Friday, September 19, 2014

Health Insurance 101

I had a dear friend contact me earlier this week, upset and panicked because she received a hefty bill from a recent doctor's visit. After miscommunicating a few times via text, I called her up, ready to pepper her with questions so I could give her some solid advice.

And then she answered the phone. My questions drifted off my mind's page as I realized she was crying. She was doing the brave cry, the one where your voice pitches just a little lower, catching slightly, teetering precariously on the ledge of sadness, carefully trying to hide it, carefully trying to keep the choking sobs at bay. I imagined her standing there, wiping at her eyes, her nose, her cheeks. Dammit, I felt her say. Damn this straight to hell.

This is not the first time I've received one of these calls. Between Army medic training, my health admin degree, and my experience in medical billing, my friends and family kinda figure me for a health insurance answer lady. I don't mind and find it flattering. It's exhilarating to actually use the skills you've learned in school to help those you love and care about, ya digg?

It got me thinking....there's a great number of people out there who struggle with understanding health insurance - especially when something goes wrong. So here you go, world, here is a simplified, broken-down, Jen version of some basic health insurance facts you might need to know somewhere down the road.

***PS: I live in America and as such, speak from the perspective of an American healthcare consumer. Sorry global readers! If any of you are reading this, I'd love to hear about your country's health insurance in the comments down below! These types of things excite me.

So let's start with some basic history and my "why" behind the importance of understanding your health insurance.

Health insurance was originally created to help pay for catastrophic events. It was never intended to sustain or maintain everyday health - only those things that were considered life-threatening. Think of your other insurance you use Gieco when you need an oil change? Does State Farm come and refinish your hardwood floors so they stay in primo-box conditions? This is how health insurance originally began....major, serious conditions only.

Great Jen, but who gives a rat's pootinanny...

Well, you do. See, when health insurance began taking over all areas of health, from prevention to sickness to minor injuries, it subsequently removed the power of the consumer. Think about it - if you paid a guy $80 a year to care for your lawn, and he did so, and it looked pretty good and healthy, would you really care how he chose to care for it? Maybe a little....but enough to become involved? Enough to do it yourself?

We live in a day and age where insurance companies run the show. They say what can be done, how it can be done, who can do it, and how much it all costs. We rely on them to pay so we don't have to - we need them. Dangerous position to be in when you're not wizened in the ways of healthcare billing and insurance. But don't worry...we're gonna fix that a little.

Some basic insurance terms:

In-network: Docs and facilities your insurance company likes and has a contract with.

Out-of-network: Docs and facilities your insurance company does not like as much because they do not hold contracts with your insurance company. Insurance companies like contracts. Contracts = control.

HMO: Health Maintenance Organization. Basically this type of policy requires you to use a gatekeeper (M for Manager, Elmo!), or PCP, for all your healthcare needs. Instead of paying deductibles, you pay copays. HMOs tend to have cheaper premiums, in my experience. Read on to figure out what the heck a copay, deductible, and premium is.

PPO: Preferred Provider Organization. This type of plan allows you the freedom of choosing who you see, when you want to see 'em. Got a hangnail you just know is due to improper toe alignment? Go see a podiatrist. Have a mark you want removed, immediately? Head on over to a dermatologist or surgeon. No need for a gatekeeper here - you are free to move about the healthcare board as you see fit. Of course, you should prolly stay within network and only see those podiatrists who hold contracts with your insurance. In exchange for this freedom, you will be subject to coinsurance, deductibles, and in most cases, higher premiums. I promise I will tell you what those things are in a minute.

High-deductible plan: Your deductible is insane. Truly it is. It's almost laughable. High deductible plans act much like those old plans of our yonder years.....they will cover you in catastrophic events, for sure. But the sniffles? Pay up. Broken arm? Gimmie all yer money. Back pain? Chronic illness? You'll be paying out the yim-yam until your deductible is met. Not for prevention, of course. And as an added bonus, get do get your power back. Remember how I said our current healthcare world keeps power in the hands of the insurance companies and not the consumers? Well, with high-deductible plans, you become an educated consumer out of necessity. You regain the shop around for affordable doctors with the best overall value. You take advantage of places like Walgreens and CVS. You start to care about how much every procedure costs and what it is....because you are paying for it yourself. That is power, pure and simple. I recently transitioned from a standard HMO to a high-deductible PPO. I can feel my comparison-shopper Jen rearing her knowledgeable head high and proud already!

Contractual adjustment: People, this is what insurance is all about. Wanna know why your doctors become affiliated with BCBS and Cigna? They get patients. So here's how it works: Dr. Smith signs a contract with BCBS. She says, hey, you give me patients, I'll give all your patients a discount on my services. Instead of charging $100 for an exam, I'll charge $82. Whammo. $18 is knocked off the price, according to the contract the doctor signs with the insurance company. That $18 is considered the contractual adjustment. 

