Author's note: This column is intended for educational purposes only. It aims to highlight gaps in health knowledge, provide support and empower organizations to guide their members in creating …
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Author's note: This column is intended for educational purposes only. It aims to highlight gaps in health knowledge, provide support and empower organizations to guide their members in creating effective health and wellness programs.
Understanding your health insurance plan matters because a misunderstanding can delay, prevent or deny needed health care services and increase your costs. Health insurance is meant to support your care, but understanding how it works — networks, deductibles, copays, plans and pre-approvals — helps you avoid surprises and enables you to make informed decisions about your care. Elements you should consider include:
1. Know if your provider is in-network or out-of-network.
Insurance companies contract with doctors, hospitals and clinics. These are called in-network providers, and appointments are usually less costly. If you see an out-of-network provider, the insurance company may pay much less — or nothing at all — with the consumer paying more.
Tip: Before scheduling an appointment, ask, “Does this provider accept my insurance plan?”
2. Understand your deductible.
A deductible is the amount you must pay out of pocket each year before your insurance begins paying for any services.
Tip: Preventive services, such as health screenings or annual checkups, are often covered before the deductible is met.
3. Know the difference between copay and coinsurance.
After the deductible is met, you may share costs with the insurance company. Copay: a fixed amount you pay for a service, for example $25 per visit. Coinsurance: a percentage of the cost, for example insurance pays 80% and you pay 20%.
4. Some health care services require prior authorization.
Specific tests, procedures, medications or specialist appointments may require pre-approval from your insurance company. This is commonly referred to as “prior authorization.”
Tip: If approval is not obtained, the insurance company may deny payment, leaving the consumer responsible for the full cost.
5. Review your Explanation of Benefits, or EOB.
After a medical visit, your insurance company sends a document called an Explanation of Benefits. This is not a bill. It explains what services were billed, what the insurance paid and what portion, if any, the patient will owe.
6. Appeals are possible.
If the insurance company denies a claim, patients have the right to appeal the decision. Sometimes claims are denied due to missing documentation or coding issues that can be quickly and easily corrected.
American health insurance frustrates everyone.
Recent polling indicates that consumers do not trust their health insurance provider. Fully 70% of the country thinks the American health care system has major problems, if not already at a breaking point. Patients complain that their health insurance coverage is expensive, complicated and fails to cover all the services they desire. In addition, insurance companies determine which health services consumers are allowed to have and when. Health care providers complain that health insurance companies bury them in paperwork, increase the need for additional staff and harm doctor-patient relationships. Identifying the actual villain in our reimbursement story is not so simple. A survey by the American Hospital Association found that more than 80% of nurses and physicians agree that insurance policies reduce the quality of care and hamper their ability to practice medicine.
Small and mid-size businesses state that providing health insurance for their employees is becoming unsustainable. Employer-sponsored insurance, or ESI, is the most common way Americans get health care coverage. This includes self-funded plans, in which the employer acts as the insurer, and commercial health insurance plans purchased by a company for its employees. Medicare is a federal entitlement program that provides health insurance for Americans age 65 and older who do not have insurance through other means. Medicaid is a government program that provides health insurance to low-income Americans. It is administered by the states within guidelines provided by the federal government. Coverage varies from state to state. Another health program provides health care for our military, their dependents and retirees.
The bottom line is that navigating the health care system should enable consumers to choose the plan that best fits their needs. Consumers expect transparency and cost-effective health insurance plans that prioritize prevention, wellness and equitable access.
The way the medical community thinks about cancer is changing. Doctors are realizing that conventional treatments that kill cancer at the body’s expense are not the only way to fight cancer. Rapidly dividing cells, the hallmark of cancer growth, are part of a new paradigm that harnesses the body’s ability to keep cancer cells in check via the immune system. Specifically, the body’s most powerful cancer-killing cells are called lymphocytes.
Dr. Cheryl Christy is a Baldwin County resident and registered nurse with nearly 30 years of experience. She holds master's degrees in nursing education and nursing practice and a doctorate in nursing practice. She is a member of Sigma Theta Tau, Phi Pi Chapter, a certified lay counselor and the author of "Voices for Healthcare," a health care blog.
Read her previous column titled "Delayed health care — A silent driver of poor health outcomes" on www.GulfCoastMedia.com.
