WIUM Tristates Public Radio

Your Health Insurance: Knowledge is Power

Feb 25, 2016

I'm here today to talk about health insurance. No, not what makes the news -whether to repeal the ACA, cutting Medicare and Medicaid,  going to Canada or another country for prescription drugs or procedures.  What I want to talk about is the importance of  knowing the details of your own individual health insurance policy.

I’ve been coordinating my family’s medical bills as they proceed through the labyrinth of insurance company payment since 1985. When I first started doing this, there were lots of people in medical providers’ offices who were often helpful. These days, it is much more difficult to get help in providers’ offices.

Gayle Carper
Credit Rich Egger

My experience dealing with health insurance companies has always been annoying, but then I like a good argument. Prior to easy on-line access to everything, I was able to talk to actual human beings at insurance companies. It took some effort and knowledge, but at least I could eventually get answers. Today with everything on-line, it is difficult to make contact with a live person. And it is  almost impossible to find a single individual  at a health insurance company who can answer questions or deal with an issue.

However, the most distressing thing I’ve encountered is that most people today know little about their own health insurance coverage. It is essential to know this stuff before disaster strikes. I have learned that the only way to win with insurance companies is to become an expert on the health insurance policy in question.

Let’s start with a little quiz – no, it will not be graded. 

1. What kind of health insurance plan do you have?

2. With which company? 

3. If you are over age 65 and qualify for it, do you have original Medicare Parts A, B  and D or Part C?

4. Regardless of your plan, where is your current Benefits Book and ID card? Have you ever read the benefits book, either on paper or on-line?

5. What is the difference between a premium, a deductible, a co-pay and co-insurance?

6. What is an EOB?

7. What is the appeal process for a denial of payment for a service you received?

8. What services or prescriptions require prior approval from your insurance company? 

So how did you do? If you are like most people, not too well.

So what can you do? Learn and question.

First, study your current plan and learn what medical services are covered and the difference between what you pay and what the insurance company pays. Don’t be like the woman who had out-patient surgery and later found out it wasn’t covered by her policy. Don’t find out too late that you have exceeded the maximum for services like physical therapy.

Second, carefully review your policy’s drug formulary – the list of drugs covered and not covered. 

Each year, to save money, many insurance companies change their formulary or the amount you pay. Total U.S. spending on prescription drugs jumped 13 percent last year, the largest increase since 2001.

Other things to look for with prescriptions – does your policy require you to try less expensive drugs before the one your doctor prescribed? Are there quantity limits? Do you need  prior authorization from your insurance company before filling a prescription?

Third, determine which doctors are in your network. One way insurance companies save money is the establishment of provider networks, where providers have agree to pricing arrangements that lower overall costs.  So-called “narrow networks” can be expensive to you when a specialist you need is not in your plan’s network.

Fourth, learn to read your EOBs. This is the multi-page Explanation of Benefits form you get from your insurance company. Look for errors or problems that could lead to unnecessary medical bills. Compare it with the billing statement from your doctor  for  total amounts charged, possible duplicate charges; dates of service; denials of coverage, how much is being applied to your deductible; and for what you must pay.

Fifth, bookmark on-line sites that help you, like Medicare.gov, or CMS.gov, your provider’s benefits book or my favorite healthcare.gov/glossary for definitions.

Finally, review your policy now and then every year during the re-enrollment period.  Remember that health insurance companies are profit-focused businesses and your knowledge is your power.

Gayle Carper is a retired attorney and retired Professor of Law at Western Illinois University.

The opinions expressed are not necessarily those of the University or Tri States Public Radio.  Diverse viewpoints are welcome and encouraged.