Preventative services: These are "keep me healthy" services. They normally include annual checkups, vaccinations, well-woman exams (think paps and mammos), and physicals. Obamacare mandates full coverage for these types of services....meaning you should not be paying a dime for your kid's annual exam, or your baby's well child visit, or your routine cancer screening (pap, mammo, testicular, those types of things). Wondering if a specific service is preventative? Ask!

PCP: Primary Care Provider. Do you have an HMO policy? This is the doctor your insurance company wants you to see before seeing any other medical professional. They love PCPs because one doctor means less hands to control...more managed care means less money wasted on specialist-seeking consumers who think they know what they're suffering from, but don't. I personally love PCP's because I live in this Little House on the Prairie world where my ideal healthcare situation is heading over to see Old Doc Murphey who's birthed every baby in town and knows everything about my medical history. It's nice to have a "guy" or "gal." I don't mind sacrificing my ability to see whoever I want, whenever I want if it means I can see the doctor I love and have bills paid with no problems.

Copay: A stupid amount you're required to pay upfront for any non-preventative care. These can range depending on your policy AND where you are getting treatment. My doctor's office copay, for example, is $35. My Emergency Room visit copay is $500. Yea. Copays are normally associated with HMO insurance plans...but I've seen them for people with PPO plans too.

Deductible: The amount of money your insurance company requires you to pay for non-preventative medical treatment before they will start picking up the tab. The cool thing about deductibles? You get the insurance discount we talked about before....that "contractual adjustment." The doctor's office can legally only charge you for the amount remaining after the insurance processes your claim with that discount. The only exception is when your claim is completely denied by the insurance - you won't get a discount if your insurance doesn't cover the procedure. Deductibles are normally only required for PPO policyholders.

Coinsurance: Another stupid amount you're required to pay. Remember those crazy percentages on your insurance card or policy package, where the insurance pays 80% of a service and the patient pays 20%? So if I need an MRI, my insurance will pay 80% of the MRI, but I need to pay 20%? That 20% is your coinsurance. It kinda sucks, this coinsurance, because it often hangs on even after you meet your deductible. It'll hang out there like a gross little booger until your annual out-of-pocket maximum is met. Awesome!

Premium: This is literally the amount you pay each pay period for your health coverage. So that $250 every two weeks that comes directly out of your check and goes to BCBS before you can even get your grubby lil' hardworking hands on it? That is your premium. I don't know why they don't just call this "payment." Whatever.

So now that we've bulked up on our terms, how about some industry insider tips?

3-Ways - Good stuff. Hear me out. So you get a bill. You call the doctor's office. They say it's an insurance problem. You call the insurance. They say it's the office's problem. Ask the insurance company to do a 3-way call with your doctor's office. They can and will do this. When I was in billing I would get 3-wayed all the time. True story. Eliminate your middleman self and make some magic on those telephone lines.

Financial Assistance - Any nonprofit healthcare entity is required to have a financial assistance program. Think you're too rich? Think again. Assistance is often awarded based on need, not income. Prove you need it (aka, I only have $100 left each month after paying bills) and chances are, you'll get portions of your bill written off.

Providers, Facilities, Labs, and Radiology -  Let's say, heaven forbid, you experience chest pain. You head to the ER at Hospital Peace. You're treated by Dr. TomTom. You get labwork done by Beam-Me-Up-Scotty Labs. You get an x-ray by Stars and Pins Radiology. You will, often times, get four. Completely. Separate. Bills. Pay attention to the bills you receive and understand your hospital stay will not be bundled and billed in one neat little package. This is life.

Policy Awareness - I hate to say it....but it is not your doctor's job to know your policy. Learn your policy inside and out. Thinking about getting a procedure? Ask your doc for a full description of the procedure, including the expected CPT codes, so you can check with your insurance. CPT codes are 5-digit numeric representations of medical treatments. They match what your insurance company pays for exactly and leave no room for confusion - so if you can get them, get them. Some doctors will draw up a pre-estimate with these codes on them. Ask! Asking questions will help you save money, I promise.

Note Taker - Calling your insurance? Write down the date, time, name of the rep, and ask for a reference number for the call. Calling your doctor's office? Take down the date, time, and name of the person you're speaking to. Learn the names of office managers and executive leaders. These people can be a godsend when something goes wrong...and believe me, it happens. People are not perfect, but they are capable of executing learn their names and take vigorous notes.

Well, there we have it, readers. Jen's lovely little Health Insurance 101 course. It ain't an exact science, but hopefully this can be a nice place to start. Luckily, my dear friend was able to work out her insurance issues and found out her huge bill was a clerical error. Sometimes it really is that simple.....just takes a couple questions to save you money and heartache!

Any of you have problems with your health insurance? And if I missed anything or you'd like additional details, please let me know in the comments down below. As always, thank you so very much for reading :)


  1. There's seriously an entire code and language involved in the healthcare world! Angel worked with billing for a clinic while we were in college and then as a nurse for the last 5 years so it's been a world I've been unusually close to till recently. We had good insurance in my opinion--mainly because we pretty much never actually went to the doctor. I usually threw a fit whenever I saw what our dental insurance wasn't covering, though, mostly because I knew that if we happened to be in Malaysia my chilhood dentist could have done the same procedures for the proverbial "pennies".

