will usually be in your Summary of Benefits or you can call the plan to ask. Then try searching on the Physician Group’s website. Sometimes this gives you more current information than going through the health plan.


Step Three is calling the provider. Once you’ve found a provider you want to see, it’s always a good idea to call them to make sure they take your plan, even if the homework you did in Step Two says they do. Doctors can join and leave networks at any time so the plan’s information may not be up to date.

Ask about the specific name of your plan, not just the insurance company—for example “The Purple Preferred PPO” rather than “Blue Cross”. Providers might accept some Blue Cross plans, but not all of them.

Step Four is finding out the rules before you get the care. Often times, the physician’s office staff can help you with this. Before you leave the office, ask them to check on coverage for tests and procedures that your doctor has prescribed. This is also a good time to ask about coverage for other needs like medical equipment, prescription drugs, or additional referrals and authorizations. These staff are often more familiar with the language and have the specific medical codes to get more exact answers than you might be able to on your own.


Picking a Health Plan: HMO vs PPO and Beyond

Choosing a health plan for you or your family may seem daunting: HMOs, PPOs, high deductible plans, different premium tiers, etc. Like everything else we buy, we want to find the best. However, this mindset may set you up for disappointment, frustration, or even worse, choosing the wrong plan for your situation. Why? Because with health insurance, there is usually no “one best plan.” Rather, there are different plan options, and people with different needs and preferences. So your goal should be to find the best plan for you.

Before you choose a health insurance plan, think through your own preferences and focus on one question:

What is most important to YOU in your health plan?

1)    I want to stay with the same doctor.

If this is your biggest priority, you should call your doctor and ask which insurance plans they take. Be sure to ask about the specific type of plan, not just the insurance company’s name, because some doctors may for example, belong to an insurer’s PPO network, but not their HMO network. Most plans will give you a printed provider network or make one available online. However, these lists can change frequently, so it is best to check with your doctor for the most accurate information.

2)    I want to be able to see any specialist I want. 

These plans have become more and more rare, since most insurers have created provider networks, or lists of doctors who will be covered.  Plans that have no physician networks are called Private Fee for Service (PFFS or just FFS). You do not need a primary care physician or a referral to see a specialist. However, these plans are rarely offered outside of Medicare today.

The next closest choice is a PPO. These plans offer better coverage when you see a physician within their network (usually around 80%) and less coverage when you see an out-of-network physician (usually around 50%). So you can still go to any doctor, but just expect to pay more out of network.

HMOs are the most strict about what they will cover. They will only cover services from providers in their network and require a referral from your primary care physician for you to see a specialist.

3)    I don't like having to get a referral to see a specialist.

If this is important to you, a PPO will work better than an HMO. You do not need referrals, and if you stay with the plan’s provider network, you’ll be able to get the best coverage.  The main drawback is that HMOs are generally much more affordable insurance than PPOs—lower premiums, co-pays, and coinsurance.

4)    I am willing to pay more on the front end to avoid high costs on the back end.

Insurance is about risk—we pay a little bit in each month, so that it will repay us a bigger sum we need it. Some people prefer the security of knowing that anything that happens will be fully covered and are willing to pay a high premium for this. PPOs generally work better for this type.

5)    I would rather pay low premiums now, even if it means I would have to pay more if I get sick.

In contrast to those in #4 above, some people would rather pay less each month, and gamble that they won’t need to use their health plan. For this crowd, a plan with lower premiums and either a high deductible or high co-insurance would be more appropriate. HMOs or high deductible plans (whether they are PPOs or HMOs) generally work better for this type.

So really, the plan you pick is really driven by your personal preference.  Get clear on what is most important to you, and let these values guide your comparison of HMO vs PPO or high-deductible vs low-deductible. Most of the time, this is far more reliable than looking for the plan that is rated the best or that your trusted co-worker chose. Let go finding the best plan of all, just the find the best plan for your own needs.