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The ‘Ins and Outs’ of Health Insurance

Health insurance

Most people pay little attention to the details of their health insurance until something unexpected happens. Once you have a significant diagnosis on your hands, many insurance questions and concerns come into focus.

There are many types of health insurance companies. While they all have differences in their products, the basics are the same. Below, the essentials are explained to help you navigate your coverage.

  • The Schedule of Benefits (SOB) is the document that has all the details of what is covered, as well as cost sharing or copays and exclusions for the insurance product that you purchased and enrolled in. Other documents that can assist you are the Member Handbook and the Prescription Drug Document. These will explain medical and pharmacy benefits in more detail.
  • It is important to make sure that the doctor you select is a Participating Provider with your insurance plan. Sometimes these are referred to as “in network providers.” Some insurers may allow you to see “out of network providers,” but the cost to you may be much greater.
  • Some procedures and services require Prior Authorization. This means your insurance plan will cover the service if the clinical information the doctor provides on your medical condition meets the requirements in the insurance company’s Medical Policy. Usually, the responsibility of prior authorization falls on your doctor, but not always. You might consider calling your insurance company’s member service center to inquire if your procedure or treatment needs prior approval, then discuss with your doctor.
  • Medical Policies are a way for an insurance company to ensure that clinicians are treating and billing only for medically necessary services and U.S. Food and Drug Administration-labeled uses of drugs. Sometimes medical policies state that first-line procedures or less costly options must be tried before moving to a more expensive option.
  • What does it mean if I get a Denial Letter from my insurance company? When your doctor submits the prior authorization for your service, an equally experienced clinician at your insurance company evaluates the request against the Medical Policy. After the review is complete, your insurer will approve or deny the request. The denial means that the treatment does not meet the medical policy criteria and if you go forward, it will not be covered, and you will be responsible for the payment. Your doctor also receives the Denial Letter and may change the service or Appeal the denial. The Denial Letter and your Member Handbook provide information on how to initiate an Appeal.
  • All this can be overwhelming, especially with the added stress of a significant health issue.  There is help available to you. Some insurance companies assign Care Managers to those insured members with significant health issues. The care manager is usually a Registered Nurse who will help you navigate all the complexities with your situation and your coverage. Your care manager will call you regularly and help sort things out.  
  • Additional help is also available by calling Member Services. These representatives are trained to look up your insurance product and explain the benefits and how your coverage works.  
  • Finally, pay close attention to your Activity Summary or Explanation of Benefits. This is the statement that comes from your insurance company illustrating how each claim was processed. Make sure you wait to pay any healthcare bills you have received until you have compared it with the Activity Summary from your insurance company.

Susan Perry is Head of Strategy Operations, Office of the Chief Medical Officer at Point32Health

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