    1. That's so nice that you have Angel! I know my friends and family love that I've got the "hook up" so to speak.......I was also a dental assistant and office biller for a couple years - the dental world is, in my opinion, even more insane than the healthcare realm!! Thanks for stopping by Rach :)

  2. Great post Jennifer! I've had so many insane issues with our insurance. At this point I question everything-- every bill, every procedure. It's so important to know your policy in and out so that you don't get stuck with a bunch of ridiculous bills.

    1. Thanks :) It's actually really awesome that you check everything and choose to be involved in your bills - so many people tend to breeze over that stuff and never really notice until something goes wrong....then they are stuck and wondering what hit them! Being proactive is the way to be!

  3. We just have Tricare, insurance through the military. It's much easier than all of this. Now, when Tom gets out, it'll get more complicated..

    1. Ah yes, I remember the good ol' days of Tricare - although to be honest, even having Tricare was wonky when we were living OCONUS.

  4. Ugh medical bills are a nightmare - I have one I don't even know where to start kiddo.. It's like obscene.. and I don't even know what to do because they keep harassing me everyday - hello 'ignore' button O_o These are good terms to know, would you recommend getting insurance through your employer or going in dependent? It's just me and my son so I'm wondering if I can get better coverage elsewhere especially since I have a sleep disorder that is unmanaged at this time haha. Thanks for the info love will bookmark this for a reference since renewal times are approaching for insurance!! -Iva

    1. UGH Iva that's terrible!! I'm sorry to hear you're in Med Bill Hell! Do they have any discount programs or payment options?? I HATE the pushy ones who call everyday - luckily when I worked customer service I never had to do that...we outsourced those types of things!

      As for the insurance coverage - in my personal experience, employer-offered plans tend to be cheaper than making a go of it on your own....your employer absorbs some of the costs and the insurance companies/plans (depending on who you work for) tend to be a bit more diverse. It never hurts to look, though, and shop around. Many major companies (BCBS, Aetna, UnitedHealthcare, Cigna) will give you price quotes online. If you're looking for more specialized coverage, you might want to go with an insurance broker. These guys and gals have the best access to some of the more intricate policies and while they do get a cut, it isn't from your pocket. I'd say if it's something you're thinking about, check it out! Doesn't hurt to try. Thanks Iva :)

    2. Yeah it blows but my main issue is I have a sleep disorder that affects me daily and while it's not as bad as it used to be it has its moments when it is a true pain in the arse. The issue is management is very pricey and for more intricate diagnosis and analysis, which I'd like, it comes with a hefty pricetag - I didn't even know there were insurance brokers - loll totally going to find one now.. I'd like to have specialized coverage for that and would like to see how much that is since this is something that affects me daily. Thanks love very helpful guide!!! :) <3

    3. HAHA yes be sure to find a good reputable one! You are pretty awesome on the research front so I'm sure you'll have no trouble distinguishing the goodies from the baddies. Good luck and if I can help at all let me know !! :)

    4. How do you feel about Cigna? We're going from United Healthcare to Cigna - IS THIS BAD?!?!

    5. HAHAHAA No, in my experience UnitedHealthcare actually has the worst customer service...especially from a provider's billing perspective. Cigna is good. You will be all good. To be honest all of 'em can be crappy if you catch the wrong person. I've mastered the hang-up-and-call-back-technique like a boss.

  5. I have some experience managing the health care system through my work. Before we hired an HR person I assisted the employees with their medical bills. I used to say never pay anything until you have the EOB and then question anything that didn't look right. Many times the medical facility coded the invoice incorrectly.

    I'd add don't pay a single penny towards a bill that is incorrect. My co-worker's husband went in for surgery. During the operation the doctor realized he had misdiagnosed the problem and changed the procedure. The insurance company denied the claim because the new correct procedure wasn't preauthorized. They received a bill for $27,000. My co-worker spent hours on the phone trying to get it corrected. The bill went to collections. The collection agency tried to get her to agree to make a $10 a week payment. Our current HR person advised her not to pay one dime. By making a payment she could be agreeing to the charge. Eventually over a year after the surgery the claim was paid. How did she resolve it - with a 3-way.

    Thanks for another informative post.

    1. It's so true - never pay a dime!!!! I didn't think about that at all but you are right on the money - your dollar literally speaks for you. There are so many people out there who don't realize that truth....including me sometimes! HAHA!

      I think my favorite part of your comment was the story got it....the 3-way. HAHAHA! Thank you so much for stopping over Sav :) Love reading your comments!

  6. That’s true; having a health insurance is a great way to avail of the medical care and treatment that someone needs. So having a thorough understanding of an insurance plan and its coverage will help them know the limits and services they can get out of it. And these information are very helpful. At the very least, people will be aware on the things to look at when they apply for a health insurance. Thanks for sharing!

    Carlton Mclaughlin @ TFSN