Healthcare Coverage Can Leave You Uncovered

Healthcare coverage is a vital financial protection yet naiveté about how coverage works leaves us vulnerable to overcharges, or worse, forced to pay medical bills that blindsided us.  Learning to navigate your healthcare coverage is a skill that will serve you well for the rest of your life.

As part of our business, we review medical bills and claims for clients and see sloppiness and errors that negatively affect the patient.  Here are recommendations for ways to protect yourself and your family from overpaying for services.

First, understand the basics of coverage such as product, network and rules.   These factors should be paramount before selecting your coverage.  Then learn the details of your particular plan:

Know your Product

It’s essential to know whether you have a PPO, HMO, EPO, POS, or a high deductible plan with HSA or HRA.

Know your Network

All plans use specified networks, and insurance companies offer a range of networks so learn your network specifics. Before scheduling visits, determine if your providers are in-network with your Plan as that provides the greatest financial protection.  Research any out-of-network benefits which are desirable, but could provide less financial protection than you expect, as the provider can charge any amount while your insurance company’s responsibility is limited.  In 2022, if you use an out-of-network provider on an emergency basis or while in an in-network facility–without being made aware of the doctor’s out-of-network status–you may have more protection against unexpected bills. This will depend on your state’s laws under the Federal “No Surprises Act,” when using an out-of-network provider is beyond your control.

Know your Plan’s Design

Understand the deductible, relevant copayments, coinsurance and the out-of-pocket maximum for in-network and out-of-network benefits,if applicable.

Know the Appeal Process

Learn your rights to appeal but try to avoid situations where appeals are necessary.

Familiarize Yourself with Your Provider’s Site

Create an on-line portal for your coverage and familiarize yourself with the site.

Learn How to Interpret Claim Information

Learn how to interpret claim information including the explanation of benefit statements (EOB’s) that are on your portal. These are the statements your insurer issues when they process a claim received from a provider.  At first they may seem inscrutable but you will become more skilled with practice.  If you have questions, use the “chat” feature on your insurance company portal, call customer service and/or type your question into a search and review the results.

Check Your Bill

When you get a medical bill, make sure the owed amount shown matches the “member responsibility” on the explanation of benefit statement. Also, make sure the information on the bill and the explanation of benefit statement matches your recollection of the services you received.  If the information doesn’t match or doesn’t seem right to you, follow up with the provider billing staff, the insurer’s customer service or both until what you think happened at the visit aligns with the claim information.  Know that almost every medical procedure includes two codes: a procedure code called a CPT which describes the type of procedure you received and a diagnostic code which describes the relevant illness or injury or that the visit was well care or preventive.  You don’t need to be a coding expert but coding errors are more common than people realize and it is easy to research this information on-line.

Common Problems that Can Cost You (a Lot of) Money

Most people tend to be aware of problems that occur with their insurance company such as the insurer denying they received a claim, losing information or multiple requests for additional information to process a claim.   To resolve most of these issues takes some knowledge and some persistence.  Problems that providers create, however, are also vexing, and often not as obvious For example:

  • The provider requests payment at the time of service before they have submitted the claim, typically when you have not met your deductible or when coinsurance is owed, and you are overcharged. Try to avoid payment until the claim is processed so you can see that the “member responsibility” amount identified on the EOB coincides with the billed amount.
  • The provider submits the claim to the insurer and the insurer requests additional information. Rather than provide additional information, the provider sends you a bill indicating the insurer declined payment. Remember, if the provider is in-network and the service was medically necessary, the insurer should process the claim before you make payment.
  • You are scheduled for an expensive procedure that requires prior authorization. Prior authorization requires your provider to submit information to your insurer before the procedure. At times providers don’t submit the backup or aren’t timely and you are pressured to pay for the procedure in advance with authorization to follow.

Such unsavory practices commonly surrounding medical claims and bills, requires us to up our skills in navigating our increasingly complicated medical insurance process. It’s crucial to become adept at identifying these erroneous practices and demand fairness and transparency.


PPO:  Preferred Provider Organization

HMO:  Health Maintenance Organization

EPO:  Exclusive Provider Organization

POS:  Point of Service Plan

HDHD:  high deductible plan with HSA (health savings account) or HRA (Health Reimbursement Account)

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