Know Your Health Coverage

It can be a nightmare. You go see your doctor simply to confirm that you are in good health. Depending on your age, your doctor may determine you need some precautionary tests done, or he may just determine that something simple such as an EKG should be performed to simply determine that your heart is beating normally and the same as it was last time you were in the office. You follow the doctor's orders and are hopefully sent on your way with the results that yes, you are perfectly fine. Maybe you need to watch a few things such as your cholesterol or your blood pressure but currently your only prescription is to routinely follow up every few years with further tests and visits. A few weeks, or even a few months later, you check the mail and find an envelope from your health insurance provider. You open the envelope to find a hefty bill for those routine tests you had done a while back. You shake your head and decide to call your insurance company- surely they have made a mistake and billed you incorrectly. You call them only to find out that the tests you had done were not covered by your insurance and you are now liable to pay for them.
It's so important to know your healthcare coverage inside and out. A couple of years ago I had a persistent earache so I made an appointment with my doctor at that time. I was told the earache was due to some excess buildup in my ear, so they would clear it out for me and I should feel much better. A nurse came into the room a few minutes later, and literally used one of those kits you can buy at the drug store that comes with a little bulb you fill with water and squeeze it into the ear until you loosen up anything that is in there. She assured me it looked better, and I was sent on my way. I ended up returning the following week with the earache that never went away and was then put on an antibiotic which cleared up the problem (Obviously it was a simple ear infection). Not only did I pay another co-pay to be seen a second time, but I was delivered a bill about a month and a half later that charge me $60 for the procedure of cleaning my ear out with a kit that costs no more than $5 at a drug store. I was in contact with my insurance company immediately only to find out that the 'Ear Lavage Procedure' that was billed to my insurance was not covered by my plan and I was responsible for paying it. I found this to be ridiculous, mainly because it was something I could have done myself for approximately $50 cheaper, and also because I felt I was being taken advantage of by my doctor's office just to make them some money (While they didn't even fix the problem). After numerous appeals to my insurance company, numerous calls to my doctor's office, and many unanswered messages from the head of the medical office, I paid my $60 and vowed to never fall victim to that scam again.
What is covered by your insurance is typically determined by the level of insurance you have. Different tiers are often available if you are receiving your coverage from your employer, or your spouse's employer. A detailed description of what is covered and what is not is always available to you, and it's a smart idea to really take some time to look it over. Also keep in mind that policies change, and you are going to want a new copy of your coverage details every 6 months or so. Something that was once covered may no longer be covered and vice versa. Also, annual deductibles play a large role in what you may end up being billed for. Your insurance policy may state that a routine mammogram is covered 100% after your annual deductible is met. This means that if you have not yet spent the amount of your annual deductible, your insurance is not going to cover the test. Once you meet that minimum you won't have to worry about being billed, but its wise to call your insurance company and find out how far away you are from reaching the amount of your deductible. Other procedures may be covered only 75% after the deductible is met, or another amount. These percentages can vary for each procedure and test that is done so again, keep that policy handy.
Another problem I ran into was that my insurance claimed I was covered for one routine hearing test every 2 years. I was at an Ear, Nose and Throat specialist for a problem I was having, and the doctor performed a hearing test just to make sure my problem wasn't causing any loss of hearing (Even though I could have confirmed that no, it was not). I assumed this would be covered as my free hearing test, but of course I was billed for the entire thing, because the specialist billed the test to my insurance as a 'necessary procedure' for my diagnosis. Since the hearing test was not 'routine' as stated in my insurance policy, I was forced to pay. Needless to say, my husband and I will be increasing our contribution to our healthcare coverage this fall to ensure we have the highest tier, and everything under the moon and stars will be covered.
The real problem is that as Americans, we are not receiving adequate health coverage. A large portion of us have no health coverage at all, and a large portion of those that do are paying out of pocket for it, only to find we're still liable to pay for any tests or procedures we have done. As Americans we should be receiving much more assistance than we are right now. The medical industry has become a money making business that is stealing the money right out from under us. Of course we want to ensure that we are healthy and are going to live long and happy lives so we will go ahead and do what our doctors suggest to us. We wouldn't want to live with the consequences of ignoring our doctor and having something critical happen to us. It's sad that the provider we have chosen to represent us for our coverage isn't always on our side and we're left to be responsible for ourselves. Today I am much more educated on what my insurance covers and I have made many medical decisions based on that. However, if I am unsure of the wording in my policy and need to inquire about whether or not something is covered, I can call the customer service number for my insurance provider and when I ask the person on the phone if something is covered, I very rarely get a definitive answer. I've called a few times just to check to see what different representatives say and I've actually gotten different answers. I've been told something will indeed be covered, only to receive a bill a month later that proves no, that was not covered at all. Most insurance companies allow members to appeal billing decisions. If you strongly disagree with something you were charged for, or if something was billed by mistake that you didn't even have done, you can complete an appeal, your insurance company will investigate the claim, and you will be notified whether or not it will be resolved. I have attempted to utilize this opportunity numerous times, and I have yet to have success with it.
Your physician's office could be a potential problem as well. Something I luckily discovered early on has saved me so far. In the area that you live in, you may have doctor's offices that are general offices that will bill your insurance directly and that's that. Other times, if you are attending a physician or specialist that is part of a private group with other doctor's in the area, they will perform many routine tests right in the office as a convenience to patients so they don't have to travel all over the city to have things done. When they process the request to your insurance company, your insurance company can send them something back that is called an 'allowed amount.' This means that if your doctor's office charges your insurance company $1,000 for a flu shot, your insurance company has guidelines that allow them to say no, you can only charge us a maximum of $500 for a flu shot. If flu shots aren't covered by your particular policy at all, then the doctor's office can only bill you $500 which yes, you are then responsible for. Your insurance may not cover the shot, but they are at least saving you $500. The private practices I described before however, typically have their own policies that state to their customers that even if your insurance has an allowed amount, they don't follow that amount and reserve the right to bill you the full amount they originally requested. This means you would end up paying the full $1,000. Absolutely check with your doctor's office to find out their policy on this. If you choose to stay with that physician you always have the right to go elsewhere for the tests you need done. This may save you money, and you will still be following the doctor's orders.
I have dealt with this situation from various physician's offices so my advice is to make sure the doctor you choose is of course, a well educated and helpful doctor, but also make sure his or her staff is also helpful so if you run into a problem they will attempt to assist you in finding a solution. When it comes to health coverage and your individual policy it is your responsibility to know the facts and to look out for yourself. It's not your doctor's responsibility to know what is and is not covered, he or she simply knows what they need to suggest for a proper diagnosis. Don't worry about the money too much however. Of course if we're talking about routine tests and there's somewhere you can go to have the test done for cheaper and less hassle, I suggest you do it. However, if something needs to be done in a timely manner, and perhaps there isn't a lot of flexibility within your diagnosis, just get it done and worry about the money later. Your health is most important. Remain educated on healthcare, conditions, advances and medication (Including the current debate of generic versus non-generic drugs). Know what you can afford, know what will be covered, and let your doctor know of your situation if your insurance doesn't cover everything. Hopefully they will be willing to help you in anyway they can.